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10314833-DS-15 | 10,314,833 | 20,839,530 | DS | 15 | 2188-11-23 00:00:00 | 2188-11-23 19:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with a hx of COPD on 3L home O2 at night, HLD, pre-DM, and
severe depression presents as outside transfer for acute hypoxic
hypercarbic respiratory failure secondary to COPD exacerbation.
The patient initially presented to ___ with increasing
dyspnea and intermittent somnolence for 2 days. He has a chronic
cough that he reports was not worse than usual. In this time,
per the pt's wife, he was also more sleepy than usual and fell
asleep on several occasions even while at the dinner table. The
pt denies fevers, chills, chest pain, leg swelling, or recent
illness. Pt says that he received flu shot earlier this year.
On the night prior to admission, the pt's wife reports that he
woke up gasping for air, prompting her to call ___. He was
brought to the hospital by EMS who found him with O2 sat in ___,
increased to ___ on nasal cannula. At that time, his initial pH
was 7.22 and pCO2 80, so the patient was placed on BiPAP and
given duonebs and solumedrol with good improvement in shortness
of breath however the pt remained hypercarbic by VBG. The pt was
transferred to ___ because he required ongoing BiPAP, but no
ICU beds were available at ___.
In the ED, the patient's initial VS were T 98.3, HR 103, BP
164/104, HR 20, O2 96% on BiPAP. His exam was notable for being
generally alert and conversant, but with diminished sounds and
faint crackles in all lung fields except left upper lobe.
Labs significant for:
WBC 9.4 (94.8% PMNs), Hbg 13.9, Plts 240
Na 142, K 4.9, Cl 101, HCO3 33, BUN 13, Cr 0.7, glucose 146
___ 13.0, PTT 29.9, INR 1.2
proBNP 30
VBG: pH 7.28, pCO2 77
The patient was given: 500mg IV azithromycin
Imaging notable for a CXR which demonstrated hyperinflated lungs
but no clear focal consolidation.
On arrival to the MICU, the pt provided the above history.
REVIEW OF SYSTEMS:
Negative for fever, chills, sore throat, increased cough, CP,
palpitations, abdominal pain, nausea, vomiting, diarrhea,
constipation, leg swelling.
Positive for shortness of breath, lethargy
Past Medical History:
- COPD
- Likely undiagnosed OSA (per sleep history provided by family)
- Pre-diabetes
- HLD
- Glaucoma
- Severe depression w/ psychotic features
Social History:
___
Family History:
No family history of early cardiovascular disease or cancers.
Physical Exam:
ADMISSION EXAM
===============
VITALS: T 98.1, HR 93, BP 143/92, RR 23, O2 93% on BiPAP
GENERAL: Alert, oriented, no acute distress, tolerating BiPAP
mask
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Markedly decreased lung sounds throughout, no crackles or
wheezes appreciated
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: AOx3
PSYCH: Mood described as "good" affect congruent
DISCHARGE EXAM
================
VITALS: 97.6 123 / 79 76 18 95 2L
AMBULTORY SATS: 84% RA, 86-88% 1L NC, 88-89% 2L NC, 90% 3L NC
GENERAL: Awake, alert, and interactive. No acute distress.
HEENT: Sclera anicteric, MMM, no visible lesions of oral mucosa.
NECK: supple, JVP not elevated, no LAD
LUNGS: No use of accessory muscles. Markedly decreased lung
sounds throughout, worst at bilateral bases. Faint inspiratory
crackles in mid-lung fields bilaterally. No wheezes appreciated.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: AOx3. ___ strength of bilateral proximal and distal UE
and
___. Sensation in upper and lower extremities grossly intact.
Face
appears symmetrical.
Pertinent Results:
ADMISSION LABS
==============
___ 02:16PM WBC-9.4 RBC-4.73 HGB-13.9 HCT-45.6 MCV-96
MCH-29.4 MCHC-30.5* RDW-13.8 RDWSD-49.0*
___ 02:16PM NEUTS-94.8* LYMPHS-4.2* MONOS-0.5* EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-8.90* AbsLymp-0.39* AbsMono-0.05*
AbsEos-0.00* AbsBaso-0.02
___ 02:16PM PLT COUNT-240
___ 02:16PM ___ PTT-29.9 ___
___ 02:16PM GLUCOSE-146* UREA N-13 CREAT-0.7 SODIUM-142
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-33* ANION GAP-8*
___ 02:24PM O2 SAT-90
___ 02:24PM LACTATE-0.8
___ 02:24PM ___ PO2-66* PCO2-77* PH-7.28* TOTAL
CO2-38* BASE XS-5
PERTINENT LABS
===============
___ 03:45AM BLOOD %HbA1c-5.8 eAG-120
___ 03:45AM BLOOD Triglyc-52 HDL-44 CHOL/HD-2.2 LDLcalc-42
LDLmeas-42
DISCHARGE LABS
===============
___ 07:30AM BLOOD WBC-11.4* RBC-4.57* Hgb-13.2* Hct-42.9
MCV-94 MCH-28.9 MCHC-30.8* RDW-14.2 RDWSD-48.6* Plt ___
___ 07:30AM BLOOD Glucose-98 UreaN-17 Creat-0.7 Na-144
K-4.2 Cl-102 HCO3-35* AnGap-7*
___ 07:30AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
___ 08:09AM BLOOD pO2-68* pCO2-70* pH-7.31* calTCO2-37*
Base XS-5 Comment-GREEN TOP
STUDIES/IMAGING
================
___ CXR
No prior chest radiographs are available. Lungs are
hyperinflated, consistent with the provided diagnosis of C OPD,
but clear of any focal abnormality. Cardiomediastinal and hilar
silhouettes and pleural surfaces are normal
___ CT-A
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Diffuse bronchial wall thickening and mild bronchiectasis is
nonspecific and
could be inflammatory or infectious in etiology.
Brief Hospital Course:
Mr. ___ is a ___ with a hx of COPD on 3L home O2 at night,
HLD, pre-DM, and severe depression presents as outside transfer
for acute hypoxic hypercarbic respiratory failure likely
secondary to COPD exacerbation.
ACTIVE ISSUES:
==============
# Acute hypercarbic hypoxic respiratory failure
# COPD exacerbation
The patient presented in hypercarbic respiratory failure, most
likely due to COPD exacerbation. Patient initially presented to
___ with O2 sats in ___ on RA. Was started on BiPAP and
transferred to ___ for ICU support. The trigger for the
exacerbation was unknown. There was nothing in the history to
suggest infection. He was afebrile and his CXR did not show a
consolidation. The patient had a CTA which was negative for PE.
CHF less likely cause of his respiratory failure given no hx and
nml proBNP. He was started on a 5 day course of steroids
(___), in addition to being given azithromycin 500mg x1,
and albuterol and ipratropium inhalers. He was weaned off of
BiPAP and able to transition to nasal cannula prior to transfer
to the floor. His steroids were weaned from 60mg to 40mg and he
was transitioned from azithromycin to levofloxacin. QTc 367. His
ambulatory O2 saturations were 84% on RA, 86-88% on 1L NC,
88-89% on 2L NC, and 90% on 3L NC. Patient received 3 days
azithromycin, transitioned to levofloxacin 750 mg daily to
finish a course on ___. He will complete a 5 day course
of steroids 40 mg on ___. His home Advair dose was
increased to 250/50 BID. Patient uses supplemental O2 at night
and needs sleep study outpatient to assess for sleep apnea.
CHRONIC/STABLE ISSUES:
======================
# Severe depression
The pt has a history of severe depression w/ psychotic features
(auditory hallucinations). Is followed by psychiatrist and
therapist, appears to be reasonably well controlled at this
time. Currently denies depressive mood or symptoms. QTc 367.
While in house, he was continued on home Seroquel 600mg QHS,
home Mirtazapine 30mg QHS, home welbutrin 200 mg QD. He was
discharged on his home medications. His zolpidem was held
pending PCP ___.
# Chronic pain
The patient has chronic pain in upper extremity and was
continued on and discharged on his home gabapentin 300mg TID.
# Pre-diabetes
Per pt, has pre-diabetes; A1c 5.8% on admission. Only on
metformin at home. Does not check BG and is not on insulin. He
was discharged on his home metformin.
# HLD: Continued on home atorvastatin 40mg QD
# Glaucoma: continued on home Dorzolamide and Latanoprost eye
drops QHS
TRANSITIONAL ISSUES
====================
VITALS: 97.6 123/79 76 18 95 2L
AMBULTORY SATS: 84% RA, 86-88% 1L NC, 88-89% 2L NC, 90% 3L NC
VBG at baseline: pH 7.31 pCO2 70 HCO3- 35
[] Recommend sleep study as an outpatient
[] Recommend PFTs outpatient
TRANSITIONAL ISSUES:
New Medications:
- Levofloxacin 750 mg daily until tomorrow ___
- Advair 200/50 BID
- Prednisone 40 mg last day ___
- Combivent Q6H
[ ] Continue prednisone 40 mg until ___
[ ] Continue levofloxacin 750 mg until ___
[ ] Consider outpatient PFTs for evaluation of COPD and lung
function
[ ] Consider outpatient sleep study for evaluation of OSA
[ ] Consider referral to ___ clinic
[ ] Consider adding Spiriva if symptoms worsen off steroids
[ ] Discharged on home O2 2L during the day and 3L at night
[ ] Patient should purchase home oximeter
# Full code
# ___ (wife): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
2. Zolpidem Tartrate 10 mg PO QHS:PRN sleep
3. QUEtiapine Fumarate 600 mg PO QHS
4. Mirtazapine 30 mg PO QHS
5. Gabapentin 300 mg PO TID
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheeze
7. Atorvastatin 40 mg PO QPM
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
10. MetFORMIN (Glucophage) 500 mg PO DAILY
11. BuPROPion (Sustained Release) 200 mg PO DAILY
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
RX *ipratropium-albuterol [Combivent Respimat] 20 mcg-100
mcg/actuation 1 INH IH every six (6) hours Disp #*1 Inhaler
Refills:*0
2. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 4 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheeze
5. Atorvastatin 40 mg PO QPM
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
7. BuPROPion (Sustained Release) 200 mg PO DAILY
8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
INH IH twice a day Disp #*60 Disk Refills:*0
10. Gabapentin 300 mg PO TID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. MetFORMIN (Glucophage) 500 mg PO DAILY
13. Mirtazapine 30 mg PO QHS
14. QUEtiapine Fumarate 600 mg PO QHS
15. HELD- Zolpidem Tartrate 10 mg PO QHS:PRN sleep This
medication was held. Do not restart Zolpidem Tartrate until you
talk with your primary care physician.
16.Home Oxygen
ICD-9: 496
2L via NC with ambulation
Concentrator and portable
Length of need: 999 days
At rest RA: 88, Amb on RA: 86, Amb on O2: 88
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute hypoxemic, hypercapneic respiratory failure
COPD exacerbation
SECONDARY DIAGNOSES:
Depression
Chronic Pain
Pre-Diabetes
Hyperlipidemia
Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing ___ for
your site of care!
Why was I admitted to the hospital?
-You were admitted because you were short of breath.
What was done for me while I was in the hospital?
-You initially required extra oxygen in the intensive care unit.
Your oxygen was decreased as your breathing improved.
-You were started on an antibiotic and a steroid to help with
your breathing.
-Your oxygen levels were checked while you were walking. You
were found to need oxygen while walking and will be discharged
with a mobile oxygen tank.
What should I do when I leave the hospital?
-You should take all of your medications as prescribed.
-You should follow up with your doctors as ___ below.
-Use your oxygen at home when you feel short of breath or when
your O2 saturation is less than 88%.
-If you are felling lightheaded or short of breath, check your
oxygen. If it is less than 85%, call your primary care doctor.
We wish you the best!
Your ___ treatment team
Followup Instructions:
___
|
10314883-DS-8 | 10,314,883 | 26,649,157 | DS | 8 | 2182-12-02 00:00:00 | 2182-12-02 20:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Niacin / Lovastatin / Ceftin /
Cisapride / Zithromax / Lipitor / Pravachol / Victoza
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o CAD, HTN, and HLD presenting with reports of chest
pressure, lightheadedness, and diaphoresis. She underwent a
cardiac catherization the day prior to presentation as part of a
work up for anginal chest pain which also included a positive
stress test. Her cath revealed two-vessel branch coronary artery
disease (70% distal small RCA, 60% D1). There were no
interventions. She reports that she was to start imdur in an
effort to help control her symptoms and she received a dose
prior to leaving.
Not long after, she began to experince some flushing. She did
not think much of this, but gradually over the course of the
afternoon she developed diaphoresis, nausea, and
lightheadedness. She also noted some chest pressure that was
similiar to the symptoms she had been experiencing prior to her
catheterization.
She called EMS and was given SLNTG en route to an OSH ED. She
reports this helped with her chest pressure. She was reportedly
hypotensive on arrival and was given IVF (unknown amount, ?2L).
As she was so soon after cardiac catherization she was
transferred to the ___ for further evaluation.
In the ED, initial vitals were: 98.4 46 118/72 16 98%
Labs and imaging significant for a hct of 35 (previously 43.0 on
week prior. Her lactate was 2.2. She received an additional
liter of NS. She was evaluated by cardiology in the ED. They
felt she required a floor level cardiology admission, but given
the persistent hypotension she was admitted to the ICU. Vitals
prior to transfer were 97.9 54 86/53 18 97% RA.
Upon arrival to the unit, the patient reports feeling amazing.
She denies CP, SOB, LH, diaphoresis. She reports that she is
hungry and thirsty.
REVIEW OF SYSTEMS:
Reviewed and otherwise negative
Past Medical History:
Per OMR, reviewed with patient.
1. CAD s/p anterior STEMI in ___ at ___
___. She underwent primary PCI with placement of a 2.5 x
28mm Xience stent to the LAD. A nuclear stress test in ___ was negative for ischemia. She presented to ___
in ___ with an NSTEMI and was treated with RCA and LCx DES
(Xience).
2. Hyperlipidemia.
3. History of tobacco use.
4. History of intolerance to statins.
5. Obesity.
6. OSA- compliant
7. Mild Anxiety
8. s/p appendectomy ___
9. ___ partial hysterectomy - for fibroids
10.left ACL reconstructions surgery
Social History:
___
Family History:
Per report, family history of early CAD.
Physical Exam:
ADMISSION EXAM
--------------
___: Well appearing woman in NAD, pleasant and interactive
with the conversation. Mood/affect wnl. Pt appears to be
mentating well
HEENT: EOMI, PERRL, MMM, OP clear
Neck: Supple, difficult to assess JVP
CV: RRR, nl s1s2, no m/r/g
Lungs: CTAB, no w/ra/rh, no accessory mm use, good air entry
throughout.
Abdomen: S/NT/ND, NABS, no HSM appreciated
Ext: WWP, no CCE
Neuro: AAOx3, moving all extremities spontaneously
Skin: No rashes/ecchymoses appreciated
DISCHARGE EXAM: UNCHANGED
Pertinent Results:
___ 03:00AM BLOOD WBC-6.5 RBC-3.93* Hgb-11.7* Hct-35.2*
MCV-90 MCH-29.7 MCHC-33.1 RDW-13.2 Plt ___
___ 07:31AM BLOOD WBC-5.7 RBC-3.92* Hgb-11.8* Hct-35.9*
MCV-92 MCH-30.2 MCHC-33.0 RDW-13.3 Plt ___
___ 03:00AM BLOOD Neuts-49.3* Lymphs-43.8* Monos-4.5
Eos-1.5 Baso-0.9
___ 03:00AM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-138
K-5.5* Cl-102 HCO3-26 AnGap-16
___ 07:31AM BLOOD Glucose-120* UreaN-13 Creat-0.7 Na-142
K-4.3 Cl-108 HCO3-24 AnGap-14
___ 03:00AM BLOOD cTropnT-<0.01
___ 03:00AM BLOOD Calcium-9.2 Phos-5.0* Mg-2.1
___ 07:31AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9
___ 04:46AM BLOOD Lactate-2.2*
Cardiac CathStudy Date of ___ (morning prior to
admission)
1. Two-vessel branch coronary artery disease (70% distal small
RCA, 60% D1).
2. Tortuous right subclavian.
CHEST (PORTABLE AP)Study Date of ___
No acute intrathoracic abnormalities identified.
Brief Hospital Course:
Pt was admitted to the CCU team given hypotension in the ED.
She had a cardiac cath earlier in the day, which revealed
two-vessel branch coronary artery disease (70% distal small RCA,
60% D1). No intervention was performed. She tolerated the
procedure well, but she began to feel flushed when she took a
dose of isosorbide mononitrate. Her symptoms progressed to
lightheadedness, diaphoresis, and nausea. She reported a
recurrance of chest pressure as EMS arrived with resolved with
nitroglycerin. She was initially hypotensive in the ED and was
started on IVF. Her BP has already begun to improve on
admission to the CCU. She was given additional 1L IVF on
arrival. There was no evidence of overt bleeding from her
catheterization site (right radial) or signs of concerning post
cath complications such as pericardial effusion. She remained
HD stable during her hospitalization and is being discharged on
her home medications but will not continue with isosorbide. She
will follow up with her PCP and cardiologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Nitroglycerin SL 0.3 mg SL PRN Chest pain
7. Fluvastatin Sodium 40 mg oral daily
8. Omeprazole 20 mg PO DAILY
9. Aspirin 325 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) Dose is Unknown
PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Fluvastatin Sodium 40 mg ORAL DAILY
7. Lisinopril 2.5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL PRN Chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Side effect of medication
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 while you were in the
hospital. You were admitted becuase you had low blood pressure
and side effects of starting a new medicaiton called Imdur (also
called Isosorbide Mononitrate). THis medication was stopped and
you should continue to do well. Please do not take any more of
this medication. Please follow up with your regular provider and
take your medications as directed.
Followup Instructions:
___
|
10315256-DS-10 | 10,315,256 | 29,433,976 | DS | 10 | 2132-03-20 00:00:00 | 2132-03-23 20:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Percocet / clindamycin
Attending: ___.
Chief Complaint:
Acute onset lower pelvic pain and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo gravida 1 para ___ who presents as a transfer from ___
___ presents c/o acute onset pelvic pain. For 3
days she has had diffuse cramping abdominal pain, similar to her
premenstrual symptoms, but also notes decreased appetite and
nausea. On ___ at approximately 0400 she had acute onset,
bilateral, sharp, lower quadrant pain. Intense in nature ___.
This started during vaginal intercourse and did not improve with
after. She went on to develop subjective fevers, chills,
malaise. She took 1mg PO Ativan which helped her sleep x 2 hours
but she awoke again with intense pain.
She also notes sore throat, nasal congestion.
No diarrhea, constipation, vomiting. No chest pain, cough, SOB,
DOE. No abnormal vaginal discharge, burning, itching. No new
sexual partners. ___ with boyfriend, uses condoms for
contraception. No dysuria. No weight loss. No sick contacts.
She was seen initially at urgent care and was then transferred
to ___. There she received 10mg total IV Morphine,
Ceftriaxone and Doxycyline and acetaminophen. She had a pelvic
ultrasound there notable for a small amount of pelvic free
fluid, a small possible Left dermoid cyst and a possible right
mostly simple appearing small dominant cyst. Otherwise
unremarkable US. Appendix not visualized.
Past Medical History:
PGYNHx:
LMP: pt unsure ___?
Cycle: q ~28 days
Fibroids/ Cysts/ STIs:
- h/o ? hemorrhagic cyst (pt unsure)
- h/o chlamydia in ___, h/o PID with hospitalization
- h/o genital HSV, last outbreak ___ year
- no Pap hx
Contraception: condoms
OBHx:
G1 tab d&c
PMH:
- anxiety (daily)
- depression (well controlled
PSH:
- D&C
Social History:
___
Family History:
Noncontributory
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding,
nondistended
Ext: no TTP
Pertinent Results:
___ 10:55AM BLOOD WBC-8.2 RBC-3.60* Hgb-8.8* Hct-28.0*
MCV-78* MCH-24.4* MCHC-31.4* RDW-16.0* RDWSD-45.9 Plt ___
___ 10:50PM BLOOD WBC-10.4* RBC-3.59* Hgb-8.9* Hct-28.8*
MCV-80* MCH-24.8* MCHC-30.9* RDW-16.2* RDWSD-46.9* Plt ___
___ 10:55AM BLOOD Neuts-76.0* Lymphs-14.7* Monos-7.3
Eos-1.1 Baso-0.5 Im ___ AbsNeut-6.24* AbsLymp-1.21
AbsMono-0.60 AbsEos-0.09 AbsBaso-0.04
___ 10:50PM BLOOD Neuts-77.7* Lymphs-14.4* Monos-7.1
Eos-0.1* Baso-0.4 Im ___ AbsNeut-8.06* AbsLymp-1.49
AbsMono-0.74 AbsEos-0.01* AbsBaso-0.04
___ 11:40PM BLOOD Glucose-83 UreaN-5* Creat-0.7 Na-138
K-3.5 Cl-104 HCO3-21* AnGap-17
___ 12:01AM BLOOD Lactate-1.3
Imaging:
US Appendix (___)
IMPRESSION:
Appendix not definitely visualized.
CT Abdomen and Pelvis (___)
IMPRESSION:
1. Moderate hyperdense free pelvic fluid, along with a
peripherally enhancing
1.6 cm left adnexal structure. Findings are most compatible
with a ruptured
hemorrhagic cyst.
2. Normal appendix.
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
for acute onset lower pelvic pain and fever.
She was seen at an OSH and given IM Ceftriaxone for concerns of
PID. She was transferred to ___ for further management. While
in the hospital, she was given IV antibiotics and transitioned
to PO antibiotics once tolerating PO. Her pain was controlled
with PO pain medications.
On hospital day 1, patients pain was improving, she was
tolerating PO antibiotics, and she was tolerating a regular
diet. She was then discharged home in stable condition with a
prescription for a ___nd outpatient
follow-up scheduled.
Medications on Admission:
Ativan
Lexapro
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain, fever
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth four times a day Disp #*30 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*28 Capsule Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN pain, fever
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*8 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pelvic inflammatory disease vs. ruptured hemorrhagic cyst
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 given severe abdominal pain
and concern for an infection called pelvic inflammatory disease
(PID). You were given the appropriate antibiotics through your
IV and transitioned to oral antibiotics when you were able to
tolerate things by mouth. You are currently able to take pills
and tolerate regular food without throwing up or severe pain. It
is safe for you to go home. Please take your prescribed
antibiotic for 14 days, as prescribed. You may take tylenol and
ibuprofen for pain, as needed, as well as Zofran for nausea as
needed. Please call your doctor if you develop fever >100.4,
shaking chills, severe abdominal pain not relieved by
medication, intractable vomiting that does not improve.
Followup Instructions:
___
|
10316069-DS-16 | 10,316,069 | 23,741,509 | DS | 16 | 2181-07-26 00:00:00 | 2181-07-26 18:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ & Related / aspirin
Attending: ___.
Chief Complaint:
AMS, failure to thrive
Major Surgical or Invasive Procedure:
PICC placed on ___, removed ___
History of Present Illness:
___ with history of Hep B, recent DVT (___), and failure to
thrive, who presents from home for decreased PO intake/urinary
output, confusion, and bilateral ___ pain.
Per patient, she reports bilateral lower extremity pain. She
denies v/d/CP/SOB/abdominal pain. She denies recent falls. She
reports that she cannot remember when she last ate and has been
drinking minimally.
Per son: ___
3 week history of seeming weak, confused with poor oral intake,
increased sleeping, lethargic, poor memory. She lives alone w/
___ services. He denies recent falls, fevers, CP, SOB, abd pain,
n/v/d, and recent illness. He reports 1 month ago she was hit
by someone in wheelchair while she was visiting someone in the
hospital that resulted in bilateral blood clots. She was started
on xarelto following that episode. He also reports a urinary
tract infection that was treated within the last month
In the ED, initial vital signs were: 97.9 96 123/77 20 97% RA
Exam notable for alert to name only, ___ with ___ wound.
2+ DPs Lower.
Labs were notable for WBC 6.8, H/H 11.0/33.4, Plts 145, Coags
with ___ 50.4, PTT 40.5, INR 4.5; glucose 78, Na 136, Cr 1.2
(baseline ___ troponin negative x 1, lactate 2.2. UA with
negative nitrite, negative leuks. Blood cultures taken x 2. CT
head limited by motion artifact, small vessel disease. No
evidence of hemorrhage or fracture.
Patient was given 500cc IVF and then admitted to medicine for
further evaluation of failure to thrive.
On Transfer Vitals were: 98.2 89 130/69 22 97% RA
Past Medical History:
1. Hypertension.
2. Rheumatoid arthritis.
3. Gastric surgery, secondary to ulcers.
4. Breast cyst removal.
5. Left shoulder surgery, secondary to rheumatoid arthritis.
6. Bilateral foot surgery, secondary to arthritis.
7. Hepatitis B carrier, secondary to blood transfusion.
8. Skin cancer of the scalp.
9. Coronary artery disease (sees Dr. ___
10. Recent DVT
11. Gastric cancer, resection with ___ anastamosis
- ___ years ago ___, - ___)
Social History:
___
Family History:
Significant for a father with MI at age ___. Mother with diabetes
at age ___. A brother who underwent a CABG at ___. A brother who
died of an MI at age ___. A sister who has an arrhythmia at age
___. Sister who underwent coronary artery bypass at age ___.
Physical Exam:
ON ADMISSION:
Vitals: 97.5| ___ 90| 14| 98% on RA
General: AO x 1 (person), lying in bed. Able to respond to
interviewer, intermittently refuses to engage or answer
questions.
HEENT: EOMI, mucus membranes dry
CV: RRR, no murmurs rubs or gallops
Lungs: CTAB, decreased respiratory effort. No wheezes or
crackles
Abdomen: Soft, ___ to palpation
GU: Foley in place
Ext: Multiple ecchymosis along bilateral upper and lower
extremities
Neuro: CN ___ grossly intact, moves all extremities freely,
grip ___ bilatearlly.
ON DISCHARGE
Vitals: 98.7| Tm 98.9| 120/76| 90s| 24| 93% on RA
I/Os: 1850/550-> UOP 23 mL/hr = .56 mL/kg/hr
General: AO x 1 (person), lying in bed, interactive.
HEENT: EOMI, mucus membranes moist
CV: RRR, no murmurs rubs or gallops
Lungs: CTAB, decreased respiratory effort. No wheezes or
crackles
Abdomen: distened, ___ to palpation, no rebound or
guarding
Ext: Multiple ecchymosis along bilateral upper and lower
extremities. Extremities edematous (bilateral lower extremities
and right upper extremity)
Neuro: CN ___ grossly intact, moves all extremities freely
Pertinent Results:
ON ADMISSION
___ 11:45AM BLOOD ___
___ Plt ___
___ 11:45AM BLOOD ___
___ Im ___
___
___ 11:45AM BLOOD ___ ___
___ 11:45AM BLOOD Plt ___
___ 11:45AM BLOOD ___
___
___ 11:45AM BLOOD ___
___
___ 11:45AM BLOOD ___
___ 11:45AM BLOOD ___
___ 07:22AM BLOOD ___
MICROBIOLOGY:
Blood cx pending
Urine cx: GNR > 100K
HBV viral load 1,090,000 IU/mL.
Urine Cx:
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S =>32 R
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- ___ I <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
IMAGING:
CT Head: No acute intracranial process.
CXR: plate basilar atelectasis and small bilateral pleural
effusions. The aorta is calcified. The heart size cannot
be assessed. No large pneumothorax is seen. The imaged bony
structures appear grossly intact.
RUQ US:
1. Normal examination of the liver, no evidence for biliary
obstruction,
patent hepatic vasculature
2. Cyst in the tail of the pancreas is increased in size to 1.9
cm
3. Bilateral renal cysts
CTA:
1. No evidence of central pulmonary embolism. Moderate right and
trace left pleural effusion with adjacent areas of atelectasis.
2. Small pericardial effusion. Small amount of ___
ascites
3. Gallbladder distension without fat stranding. Recommend
clinical
correlation.
4. Wall thickening from cecum extending to the hepatic flexure
concerning for colitis, infectious versus inflammatory versus
ischemic in etiology.
5. Extensive atherosclerotic disease of the abdominal aorta.
6. Small right thyroid nodule.
7. Pancreatic body and tail hypodensities appear relatively
similar to prior MRCP may represent side branch IPMNs.
8. Extensive colonic diverticulosis.
9. Small amount of air within the bladder likely due to recent
instrumentation/Foley catheterization. Recommend clinical
correlation.
MRCP: Mild dilated gallbladder with associated gallbladder wall
thickening, pericholecystic fluid, gallstones and sludge.
However, the gallbladder was thickened and collapsed on the
ultrasound 30 hr prior to this study. Therefore, the short time
frame makes acute cholecystitis less likely. The appearance of
the gallbladder can be explained by the patient's fasting state
and third spacing superimposed over chronic cholecystitis. The
patient is
still at risk for developing acute cholecystitis however.
No evidence of cholangitis.
Mild colitis of the cecum and ascending colonl, similar to the
patient's recent CT.
Small volume ascites. Bilateral small pleural effusions, with
associated right lower lobe atelectasis.
Left mid to lower kidney cyst with hemorrhagic/proteinaceous
content. This can be ___ on subsequent imaging to
differentiate from a solid lesion. Minimally complex right upper
pole renal cyst.
EKG: without significant change from previous EKG
ON DISCHARGE:
___ 09:32AM BLOOD ___
___ Plt ___
___ 09:32AM BLOOD Plt ___
___ 09:32AM BLOOD ___ ___
___ 09:32AM BLOOD ___
___
___ 09:32AM BLOOD ___
___ 09:32AM BLOOD ___
___ 03:40PM BLOOD ___
___ 03:40PM BLOOD ___
___
___ 03:40PM BLOOD ___ *
___ 03:40PM BLOOD ___
___ 08:09AM BLOOD ___
Brief Hospital Course:
___ with history of Hep B, recent DVT (___) who presents from
home for decreased PO intake/urinary output, confusion, and
failure to thrive.
#Sepsis/hypotension: soft BPs (88/65 - 110s/60s), temp of 100.0.
Multiple sources of infection: UTI, c.diff, hepatitis B,
possible acute cholecystitis overlying chronic cholecystitis.
PICC placed on ___. Cortisol 10.2 in AM, 22.6 random
(unconcerning for adrenal insufficiency).
- Continue PO vancomycin 125 mg PO/NG Q6H (day 1 = ___ for
c.diff
- Start bactrim DSS 1 tab BID x 3 days (day 1 = ___
# UTI: UA on admission normal, on ___ UA with large
leukocytes, neg nitr., many bacteria. REpeat UA with mod leuk,
16 WBC. Urine cx with Klebsiella, Enteroccus - sensitive to
bactrim
- Completed zosyn for UTI 2.25 g IV Q6H (day 1= ___, last
day ___
- Start bactrim DSS 1 tab BID x 3 days (day 1 = ___
# C.diff: (+) on ___. Multiple BM on admission, down to ___
loose BM/day on discharge. IV flagyl discontinued on ___.
Continue PO vancomycin 125 mg PO/NG Q6H (day 1 = ___ for
c.diff.
# Hepatitis B: viral load returned at 1,090,000 IU/mL.
- started on Entecavir 0.5 mg PO DAILY (day 1 ___.
Hepatology to follow up to ensure viral load and LFTs
downtrending.
# Abdominal distension: increasing abdominal distension. Ascites
vs. toxic megacolon (unlikely WBC stable, no abdominal pain).
Ascites likely due to chronic poor
nutrition/hypoalbuminemia/chronic liver failure.
- f/u nutrition recommendations
# ___: Cr of 1.4, baseline from previous admissions near 1.0.
BUN: Cr > 20, likely ___ azotemia. Cr Improved to 1.1 on
discharge w/ hydration Likely in the setting of poor PO intake,
___ studies. UOP 23 mL/hr = .56 mL/kg/hr on ___
#Liver failure: Acute on chronic. No abdominal pain, guarding or
rebound endorsed on physical exam. RUQ u/s with pacnreatic cyst
(increased from previous). CT abd on ___ concerning for
gallbladder distension, colitis. MRCP on ___ wet read showed
no cholangitis, likely chronic cholecystitis. Elevation in LFTs
consistent with prior hospitalizations (per ___
records) and not significantly changed. ___ Ab (+), 1:20
- not sig concerning for autoimmune hepatitis. Hep B viral load
1.09 million.
# Cholecystitis: possibly acute on chronic. MRCP showed chronic
cholecystitis, no cholangitis. In setting of sepsis, will hold
further imaging until other medical issues more resolved. LFTs
downtrending
# Altered mental status: 3 week history of decreased PO intake,
poor urinary output. LIkely multifactorial: delirium (infection,
possible depression) with underlying chronic dementia. ABG on
___ showed respiratory alkalosis with lactate 3.1, CTA
negative for PE. Urine cx positive for Klebsiella and
Enterococcus C.diff (+). Now largely returned to baseline status
# H/o DVT: previously on anticoagulation with rivaroxiban. INR
of 2.2 on discharge. CTA on ___ negative for PE
- Continue warfarin to 1 mg qD
# Failure to thrive: likely multifactorial - physical
limitations (lives alone, ___, possible depression, dementia.
Continue ensure TID w/ meall, magic cup TID
# Anemia: Macrocytic, H/H: 11.0/33.4. From prior admissions,
baseline appears near 10. Likely secondary to poor PO
intake/nutritional status B12 1186 (high), peripheral smear w/o
sig abnormalities. Now stable ___, continue home
cyanocobalamin, folic acid
# Rheumatoid arthritis: continue home prednisone 5mg qD,
oxycodone 2.5 mg q4 hr PRN
# HTN: discontinued metoprolol
# CAD: discontinued simvastatin
TRANSITIONAL INFORMATION:
- discontinued on metoprolol and simvastatin during admission,
would recommend continued discontinuation on discharge
- currently being anticoagulated with warfarin 1 mg qD (last INR
check on ___ of 2.2) for recent DVT (___). Ongoing
anticoagulation should be discussed with pt and family by PCP
- ___ continue vancomycin 125 mg PO q6H for 14 days AFTER her
last diarrhea stops. Patient still having ___ diarrheal bowel
movements on day of discharge.
-discharged on bactrim DS 1 tab BID 3 days (last day on
___, entecavir (ongoing, will follow up with hepatology for
confirmation of suppression of viral load and decreasing LFTs)
- patient previously living alone with ___ services. Patient
cannot return home alone and will likely need to go to a long
term care facility.
# Code: DNR/DNI, per HCP
# Emergency Contact: (HCP) ___ Cell: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 10 mg PO HS
2. Calcium 600 + D(3) (calcium ___ D3) 600
mg(1,500mg) -200 unit oral qd
3. FoLIC Acid 1 mg PO DAILY
4. Cyanocobalamin 100 mcg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Hydrocortisone (Rectal) 2.5% Cream ___ID
7. PredniSONE 5 mg PO DAILY
8. Vitamin D 50,000 UNIT PO 2X/WEEK (___)
9. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Discharge Medications:
1. Cyanocobalamin 100 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydrocortisone (Rectal) 2.5% Cream ___ID
4. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
5. PredniSONE 5 mg PO DAILY
6. Entecavir 0.5 mg PO DAILY
7. Vancomycin Oral Liquid ___ mg PO Q6H
Please take first dose ___ at 1800. Last dose on ___
8. Warfarin 1 mg PO DAILY16
9. Calcium 600 + D(3) (calcium ___ D3) 600
mg(1,500mg) -200 unit oral qd
10. Vitamin D 50,000 UNIT PO 2X/WEEK (___)
11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 6 Doses
Please take first dose on ___. Please take last dose on
___
Discharge Disposition:
Extended Care
___:
___
Discharge Diagnosis:
Primary Diagnosis
1. Sepsis
2. Urinary tract infection
3. C. diff infection
4. Hepatitis B
5. Failure to thrive
6. ___
7. Acute confusion with baseline dementia
Secondary Diagnosis
1. Liver failure, acute on chronic
2. Chronic cholecystitis
3. H/o DVT
4. Anemia
5. Rheumatoid arthritis
6. HTN
7. CAD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you. You were admitted for
confusion and decreased oral intake. During your admission, we
were able to determine that you had a urinary tract infection,
clostridium difficile infection, and hepatitis B infection. Your
infections were treated with antibiotics and an ___
medication. As your infections were treated, your mental status
returned to normal and we felt comfortable discharging you to
rehab.
Please continue to take your vancomycin, bactrim, and entecavir.
Thank you for allowing us to care for you,
Your ___ Care Team
Followup Instructions:
___
|
10316080-DS-10 | 10,316,080 | 25,890,514 | DS | 10 | 2150-12-04 00:00:00 | 2150-12-04 16:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Right ___ prosthetic patella fracture
Major Surgical or Invasive Procedure:
___ - ORIF Right ___ patella fracture
History of Present Illness:
___ history of HTN, HL, afib on warfarin who presents to the ED
for evaluation of right patellar fracture. He states that he was
trying to get up and out of bed this am when his knee buckled
under him. Patient gentle lowered himself to the ground. He was
taken to his local ED at ___ where he was
transferred to ___ for higher level care.
Past Medical History:
HTN
HL
Afib on Warfarin
Prior To knee replacement done at ___
approximately ___
___ History:
___
Family History:
NC
Physical Exam:
Gen: NAD
MSK:
RLE long leg cast c/d/i, SILT over distal toes, toes wwp
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a R periprosthetic patella fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF Right ___ patella
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The 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 RLE, 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:
warfarin 5 mg Qday
Aspirin 81 Mg Qday
Vitamin D 1000 Units
HCTZ 25 Mg Qday
lisinopril 40 mg qDay
atenolol 50 mg tablet
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
3. Atenolol 50 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4h to q6h prn
Disp #*30 Tablet Refills:*0
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Warfarin 5 mg PO DAILY16
10. Senna 8.6 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R ___ patellar fracture
Discharge Condition:
Stable
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:
- Weight bearing as tolerated in R lower extremity in long leg
cast
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 continue Warfarin as you were before surgery, with
monitoring by your PCP. INR goal 2.0-3.0
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.
- Cast must be left on until follow up appointment unless
otherwise instructed
- Do NOT get cast wet
Physical Therapy:
___
WBAT RLE
Treatments Frequency:
Wound monitoring
___
WBAT RLE
Followup Instructions:
___
|
10316237-DS-31 | 10,316,237 | 24,463,773 | DS | 31 | 2170-11-28 00:00:00 | 2170-12-05 17:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
EGD/Colonoscopy
Capsule Study
Bilateral Ureteral Stents
History of Present Illness:
___ male with history of bladder cancer, CAD, possible
asthma (not on home O2, rarely uses PRN albuterol) presenting
with dyspnea on exertion.
He traces the onset of his symptoms to swelling in his
testicular area after a catheter exchange on the ___.
He was initially treated with cephalexin and then more recently
ciprofloxacin (today is day 5 of 7) for presumptive orchitis. No
pain at the site, just swelling. Around the time of this
catheter exchange he noted that he was starting to get more
short of breath with exertion. No chest pain or pressure,
syncopal symptoms, nausea or emesis. He was seen by his PCP ___
___, and his SOB was presumed due to asthma and anemia, but not
heart failure. He continue to have progressive dyspnea and
orthopnea on exertion until today.
Today, patient was walking very short distance home and became
significantly short of breath. Home O2 sat monitors showed O2
saturation in the ___. Patient called the patient's physician,
and was referred to the emergency room for further workup.
Denies fever, chills, nausea, vomiting, chest pain, abdominal
pain, melena, hematochezia, hematuria.
In the ED, initial vitals were:
- Labs were significant for BUN/Cr 48/3.3, sodium 131, K 5.2,
HCO3 15, Trop 0.08, BNP 33118, H/H ___
- CXR showed pulmonary edema and small bilateral effusions
- Bedside echo showed trace pericardial effusion, large L
pleureal effusion, moderate R pleural effusion
- The patient was given 20 mg IV lasix
Vitals prior to transfer were: afebrile, 66, 128/59, 14, 98% 3L
Upon arrival to the floor he endorses the above story. Currently
with significant dyspnea but satting well on room air.
Past Medical History:
# Bladder cancer ___ (recurrent, multifocal) s/p BCG
treatment
- Path ___ Papillary urothelial carcinoma, low grade no LP
invasion
- Path ___ R lateral wall papillary urothelial carcinoma
high-grade no invasion
- s/p mult TURBT ___
- last cystoscopy ___: unremarkable
# BPH (bladder incontinence with chronic indwelling foley ___
to
prevent night time incontinence)
# Urosepsis ___
# Recurrent UTI (last ___ - pansens Klebsiella)
# R epididymitis ___
# L epididymitis c/b urosepsis requiring orchiectomy (___)
- c/b L hemiscrotal abscess (MSSA, enterococcus) due to
communicating vas remnant
# HTN
# CAD
- Echo (___): EF of 60%, mild ___, elongated LA, mild sym LVH,
1+MR
# CKD, stage IV (Cr 2.2-2.5 recent baseline)
# s/p Lap chole ___
# OA
# diverticulosis
# h/o gout
# Duodenal ulcer ___
# H. pylori late ___ s/p triple therapy
# Severe Mitral Regurge with Flail Leaflet
# CKD V
Social History:
___
Family History:
Mother had diabetes that was diet controlled. Father had lung
problems after exposure to gas in WWI.
Physical Exam:
ADMISSION PE:
Vitals: 97.8 151/73 78 20 96% RA
General: Alert, oriented, wheezy in mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD, difficult to assess JVP given neck habitus
and shallow inspiration
CV: Regular rate and rhythm, normal S1 + S2, ___ SEM heard
loudest at RUSB
Lungs: Significant wheezing, mild rales in bilateral bases
Abdomen: Soft, non-tender, obese, bowel sounds present, no
rebound or guarding
GU: foley
Ext: Warm, well perfused, 1+ pulses, ___ pitting edema almost
to knee
Neuro: CNII-XII intact, no focal motor deficit, gait deferred.
DISCHARGE PE:
VS: 99.6; 91-142/40-70; 62-72; 18; ___ RA
Wt: 102.9 kg bed weight (97.1kg standing) (113kg Bed weight on
admission)
I/O: 1260/1000; 240/200 since MN
GENERAL: Well appearing obese gentleman in NAD.
HEENT: NCAT. Sclera anicteric. EOMI.
NECK: JVD 8-10cm
CARDIAC: RRR, ___ systolic ejection murmur ___ heard at LSB, no
Rubs, gallops
LUNGS: Clear, poor inspiratory effort, poor air movement
throughout
ABDOMEN: Obese, distended, Soft, NTND. normoactive BS. No HSM
appreciated
EXTREMITIES: 1+ pitting edema to knee. WWP
GU: foley draining urine
SKIN: No stasis dermatitis, ulcers, scars.
Pertinent Results:
ADMISSION LABS:
___ 09:49PM BLOOD WBC-8.4 RBC-2.90* Hgb-9.0* Hct-28.8*
MCV-100*# MCH-31.0 MCHC-31.2 RDW-14.7 Plt ___
___ 09:49PM BLOOD Neuts-71.3* ___ Monos-7.6 Eos-1.7
Baso-0.8
___ 09:49PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-OCCASIONAL
___ 09:49PM BLOOD ___ PTT-25.5 ___
___ 09:49PM BLOOD Glucose-128* UreaN-48* Creat-3.3* Na-131*
K-5.2* Cl-101 HCO3-15* AnGap-20
___ 09:49PM BLOOD CK(CPK)-265
___ 09:49PM BLOOD CK-MB-9 cTropnT-0.08* ___
___ 07:00AM BLOOD Calcium-8.7 Phos-4.6* Mg-1.9
___ 07:52AM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-15.2* RBC-2.66* Hgb-8.2* Hct-23.8*
MCV-90 MCH-30.7 MCHC-34.3 RDW-14.8 Plt ___
___ 07:00AM BLOOD Neuts-86.1* Lymphs-6.7* Monos-6.4 Eos-0.8
Baso-0.1
___ 07:00AM BLOOD Glucose-127* UreaN-81* Creat-4.5* Na-132*
K-5.5* Cl-100 HCO3-21* AnGap-17
___ 07:00AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.0
Urinalysis:
___ 12:42PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 12:42PM URINE Blood-LG Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 12:42PM URINE RBC-163* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0
MICRO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 12:42 pm URINE Source: Catheter.
URINE CULTURE (Pending)
STUDIES/IMAGING:
CXR: Interval development of mild pulmonary edema and small
bilateral pleural effusions.
TTE: The left atrium is moderately dilated. There is severe
symmetric left ventricular hypertrophy. The left ventricular
cavity size is top normal/borderline dilated. There is mild
regional left ventricular systolic dysfunction with XXX.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size is normal. with borderline normal free
wall function. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is partial XXX mitral
leaflet flail. Severe (4+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild symmetric LVH with probable mild hypokinesis of
the basal to mid inferolateral wall. There is partial flail of
the posterior leaflet of the mitral valve with severe mitral
regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images unavailable for review) of
___, the severity of mitral regurgitation has increased and
the valve is partially flail.
Renal US: Bilateral moderately severe hydronephrosis and
decreased renal sizes compared to the prior study in ___.
CT Abd/Pelvis:
1. Moderate bilateral hydronephrosis and hydroureter with no
obstructing
stone. Concurrent progressive renal atrophy suggests chronic
course.
2. Small irregularly contoured bladder. Mass cannot be excluded
based on this
study.
3. Small bilateral pleural effusions.
4. Possible retained endoscopic capsule within the cecum.
Correlate with
clinical history.
Pharmacologic Stress/Perfusion Imaging: Non-anginal type
symptoms in the absence of ischemic EKG changes. Nuclear report
sent separately.
Probably normal perfusion with moderate enlargement of the left
ventricle and ejection fraction of 48%.
KUB ___: 1. The capsule appears to be lodged in the
ascending colon for 6 days,
possibly within a diverticulum.
2. Interval changed configuration of right double-J catheter,
unclear if in the bladder or distal ureter.
Brief Hospital Course:
___ with history of bladder cancer, CAD, possible asthma (not on
home O2, rarely uses PRN albuterol) presenting with dyspnea on
exertion likely due to new onset heart failure due to severe
mitral regurge with flail valve. Hospital course complicated by
anemia with concern for GI bleed, worsening renal function and
hydronephrosis (likely chronic) for which stents were placed.
# Acute decompensated heart failure: Patient presented with
worsening dyspnea and edema. BNP 33k up from 16K 3 weeks prior.
Wt also up (228.5 lbs from 222 at PCP 6 days prior). Patient
underwent TTE and TEE which showed new severe mitral regurge
without evidence of ischemia. Echo also notable for LVH (concern
for infiltrative disease though SPEP, UPEP and ferratin
unrevealing of cause). Patient was diuresed with 40mg IV lasix
BID with good effect and symptomatic improvement. He was also
started on Imdur 60mg and Hydralazine 25mg TID for afterload
reduction. He underwent evaluation for MVR with CSurg and
consideration for mitral clip placement with interventional
cardiology. Patient was considered a poor operative candidate
___ hx of malignancy, CKD and general comorbidities. Initially
planned for patient to undergo mitral clip placement, however
patient developed worsening anemia and renal function.
Furthermore, patient's volume and respiratory status remained
stable on ___ PO torsemide daily. Therefore, plan to defer
possible intervention to outpatient. Will follow up with Dr.
___ to eval functional status and need for trial of mitral
clip or possibly continuation of oral diuretic for symptomatic
management. Patient's weight on discharge was 98.1kg (standing).
Discharge diuretic regimen Torsemide 20mg PO daily.
# Chronic kidney disease: Renal function at baseline on
admission (Cr 3) but trended up with diuresis. This admission,
felt component of diuresis and cardiorenal contributing to
worsening renal function. Unfortunately, given MR described
above, unable to maintain patient's respiratory status without
small volume diuresis so goal diuresis with daily I/O's net even
this admission which was effectively accomplished with ___
PO torsemide daily. Patient seen and followed by nephrology
service this admission and felt that patient with significant
baseline CKD ___ most likely ___ chronic hypertension and
recommended maintatin SBP>110. SPEP/UPEP negative. Renal
ultrasound showed moderate bilateral hydronephrosis that was
likely chronic in nature. NCCT abdomen pelvis was performed
which showed no evidence of stone or obstructive mass and
patient with chronic indwelling foley draining urine. Patient
underwent stent placement with urology this admission in the
hope that any relief of the hydro could slightly improve the
patient's renal function. Also discussed possibility of dialysis
with patient's family. Given multiple comorbities, patient is
likely a poor dialysis candidate, however patient and family
expressed continued interest in a trial of dialysis if
indicated. Cr was 4.5 at discharge. Patient will continue to
follow with nephrology after discharge.
# Urinary Tract Infection: patient complained of bladder spasms/
penile discomfort which coincided with an elevated WBC to 15
from roughly 11 the day prior. UA was concerning for urinary
tract infection, and while culture was pending, we started
empiric treatment for complicated UTI with Ciprofloxacin (___nd date ___. Final culture results should be
followed up at his extended care facility.
# Anemia - patient with black BM on ___ but states often is
black as taking iron pills at home. H/H coninued to trend down
with nadir of 6.8. Patient transfused 2U pRBCs with appropriate
bump, however given hx of duodenal ulcer and guiac positive
stools, GI consulted. Patient underwent EGD, colonoscopy and
capsule study which showed no evidence of acute bleed. It did
show gastritits for which the patient was continued on
omeprazole. LDH/haptoglobin not suggestive of hemolysis.
Patients hemaglobin remained stable 8.0-8.5. Feel that anemia
likely ___ CKD. Can consider possible EPO injection when seen by
renal as outpatient.
**Of note, capsule noted to be persistently in ascending colon
on KUB ___. Per GI, no intervention needed and will likely pass
on its own, however patient should undergo KUB prior to any MRI
in the future.
# Atrial fibrillation: Per patient this is not a new diagnosis.
Remained rate controlled with metoprolol 50XL and had periods in
NSR. CHADS2= 3. Therefore, after discussion with patient and
son, ___, patient was initated on warfarin for anticoaulation.
Patient started on 5mg PO Warfarin qD on ___ with plan to
monitor INR and adjust warfarin dosing as needed. Discharged
with therapeutic INR with 2mg daily.
# Abdominal Pain/Bloating - initial concern for illeus vs
obstrcution based on Xray ___. Patient continued to pass flatus
and had multiple BMs this admission. Resolved.
# Chest Pressure - patient developed symptoms concerning for
angina on ___, however given poor renal function, would be very
poor cath candidate. EKG unchaged from admission without
evidence of acute ischemia. Repeat troponins elevated to 0.15,
however patient has sig renal disease. Patient underwent pharm
stress with perfusion testing negative. Pharm stress test normal
on ___. Currently CP free. Continued CAD treatment as above
with BB, ASA, statin.
# Coronary artery disease: Continued BB this admission at 50mg
XL. Also continued ASA 81 and initiated patient on atorvastatin
40mg qHS.
# Orchitis - on admission, patient undergoing active treatment
for possible orchitis given urologic hx per PCP. Continued cipro
to complete ___ut also ? if in fact only scrotal
edema in setting of admission for CHF. Improved this admission.
TRANSITIONAL ISSUES:
- Weight on Discharge: 98.1 kg (standing)
- Diuretic Dosing on Discharge: Torsemide 20mg PO daily
- Trend INR and adjust warfarin dosing as needed
- F/U with Neprology
- F/U with Dr. ___ in Cardilogy
- F/U with Urology
- Per GI, retained capsule in ascending colon. Will likely pass
eventuall, but would obtain KUB prior to any MRI in future
- Noted to have ? R ureter stent migration. Urology aware and
will plan for future operative intervention to either remove or
reposition stents
- patient had positive UA on day of discharge and was started
empirically on PO ciprofloxacin to treat for complicated UTI.
Urine culture results should be followed up at extended care
facility.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Ciprofloxacin HCl 250 mg PO Q12H
3. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN
scalp itching
4. Lidocaine 5% Ointment 1 Appl TP Q4WEEK
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Aspirin 81 mg PO DAILY
10. Bisacodyl 5 mg PO DAILY:PRN constipation
11. Ferrous Sulfate 325 mg PO BID
12. lactobacillus acidophilus unknown oral DAILY
13. Miconazole 2% Cream 1 Appl TP BID
14. Multivitamins 1 TAB PO DAILY
15. Senna 8.6 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl 5 mg PO DAILY:PRN constipation
3. Ferrous Sulfate 325 mg PO BID
4. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN
scalp itching
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO BID:PRN pain
9. Senna 8.6 mg PO BID
10. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
11. Belladonna & Opium (16.2/30mg) ___ID:PRN bladder
spasm
RX *___ alkaloids-opium [Belladonna-Opium] 30 mg-16.2 mg
1 suppository(s) rectally BID:PRN Disp #*24 Suppository
Refills:*0
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
13. HydrALAzine 50 mg PO TID
RX *hydralazine 50 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
14. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
15. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
17. lactobacillus acidophilus 0 ORAL DAILY
18. Lidocaine 5% Ointment 1 Appl TP Q4WEEK
19. Miconazole 2% Cream 1 Appl TP BID
20. Warfarin 2 mg PO DAILY16
This is a new medication to treat your abnormal heart rhythm,
atrial fibrillation.
RX *warfarin 1 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*0
21. Torsemide 20 mg PO DAILY
This is a new medication to treat the extra fluid in your body.
RX *torsemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
22. Ciprofloxacin HCl 500 mg PO Q24H Duration: 6 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- acute on decompensated diastolic CHF ___ mitral regurge
Secondary Diagnosis:
- Chronic Kidney Disease Stage 5
- Orchitis
- Anemia
- Atrial Fibrillation
- Hydronephrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted for shortness of breath which we feel is due
to acute congestive heart failure due to a leaky valve in your
heart which resulted in fluid build up in your lungs. You were
given medications to make you pee out the excess fluid and your
breathing improved. You were then started on a stable dose of
medication to make you pee at home to keep the fluid off. You
were also evaluated by the cardiologists to consider fixing the
valve in your heart. As your breathing was stable, we feel that
you can follow up as an outpatient to determine if there is a
need for this procedure.
You were also seen by the kidney doctors for your ___
kidney function. You will need to follow up with them after you
are discharge. You were also seen by the urologists who placed
stents with the hopes that they can improve your renal function.
You were seen by the GI doctors as there was a concern that you
were bleeding in your GI tract. You underwent an endoscopy,
colonoscopy and video study which was negative for any evidence
of bleeding.
We wish you all the ___ in the future.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10316267-DS-11 | 10,316,267 | 27,710,095 | DS | 11 | 2143-03-19 00:00:00 | 2143-03-28 20:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Local Anesthetics Classifier / Shellfish Derived / Novocain
Attending: ___.
Chief Complaint:
breast pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o ovarian cancer and DCIS presenting with R breast and
shoulder pain for the past ___ months. She describes a stabbing
pain in her deltoid, right bicep and lateral breast that have
been getting worse. Her breast was reportedly not very red, but
swollen and painful; she denies systemic fevers, chlls, or
nipple discharge. She says she went to the ___ ED 10 days prior
to admission where she received a chest X-ray and breast
ultrasound both of which were normal. She went to her PCP ___
___ who diagnosed her with mastitis and gave her Augmentin for
7 days. She completed this regimen and says she felt better but
not quite back to normal. The day of presentation, she felt
slightly worse so she came to the ___ ED. Vital Signs: Temp:
97.8 °F (36.6 °C), Pulse: 70, RR: 20, BP: 172/68, O2Sat: 98%
r/a. Given Vancomycin 1g IV. RUE ultrasound was negative for
thrombosis but showed bilateral supraclavicular lymph nodes
largest on left 2.6 x 2 cm, largest single/confluence of nodes
on right 2.5 x 1.9 cm.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, Denies
chest tightness, palpitations, lower extremity edema. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, abdominal pain, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias. All other systems negative.
.
Past Medical History:
ONCOLOGIC HISTORY:
1. ___, right ovarian cyst CA-125 greater than 1000
preoperatively.
2. ___ CT with marked omental caking measuring greater than
6 cm possible involvement of the rectal wall. She underwent
exploratory laparotomy TAH-BSO with optimal debulking.
Diagnosed
with stage III pap serious primary peritoneal cancer grade 3.
3. ___ six cycles of adjuvant chemo with carboplatin and
paclitaxel. Initial CA-125 response and then subsequent
progression.
4. ___ two cycles of gemcitabine without documented
progression.
5. ___ one cycle of Doxil CA-125 increased, so she was
switched to a different agent.
6. ___ to ___ weekly Taxol with initial good CA-125
response and then subsequent progression by CA-125.
7. ___ Alimta CA-125 progression.
8. ___ Arimidex progressing by CA-125 is rising since.
___. ___. She has been followed without active treatment.
CA-125 was initially stable on the 1500 to ___ range but then
subsequently began rising about ___. ___. CT torso documented "mixed response" with some
decreasing size of retroperitoneal lymph nodes compared to the
prior one.
___. ___t ___ PET avid lymphadenopathy in the
left
groin and right supraclavicular, also PET avid retroperitoneal
lymph nodes. ___ left inguinal lymph node biopsy positive
for malignant cells consistent with PET metastatic disease and
the patient is now on Pap serous carcinoma. Tumor cells
immuno-active for keratin AE 1/AE3, CAM 5.2, CK7, Wt - 1 and
estrogen receptor negative for CK20.
.
PAST MEDICAL AND SURGICAL HISTORY:
DCIS S/P LUMPECTOMY
DIABETES TYPE II
GASTROESOPHAGEAL REFLUX
HYPERLIPIDEMIA
HYPERTENSION
HYPOTHYROIDISM
OVARIAN CANCER
OVARIAN CYSTS
H/O HIATAL HERNIA
FATTY LIVER DISEASE
Social History:
___
Family History:
aunt with MI in her ___, otherwise negative for malignancies
Physical Exam:
Vitals - T: 97.2 BP: 180/74 HR: 67 RR: 16 02 sat: 98RA Wt
200.0lbs
GENERAL: NAD, obese, bilingual in ___ and ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM,
good dentition, nontender supple neck, no LAD, no JVD
BREAST/SKIN: Diffuse mild swelling and mild erythema around the
nipple area. Skin has pale pinkish hue and blanchable; line
drawn with black pen ___. Very minimal tenderness, No
nipple discharge, well-healed scar from previous excition at 7
o'clock. No nodules or abcesses appreciated
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: no focal deficits.
Pertinent Results:
admission labs
___ 05:10PM BLOOD WBC-5.7 RBC-4.33 Hgb-10.9* Hct-36.6
MCV-85 MCH-25.2* MCHC-29.8* RDW-14.2 Plt ___
___ 05:10PM BLOOD Neuts-64.8 ___ Monos-3.6 Eos-1.8
Baso-0.8
___ 05:10PM BLOOD Glucose-110* UreaN-11 Creat-0.6 Na-141
K-4.0 Cl-107 HCO3-27 AnGap-11
___ 05:33PM BLOOD Lactate-1.2
.
discharge labs
___ 10:51AM BLOOD WBC-5.0 RBC-4.07* Hgb-10.7* Hct-33.4*
MCV-82 MCH-26.2* MCHC-31.9 RDW-14.9 Plt ___
___ 10:51AM BLOOD Neuts-63.9 ___ Monos-4.9 Eos-2.0
Baso-0.2
___ 06:36AM BLOOD Glucose-128* UreaN-10 Creat-0.6 Na-143
K-4.4 Cl-104 HCO3-31 AnGap-12
.
micro
blood cultures - no growth
.
studies
RUE ultrasound
RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: Gray-scale and Doppler
sonograms of
the right subclavian and left subclavian veins show normal flow
and waveforms.
There is normal compression of the right internal jugular, right
axillary,
right brachial, right basilic, and right cephalic veins which
show normal
compressibility, flow, and augmentation. There is no evidence of
DVT in the
right upper extremity veins. Bilateral supraclavicular lymph
nodes are noted,
the largest on the left measures 2.6 x 2 cm. Confluence of lymph
nodes at the
right supraclavicular region measures approximately 2.5 x 1.9
cm. These are
worrisome for malignancy.
IMPRESSION:
1. No evidence for venous thrombosis.
2. Right supraclavicular lymphadenopathy worrisome for
malignancy.
.
R breast ultrasound
IMPRESSION
1. No evidence of breast abscess.
2. Hypodense irregular area at the post surgical site in the
right lower
outer breast, likely represents post-surgical scar. However,
this study is not
sensitive to differentiate post-surgical changes from recurrent
mass in the
setting of prior DCIS. Please correlate with prior mammograms
for the same.
Brief Hospital Course:
___ h/o ovarian cancer and DCIS presenting with R breast pain
concerning for mastitis
.
# breast pain- DDx includes infectious mastitis (simple mastitis
vs. complicated mastitis with abscess) vs noninfectious mastitis
vs. underlying malignancy vs adhesions from prior surgery vs
neuropathic pain. She underwent a right upper extremity
ultrasound which was negative for clot but did show right
supraclavicular lymphadenopathy concerning for malignancy. She
also underwent a right breast ultrasound which did not show any
evidence of abscess (see results). She was treated with
vancomycin during admission with clinical improvement. She
remained afebrile throughout admission. She was discharged with
plans to complete 2 weeks of bactrim and to follow up with her
outpatient providers.
.
#DCIS s/p lumpectomy ___ years ago at ___. Patient underwent R.
breast ultrasound which did not show any evidence of abscess but
it did show an hypodense irregular area at the post surgical
site in the right lower outer breast that was unable to
differentiate from post surgical changes from recurrent mass in
the setting of prior DCIS. The patient has plans to follow up
with her outpatient oncologist and further breast imaging will
likely need to be obtained in addition to possible lymph node
biopsy.
.
#DM2 - held metformin while in house but was restarted upon
discharge
.
#HTN - continued valsartan
.
#Stage III Ovarian CA - in remission
.
#Hypothyroidism - continued home amour thyroid
.
transitional issues
- no labs or studies pending at time of discharge
- patient will need to follow up with outpatient oncologist. she
will likely need further breast imaging and possible lymph node
biopsy
- patient full code during admission
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs(s)
inhaled q ___ h prn
AMOXICILLIN-POT CLAVULANATE - 875 mg-125 mg Tablet - 1 Tablet(s)
by mouth twice a day
BUSPIRONE - 10 mg Tablet - 0.5 (One half) Tablet(s) by mouth
twice a day
DEXLANSOPRAZOLE [DEXILANT] - 30 mg Cap, Delayed Rel.,
Multiphasic
- 1 Cap(s) by mouth once a day
DICLOFENAC SODIUM [SOLARAZE] - 3 % Gel - apply to affected area
twice a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2
puffs(s) by mouth twice a day
LAB TEST FOR CA-125 - - once
LOSARTAN - 50 mg Tablet - ___ Tablet(s) by mouth daily
METFORMIN - 500 mg Tablet - 1 tab Tablet(s) by mouth once a day
METRONIDAZOLE - 0.75 % Gel - apply to affected skin once a day
THYROID (PORK) [___ THYROID] - (Prescribed by Other
Provider;
per patient) - 30 mg Tablet - 2 Tablet(s) by mouth daily
Medications - OTC
ACETAMINOPHEN - 650 mg Tablet Extended Release - 1 Tablet(s) by
mouth three time a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - as
directed once a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day
WHEY [IMMUNOCAL] - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing.
2. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
4. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Armour Thyroid 60 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
9. Dexilant 30 mg Cap, Delayed Rel., Multiphasic Sig: One (1)
Cap, Delayed Rel., Multiphasic PO once a day.
10. losartan 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: mastitis
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 while you were in the hospital.
You were admitted because you were having breast pain. You were
started on intravenous antibiotics. You had an ultrasound of
your breast which did not show any abscess. Ultimately, you were
switched to oral antibiotics and were discharged in stable
condition.
.
The following changes have been made to your medication regimen.
Please START taking
Sulfameth/Trimethoprim DS 1 TAB by mouth twice a day
.
No other changes to your medications.
.
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
Followup Instructions:
___
|
10316305-DS-10 | 10,316,305 | 23,253,710 | DS | 10 | 2132-09-26 00:00:00 | 2132-09-27 10:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Details obtained from ___ note. Also obtained history
from wife and daughter which corroborates story below.
Mr. ___ is a ___ year old ___ male with a pmh of
frontotemporal dementia, parkinsonism, paranoid schizophrenia,
GERD, and chronic Hep C who presented from ___ with
recurrent fevers since ___ without a clear source.
He has become more weak, and decreased in mobility. He had mild
resp symptoms with a weak cough: Chest X-ray negative (concern
for ongoing aspiration, and new inability to chew his food). CBC
with WBC of 11. UA benign per report. Flu swab was negative and
he was empirically treated with Tamiflu. Yesterday he was given
one dose of Levaquin 500 mg empirically, but today remained
febrile to 102 rectally.
Baseline status with very diminished: difficulties with
mobility, needs to be fed, could walk with assistance from his
room to the dining room, but stopped about 3 weeks ago per CAN.
He can barely answer ___ questions, with yes or no at baseline.
He is stiff, immobile most times, and incontinent.
Chest X-ray stat today:
FINDINGS: One portable view. Comparison with the previous study
done ___. Lung volumes are low and there is motion
artifact. Minimal streaky density at the lung bases consistent
with subsegmental atelectasis persists. The lungs appear
otherwise clear. The heart and mediastinal structures are
unchanged. The bony thorax is grossly intact.
IMPRESSION: Limited study demonstrating no acute change.
In the ED, initial vitals: 100 99 130/89 28 96% 2L Nasal
Cannula. Temperature reached as high as 103.1. He was given
tylenol, Cipro, and a foley was placed. A head CT and CXR were
performed and were unremarkable. Vitals prior to transfer: 99.9
88 123/84 26 95%
Currently, he is rigid. Tracking me with his eyes around the
room. Mouth open. Non conversant.
ROS: unable to obtain.
Past Medical History:
Parkinsonism (failed trial of sinemet)
Insomnia
Chronic Hepatitis C
BPH
Senile depressive disorder
Asthma
GERD
Aspiration (chronic)
Frontotemporal dementia
Paranoid Schizophrenia
Social History:
___
Family History:
Not pertinent to this hospitalization.
Physical Exam:
Admission:
VS - Temp 99.4F, BP 129/82, HR 87, R 18, O2-sat 98% 2L
GENERAL - NAD tracking, but not moving. Not following commands
HEENT - NC/AT, PERRLA, EOMI, dry MM, mouth agape, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
warm peripherally
SKIN - no rashes or lesions
NEURO - Tracking with eyes, downgoing babinski, 1+ reflexes in
the biceps and patella, cogwheeling in the upper extremities,
and increased tone in the lower extremities. Masked facies.
Discharge:
VS - Tm /Tc 97.6F, BP 106/67, HR 81, R 18, O2-sat 98% 2L
GENERAL - NAD tracking, but not moving. Not following commands
HEENT - NC/AT, PERRLA, EOMI, dry MM, mouth agape, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB anteriorly, does not take deep inspirations
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
warm peripherally
SKIN - no rashes or lesions
NEURO - Tracking with eyes, downgoing babinski, 1+ reflexes in
the biceps and patella, cogwheeling in the upper extremities,
and increased tone in the lower extremities. Masked facies.
Pertinent Results:
Admission Labs:
___ 03:20PM BLOOD WBC-15.3*# RBC-4.97 Hgb-16.3 Hct-49.9
MCV-100*# MCH-32.8* MCHC-32.7 RDW-12.6 Plt ___
___ 03:20PM BLOOD Glucose-112* UreaN-30* Creat-1.2 Na-150*
K-3.9 Cl-115* HCO3-25 AnGap-14
___ 07:10AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.1
Discharge Labs:
___ 07:25AM BLOOD WBC-9.1 RBC-4.17* Hgb-14.2 Hct-41.7
MCV-100* MCH-34.0* MCHC-34.0 RDW-13.1 Plt ___
___ 07:25AM BLOOD Glucose-113* UreaN-23* Creat-0.8 Na-142
K-3.6 Cl-111* HCO3-23 AnGap-12
___ 07:25AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.1
CXR:
FINDINGS: A frontal view of the chest was obtained portably.
Low lung volumes results in bronchovascular crowding. There is
no focal consolidation, pleural effusion or pneumothorax.
Pulmonary vasculature is normal. Heart size is normal. The
aorta is tortuous.
IMPRESSION: No acute cardiopulmonary process.
CT Head:
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect or major vascular territorial infarct. Ventricles and
sulci are more prominent than in ___ and compatible with global
age-related volume loss. There is no shift of normally midline
structures. Basal cisterns are preserved. Gray-white matter
differentiation is preserved. Mild hypoattenuation in the left
subinsular region is likely sequelae of chronic microvascular
ischemic disease. No osseous abnormality is identified. The
visualized paranasal sinuses are clear. The right mastoid air
cells are under developed. The left mastoid air cells are
clear.
IMPRESSION: No acute intracranial process.
Microbiology:
URINE CULTURE (Final ___: NO GROWTH.
___ 2:20 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
YEAST. 10,000-100,000 ORGANISMS/ML..
___ 8:47 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Blood culture x4 no growth to date. Final pending.
Brief Hospital Course:
Mr. ___ is a ___ year old ___ male with a pmh of
frontotemporal dementia, parkinsonism, paranoid schizophrenia,
GERD, and chronic Hep C who presented from ___ with
recurrent fevers since ___ without a clear source.
# Fever. Currently with a negative work-up. There were several
concerns. He had a leukocytosis and fever to 103 in the ED, WBCs
on his UA, with concern for chronic aspiration and a midline
line IV in place on admission. Blood, lung, and urine were all
potential sources. He had cultures sent for all three sources
and had been covered with levo, flagyl, and vanc at his NH. His
urine culture was negative, sputum grew yeast and respiratory
flora and his blood cultures were NGTD at discharge. He was
initially covered broadly with vanc and imipenem out of concern
for aspiration, but CXR and sputum pointed away from this. He
was narrowed after 48 hours to Ciprofloxacin and remained
afebrile. His midline was removed.
# Hyponatremia. 150 on admission, likely from decrease in PO
intake, and inability to access free water with increased
insensible losses. He was given 2L NS in the ED and Repleted
with D5W at 125cc/hr which corrected his sodium to 143. He was
able to take fluids PO without coughing. He will need a formal
speech and swallow evaluation to determine what he will be able
to take by mouth going forward.
# Frontotemporal dementia/Parkinsonism. He failed a trial of
treatment in the past with worsening psychosis on
antiParkinsonian meds. Currently on bupropion and mirtazapine
and treating insomnia with lorazepam.
# Somnolence: Unclear etiology during his stay. He had waxing
and waning and the differential included hypoactive delirium
complicated by acute illness. Also likely a medication effect.
He had received metoclopramide standing during admission. This
was discontinued for somnolence. His psychiatric medications
were also held for 1 dose and bupropion was halved in dosing to
37.5mg BID, with mirtazapine and lorazepam being made prn due to
somnolence. As he continues to clinically improve his
medications can be uptitrated as he tolerates to his regular
dosing.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO/PR 3X/WEEK (___)
2. Polyethylene Glycol 17 g PO DAILY
3. BuPROPion 75 mg PO BID
4. Mirtazapine 30 mg PO HS
5. Lorazepam 0.5 mg PO HS
6. Omeprazole 20 mg PO DAILY
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze
8. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Metoprolol Tartrate 25 mg PO BID
11. Polytrim *NF* (trimethoprim-polymyxin B) 0.1-10,000
%-unit/mL ___ BID
12. Acetylcysteine 20% ___ mL NEB BID
13. Acetaminophen 650 mg PO Q8H
14. Metoclopramide 10 mg PO TID with meals
15. Levofloxacin 500 mg IV Q24H
16. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
17. Vancomycin 1000 mg IV Q 24H
18. Ibuprofen 400 mg PO Q8H:PRN pain/fever
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze
2. Bisacodyl 10 mg PO/PR 3X/WEEK (___)
3. BuPROPion 37.5 mg PO BID
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Metoprolol Tartrate 25 mg PO BID hold for SBP <100, HR <60
6. Mirtazapine 30 mg PO HS:PRN insomnia
7. Omeprazole 20 mg PO DAILY
8. Ciprofloxacin 400 mg IV Q12H Duration: 4 Days
9. Acetaminophen 650 mg PO Q8H
10. Acetylcysteine 20% ___ mL NEB BID
11. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
12. Ibuprofen 400 mg PO Q8H:PRN pain/fever
13. Lorazepam 0.5 mg PO HS
14. Polyethylene Glycol 17 g PO DAILY
15. Polytrim *NF* (trimethoprim-polymyxin B) 0.1-10,000
%-unit/mL ___ BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI
Frontotemporal dementia
___
Discharge Condition:
Mental Status: Eye's open, tracks, unresponsive otherwise
Level of Consciousness: Alert with periods of somnolence
Activity Status: bedbound
Discharge Instructions:
Mr. ___,
It was a pleasure taking part in your care. You were admitted to
___ for fevers. We tested your sputum, blood, and urine for
infection. All of these cultures were negative, or without
growth at the time of your discharge. You were initially covered
with broad spectrum antibiotics for fever of 103. However, your
fevers broke and you were treated with Ciprofloxacin, and you
will require 7 days total of antibiotics.
The midline IV in your right arm was discontinued out of concern
that this was the source of your infection.
You also had periods of somnolence that was likely related to
your acute illness and medications.
Followup Instructions:
___
|
10316305-DS-11 | 10,316,305 | 29,386,252 | DS | 11 | 2133-01-17 00:00:00 | 2133-01-17 14:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fever tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Primary Care Physician:
___: Fever,Tachycardia
Reason for MICU transfer: Tachycardia
History of Present Illness: Mr. ___ is a ___ year old ___
male with frontotemporal dementia, parkinsonism, paranoid
schizophrenia, GERD, and chronic Hep C who presented from ___
___ with fevers to 100.3 and tachycardia to 117. At baseline,
pt is non-verbal. Staff from rehab found him with mild hypoxia
to 93% on RA. He was treated with tylenol and levoquin 750mg,
started on 100cc/hr.
Initial VS in the ED: 99.4 (max 100.2) 100 (max 129) 146/92 14
97% 2L Nasal Cannula. Exam in the ED notable for wheezing, but
otherwise unremarkable with a non-tender abdomen and no
meningeal signs to indicate any specific source of infection. Pt
was given 125cc NS, 2L LR, Vancomycin 1000 mg IV, CefePIME 2 g
IV, acetaminophen 650 PR x1 as well as albuterol and
ipratroprium nebs. U/A was clean with trace protein and 4 uro
bili. Labs notable for Na 152, BUN 29, Glucose 219. CXR did not
appear to show any acute cardiopulmonary process. CTA was
performed, which showed no PE on preliminary read. VS On
transfer: 99.1 121 129/79 28 98%
On arrival to the MICU, pt is alert, non-verbal. No expressions
of pain or discomfort.
Review of systems:
(+) Per HPI
(-) Unable to obtain per pt as he is nonverbal
Past Medical History:
Parkinsonism (failed trial of sinemet)
Chronic vomiting
Constipation
Hyponatremia 128-133, attributed to Wellbutrin
Benign essential HTN
Insomnia
Chronic Hepatitis C
BPH
Senile depressive disorder
Asthma
GERD
Aspiration (chronic)
Frontotemporal dementia
Paranoid Schizophrenia
Prostate carcinoma s/p radical prostatectomy in ___ at ___
Social History:
___
Family History:
Family History (per OMR): Not pertinent to current
hospitalization. Unable to obtain from pt as he is nonverbal.
Physical Exam:
Vitals: T: 99.5 BP: 161/80 P: 106 R: 25 O2: 94% RA
General: NAD, tracks with eyes, focuses
HEENT: PERRL, MM dry
Neck: No LAD
CV: Tachycardic, reg rhythm, no murmurs/rubs/gallops
Lungs: Poor respiratory effort, but CTAB, no
wheezines/rales/rhonchi.
Abdomen: Soft, NT, ND, hypoactive bowel sounds
GU: Foley
Pertinent Results:
___ 10:10PM BLOOD WBC-11.0 RBC-4.91 Hgb-16.4 Hct-47.1
MCV-96 MCH-33.4* MCHC-34.7 RDW-13.0 Plt ___
___ 10:10PM BLOOD Neuts-60.9 ___ Monos-7.7 Eos-0.4
Baso-0.7
___ 10:10PM BLOOD Plt ___
___ 10:10PM BLOOD Glucose-219* UreaN-29* Creat-1.0 Na-152*
K-3.8 Cl-114* HCO3-28 AnGap-14
___ 04:35AM BLOOD Glucose-148* UreaN-23* Creat-0.8 Na-144
K-3.8 Cl-110* HCO3-27 AnGap-11
___ 10:10PM BLOOD ALT-108* AST-81* CK(CPK)-87 AlkPhos-85
TotBili-1.0
___ 01:29PM BLOOD CK-MB-2 cTropnT-0.02*
___ 10:10PM BLOOD CK-MB-2 cTropnT-0.02*
___ 04:35AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.3
___ 10:10PM BLOOD Osmolal-323*
___ 10:22PM BLOOD Lactate-1.9
.
CTA chest:
FINDINGS: No enlarged axillary, mediastinal, or hilar
lymphadenopathy. The visualized thyroid gland is unremarkable.
The airways are patent to the subsegmental level. There are a
small amount of secretions in the mid trachea. The aorta is
normal in size. There is no filling defect in the pulmonary
arteries to the subsegmental level. There are calcified lymph
nodes in the subcarinal station and left hilum. No pleural
effusion, pericardial effusion or pneumothorax. There is mild
cardiomegaly. There is a streaky opacity in the right lower
lobe. Mild amount of dependent opacity is also
noted within the left upper lobe. This study is not tailored
for evaluation of the intra-abdominal organs,
limited evaluation is unremarkable.
BONES: No acute bony abnormality.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Right lower lobe streaky opacity likely atelectasis,
although infection is not excluded.
3. Left upper lobe dependent opacity could represent
atelectasis or
aspiration especially given tracheal secretions.
Brief Hospital Course:
Assessment: ___ year male with multiple medical problems
including frontotemporal dementia who is non-verbal at baseline,
parkinsonism, paranoid schizophrenia, chronic aspiration, and
chronic Hep C who presented from ___ with fever to
100.3 that appears to be most likely due to aspiration and found
to have hypernatremia.
.
Hospital course:
.
#FEVER: He has several risk factors as well as a personal
history of aspiration. Aspiration pneumonitis or pneumonia was
considered to be the most likely etiology given CT findings of
bibasilar pulmonary opacity and secretions in trachea. He was
afebrile and on room air during his hospital course. He was
treated with levofloxacin and metronidazole (penicillin allergy)
with good response. He will be treated for a total of 7 days
with a completion date of ___. On date of discharge he was
afebrile with oxygen saturation in the mid ___ on room air.
A bedsite swallow eval was performed and the recommendation
was to continue with pureed diet with thin liquids, med crush in
apple sauce and close supervision while eating. He was
continued to be placed on aspiration precaution. U/A was
negative and blood cxs have been negative to date.
.
#HYPERNATREMIA: The most likely etiology is hypovolemia in the
setting of fever and possibly reduced PO intake. He was given
IVF with normalization of his sodium.
.
.
Chronic issues:
# Asthma, chronic: He was continued on home albuterol PRN.
# Frontotemporal dementia/Parkinsonism: He was continued on
mirtazapine and bupropion
# Hepatitis C, chronic: Mild transaminitis on LFT.
.
Transitional:
-pending studies:
-code status: DNI/DNR
# Emergency Contact: ___ HCP ___, cell ___ ___ (wife) cell ___, home ___
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezing
3. Mirtazapine 15 mg PO HS
4. Bisacodyl 10 mg PR QMOWEFR
5. Polyethylene Glycol 17 g PO DAILY
6. BuPROPion 75 mg PO BID
7. Metoclopramide 5 mg PO BID
8. Acetaminophen 650 mg PO Q6H:PRN fever/discomfort
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever/discomfort
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheezing
3. Bisacodyl 10 mg PR QMOWEFR
4. BuPROPion 75 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Mirtazapine 15 mg PO HS
8. Levofloxacin 750 mg PO DAILY Duration: 4 Days
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 4 Days
10. Metoclopramide 5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aspiration pneumonia
Dementia
Hypernatremia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure looking after you. As you know, you were
admitted with fever and rapid heart rate. A chest CT scan was
done and identified findings consistent with a pneumonia -
possibly aspiration related (food/saliva going down the airway).
You received antibiotics with good response. Please continue
the antibiotics until ___. They can be crushed and putting
into pureed diet.
Followup Instructions:
___
|
10316343-DS-7 | 10,316,343 | 22,611,765 | DS | 7 | 2166-08-09 00:00:00 | 2166-08-10 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
Fever/Chills
Cough
Myalgias
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F PMHx HTN presents with 2 days of cough, fever, dyspnea,
and body aches. She has been coughing (dry then yellow-green
phlegm, hurts when coughing), having body aches (hips, chest,
headache), and having dyspnea (wheezing) and long with a fever
for the past 2 days. She made an outpatient appointment for
___ but when she showed up they immediately sent her to ___
ED. ROS significant for weight loss (142 pounds to 135
poiunds), good appetite, no palpitations, mild sore throat,
rhinorrhea at beginning of illness, no N/V/D/C, no urinary
symptoms, no visual changes, and no photophobia.
In the ED, vitals were Tmax 101.4, HR 103-111, BP 112-181/76-95,
___, 91-94% on RA or 97% on 4L. She was given acetaminophen
1g, 2L NS, albuterol-ipratropium nebulizers, and azithromycin.
Past Medical History:
Hypertension
Uterine Fibroids
Pelvic Inflammatory Disease / Gonorrhea
Social History:
___
Family History:
Hypertension, Asthma (sister and brother)
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals = Temp: 99.8 HR: 110 BP: 181/95 Resp: 18 O(2)Sat: 97
Normal
Gen: NAD, pleasant and cooperative
HEENNT: NCAT, EOMI/PERRL, MMM, no LAD, no JVD
CV: RRR, no MRG
Lungs: Dry crackles throughout lung fields most prominent in LL
fields, mild expiratory wheezes
Abd: NT/ND, + BS, no organomegaly
Ext: No peripheral edema, WWP
Neuro/Psych: A+Ox3, fluent speech, gross motor/sensory function
intact
DISCHARGE PHYSICAL EXAMINATION:
Vitals = 99.0 (101.4 in ED), 92-99, 136-141/86-90, 18, 98% on
RA, no strict I/Os
Gen: NAD, pleasant and cooperative
HEENNT: NCAT, EOMI/PERRL, MMM, no LAD, no JVD
CV: RRR, no MRG
Lungs: CTAB
Abd: NT/ND, + BS, no organomegaly
Ext: No peripheral edema, WWP
Neuro/Psych: A+Ox3, fluent speech, gross motor/sensory function
intact
Pertinent Results:
___ 03:55PM BLOOD WBC-17.7*# RBC-5.04 Hgb-10.3* Hct-34.4*
MCV-68* MCH-20.5* MCHC-29.9* RDW-17.1* Plt ___
___ 03:55PM BLOOD Neuts-80.4* Lymphs-11.2* Monos-6.9
Eos-1.1 Baso-0.3
___ 07:50AM BLOOD WBC-13.4* RBC-4.38 Hgb-8.8* Hct-30.4*
MCV-69* MCH-20.2* MCHC-29.2* RDW-17.0* Plt ___
___ 03:55PM BLOOD Glucose-91 UreaN-13 Creat-0.9 Na-135
K-3.4 Cl-99 HCO3-22 AnGap-17
___ 07:50AM BLOOD Glucose-84 UreaN-11 Creat-0.8 Na-138
K-3.7 Cl-107 HCO3-21* AnGap-14
___ 03:55PM BLOOD Iron-___*
___ 03:55PM BLOOD calTIBC-420 Ferritn-14 TRF-323
___ 03:57PM BLOOD Lactate-1.3
CXR = Reticulation and peribronchial cuffing which could be seen
with lower airway inflammation or infection. Atypical pneumonia
should also be considered.
Brief Hospital Course:
___ yo F PMHx HTN presents with 2 days of cough, fever, dyspnea,
and body aches along with tachycardia, mild hypoxemia, and chest
X-ray concerning for atypical pneumonia. She was put on
influenza precautions, given fluids/APAP/ibuprofen/nebulizer
treatments along with ceftriaxone/azithromycin/osteltamivir.
The next day, she had no hypoxemia/dyspnea, no fevers, and her
myalgias improved significantly and she was discharged home on
levofloxacin/oseltamivir.
# Community-Acquired Pneumonia / Influenza: Patient presented
with dyspnea and viral symptoms in the setting of tachycardia
and CXR findings consistent with atypical pneumonia. Patient
was started on IV fluids, APAP/ibuprofen,
Ceftriaxone/Azithromycin/Oseltamivir, and nebulizer treatments.
She was never O2-dependent (SaO2 ___ on arrival and discharge).
ROS significant for weight loss (142 pounds to 135 poiunds),
good appetite, no palpitations, mild sore throat, rhinorrhea at
beginning of illness, no N/V/D/C, no urinary symptoms, no visual
changes, and no photophobia. After treatment, patient had no
fever/tachycardia, no dyspnea/hypoxemia, and her cough/myalgias
were improving. She was placed on influenza precautions and
nasopharyngeal swabs were sent (influenza DFA quantity
insufficient x2). She was discharged on oseltamivir and
levofloxacin, as well as symptom controlling medications.
# Iron-Deficiency Anemia: Presented with microcytic anemia with
iron-deficiency anemia (low Iron:TIBC ratio). Had this
diagnosis previously but did not tolerate oral iron
supplementation (was given one dose of IV iron).
# Hypertension: Chronic stable issue with Lisinopril/HCTZ held
on admission and restarted on discharge.
# Code: Full Code
# Contact: Patient, Sister ___ (___), ___
___ (___), can be quasi-HCP
# Disposition: Home
# Transitional Issues:
- Ensure resolution of clinical symptoms or at least reduction
in cough and left ear effusion
- Encourage patient to use good hand hygeine
- Encourage treatment of iron-deficiency anemia (had significant
microcytic anemia, had not tolerated PO ferrous sulfate)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain / Fever
RX *acetaminophen 325 mg ___ tablet(s) by mouth Every 6 hours
Disp #*30 Tablet Refills:*0
2. Guaifenesin-Dextromethorphan ___ mL PO Q6H:PRN Cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL ___ mL by
mouth Every 6 hours Refills:*0
3. Ibuprofen 800 mg PO Q8H:PRN Pain / Fever
RX *ibuprofen 800 mg 1 tablet(s) by mouth Every 8 hours Disp
#*30 Tablet Refills:*0
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Levofloxacin 750 mg PO Q24H Duration: 5 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*6
Tablet Refills:*0
7. OSELTAMivir 75 mg PO Q12H Duration: 5 Days
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth Twice a
day Disp #*10 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Community Acquired Pneumonia
Influenza
SECONDARY:
Hypertension
Iron-Deficiency Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
concern that you had a pneumonia (from bacteria or from
influenza virus). You were given IV fluids, antibiotics and
antivirals, and medications to help your breathing, pain, and
cough. Afterwards, you felt better, had no fevers, and had no
difficulty breathing and thus were able to go home safely.
Wash your hands and cover up your mouth when coughing to avoid
spreading influenza to other people. Please take all medications
as prescribed, attend all doctors ___ as directed, and
call a doctor if you have any questions or concerns. Your
influenza test was still pending at time of discharge; please
take the medication for bacterial pneumonia and influenza
pneumonia and we will call you to stop one of the medications
depending on the results of your testing.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10316385-DS-18 | 10,316,385 | 29,948,326 | DS | 18 | 2159-05-23 00:00:00 | 2159-05-28 15:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Difficulty reading, headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo RH woman with PMH of insulin dependent
diabetes, HTN, HLD and chronic kidney disease who present with
headaches and right sided visual change for 5 days.
She reports that she was down in ___ for a wedding. On
___, she was sitting out by the pool and was trying to read
her kindle when she noticed that the right side of her visual
field was blurry. It felt like there was something "extra" like
sparkling light that was overlying the words on the right hand
side and she couldn't not read it as well. When she moved it to
the left side, it was fine. She also noticed that she was
starting to get a headache with some nausea, so she stopped
reading and went to rest. Afterwards, she went out for dinner
and generally felt ok.
As they were driving back on ___, she began to get headache
which was initially right sided and then travelled to the left
side of her brain. It was throbbing pain with associated nausea
and photophobia, and she thought it might be one of her
migraines which she has not had in years. She took some tylenol
but the headache kept on getting worse. ___ morning, she
still had a headache so she went and got herself some tylenol
migraine and took them and felt that headache was getting
better. Last night, when she was trying to read something, she
noticed that her vision on right side was still bed, so she went
to bed and tried to rest. She is not sure if this was new visual
change or if the change persisted from ___, as she had not
tried reading again until ___ night and her symptoms are
only felt when she is trying to read.
This morning was the first morning back to work, and she drove
to work feeling fine. Did not notice any difficulty with
driving. At work, when she was looking at the screen, she
noticed that the right side of screen was blurry just her vision
was on ___ or last night. In addition, she couldn't remember
the code for her computer and also had difficulty completing
different tasks in order. She called her PCP who had her come in
for a visit, and then sent her to ED.
On neuro ROS, the pt denies 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 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:
CKD (baseline Cr 2.3-2.6)
DM - mild retinopathy
HTN (since age ___ per atrius record)
HLD
tobacco use (cut down a lot)
history of migraine when she was younger, no aura per patient
Social History:
___
Family History:
Significant for HTN and heart disease. Some history of diabetes.
Denies history of stroke.
Physical Exam:
Initial Physical Exam
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, warm to touch
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able to
read and write without difficulty, though she does describe the
right sided visual change as above. Speech was not dysarthric.
Able to follow both midline and appendicular commands. There was
no evidence of apraxia or neglect. Calculation was intact
(answers seven quarters in $1.75 and 32+17=49). There was no
evidence of left-right confusion as the patient was able to
accurately follow the instruction to touch left ear with right
hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation to movement,
?minimally decreased to fingercounting on R peripheral visual
field.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Mild L NLF but daughter reports it's chronic.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-Sensory: No deficits to light touch or pinprick throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2+ 2 2+ 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Pertinent Results:
___ 04:05PM GLUCOSE-123* UREA N-51* CREAT-2.5* SODIUM-139
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17
___ 04:05PM WBC-8.7 RBC-3.86* HGB-11.4* HCT-33.6* MCV-87
MCH-29.4 MCHC-33.8 RDW-13.0
___ 04:05PM PLT COUNT-204
___ 04:05PM SED RATE-75*
___ 04:05PM CRP-4.5
___ 04:05PM ALBUMIN-4.6
___ 04:05PM BLOOD ESR-75*
___ 04:05PM BLOOD ALT-22 AST-20 LD(LDH)-185 CK(CPK)-85
AlkPhos-52 TotBili-0.3
___ 08:11AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:05PM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:11AM BLOOD %HbA1c-5.8 eAG-120
___ 08:11AM BLOOD Triglyc-226* HDL-33 CHOL/HD-4.5
LDLcalc-72 LDLmeas-86
___ 08:11AM BLOOD TSH-1.7
___ 04:05PM BLOOD CRP-4.5
___ 04:05PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
MRI:
1. Acute left posterior cerebral artery territorial infarct
visualized. No evidence of hemorrhage.
2. MRA of the neck shows atherosclerotic disease at both
carotid bifurcations. The evaluation is somewhat limited as
gadolinium-enhanced MRA could not be performed.
3. MRA of the head shows no evidence of vascular occlusion. No
evidence of high-grade stenosis seen.
ECHO (___): No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers. The
left atrium is normal in size. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF 70%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
HCT (___):
IMPRESSION: Acute infarct in the left occipital lobe. No
evidence of hemorrhagic
Brief Hospital Course:
Ms. ___ is a ___ yo right-handed woman with PMH of HTN, HLD
and insulin dependent diabetes who present with R sided visual
change associated with headache x5 days. On exam, patient
describes that the right side of her vision is "blurry" as if
there is extra layer of color or spots over it. These deficits
were homonymous, though there was no clear visual deficit on
confrontational testing to movement. There was minimal decrease
to finger counting. Her CT showed hypodensity in medial left
occipital lobe concerning for infarct and she was admitted for
further stroke workup. MRI demonstrated the infarct as well,
and MRA was normal. We monitored her on telemetry, which did
not demonstrate atrial fibrillation. Because she noted a history
of irregular heartbeats (type unknown), we gave her a holter
monitor at discharge. Her hemoglobin was 5.8, demonstrating
good control of her diabetes. Her LDL cholesterol was 72, but
her triglycerides were elevated to 226. TSH was normal. She had
an ECHO done which demonstrated no ASD or PFO. Her creatinine
was 2.4, which is consistent with her baseline. ASA 325 was
started.
The patient was counseled that she cannot drive while she has
this visual impairment, and should have a driving test before
she can start driving again. We also recommended
neuro-opthalmology follow up for visual field testing.
An outpatient TEE was planned, as well as an outpatient Holter
Monitor.
# diabetes: diabetic medications were continued
# HTN/HLD: cont lisinopril, nifedepine, propranolol, simvastatin
TRANSITIONAL ISSUES:
- the patient needs outpatient Holter Monitor after discharge
- the patient needs outpatient TEE after discharge
- the patient needs outpatient neuro-opthalmology follow up with
visual fields testing after discharge with Dr. ___
- ___ triglycerides (226) were noted, please followe up and
adjust medication as needed
- cont ongoing managmenet of HTN and diabetes
- F/U with PCP and ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 10 mg PO DAILY
hold for SBP < 100
2. Lisinopril 20 mg PO DAILY
hold for SBP < 100
3. NIFEdipine CR 30 mg PO DAILY
hold for SBP < 100
4. Glargine 10 Units Bedtime
5. GlipiZIDE 5 mg PO BID
6. Propranolol 40 mg PO DAILY
hold for SBP < 100, HR < 60
7. Simvastatin 20 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. Ferrous Sulfate 650 mg PO DAILY
10. Calcium Carbonate 500 mg PO BID
11. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Ferrous Sulfate 650 mg PO DAILY
2. Furosemide 10 mg PO DAILY
3. Glargine 10 Units Bedtime
4. Omeprazole 20 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Calcium Carbonate 500 mg PO BID
8. GlipiZIDE 5 mg PO BID
9. Vitamin D 400 UNIT PO DAILY
10. Propranolol 40 mg PO DAILY
11. NIFEdipine CR 30 mg PO DAILY
12. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. stroke, likely embolic
Secondary diagnosis
1. diabetes
2. hypertension
3. hyperlipidemia
3. chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: intact, no obvious visual field cut on clinical exam
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for some visual changes, and
you were found to have a stroke. You should follow up with your
primary physician and stroke doctor as an outpatient.
You cannot drive while you have this visual impariment, and you
should not drive again until you pass a driving assessment,
details of which are available at your local ___. You will also
need to be seen in ___ clinic for visual field
testing (see details below).
It is important that you take all medications as prescribed, and
keep all follow up appointments.
You will also need to schedule a transesophageal echocardiogram
to better assess for a possible blood clot in your heart. Please
see below for further details.
We are also going to set you up with a Holter monitor to watch
your heart rhythm for a few more days after your discharge. You
may call ___ to set this up.
Followup Instructions:
___
|
10316389-DS-3 | 10,316,389 | 20,495,924 | DS | 3 | 2182-01-22 00:00:00 | 2182-01-29 11:41:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Erythromycin Base / Tetracycline Analogues / Percocet
/ Demerol / Bacitracin / Monistat 1 / Percodan / Sulfa
(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
diarrhea, lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMH significant for lupus (diagnosed
in ___, on cellcept, plaquenil and prednisone), IgA deficiency,
IgM MGUS, and chronic diverticular disease (s/p partial
colectomy in ___ who presents with chronic diarrhea. She was
evaluated at her GI physician's office and was noted to be
bradycardic with signs of ___ so she was sent to the ED
for more thorough evaluation.
With regard to the patient's diarrhea, she has been having this
issue since ___, with waxing and waning periods of time. Since
early ___, she has been having >10 bowel movements per day
that are brown and liquid. She reports urgency, but denies any
abdominal pain, or black or bloody stools. She denies flushing
or rash. She reports ___ pound weight loss in the past 6
months. She actually had similar symptoms one year ago resulting
in multiple syncopal/pre-syncopal episodes related to
dehydration.
She has been followed by Dr. ___ recently performed a
small bowel follow-through, which was significant for jejunal
diverticula. She has been negative for anti-ttG. Her last
colonoscopy was in ___ and demonstrated diverticulosis. While
at her GI visit on the day of admission, the plan was to send
stool cultures, anti-DGP, and serum serologies for amoeba and
strongyloides. She was started on Rifaximin although her SIBO
breath test was negative.
Of note, she reports a dry cough for the past week with some
associated chills. She denies nausea, vomiting, or any fevers.
In the ED, initial vitals were 97.8 60 108/49 16 97% RA. Labs
remarkable for CBC wnl, BNP wnl, TnT neg, and D-Dimer elevated
to 901. Her EKG was unchanged from priors. CXR was negative for
PNA and CTA Chest was negative for PE.
On the floor, she confirms the history of chronic diarrhea, dry
cough, but says she currently feels well. Denies dizziness or
any recent LOC.
Review of systems:
(+) Per HPI: Diarrhea, cough, weight loss, chills. Arthralgias
and mouth ulcers with lupus flares.
(-) Denies fever, night sweats, headache, shortness of breath,
chest pain or tightness, palpitations, nausea, vomiting. No
dysuria.
Past Medical History:
PMH:
- Diverticulitis and diverticulosis (chronic)
- Perforated appendix (with Salmonella septicemia in ___
- Breast cancer diagnosed ___ with R mastectormy ___
- Migraines
- Hypertension,
- Reflux
- Lupus ___ postive speckled 1:40, dsDNA negative, on Cellcept
and Plaquanil, flares with mouth ulcers, back ulcers and
arthralgias)
- Relapsing polychondritis
- Osteoarthritis
- IgM MGUS
- Chronic elevation of AST with negative liver biopsy, followed
by liver team.
- Liver hemangioma and cyst
PSH:
- R mastectomy ___
- Laparoscopic sigmoid colectomy, splenic flexure takedown and
rigid sigmoidoscopy (___)
- Tonsillectomy
- Benign tumor excision
- Spinal laminectomies
- Hemorrhoidectomy
- Total abdominal hysterectomy with salpingo-oophorectomy
- Laparoscopic cholecystectomy complicated by bleeding
- Rectocele repair
- Total Knee Replacement
Social History:
___
Family History:
GF: DM
Mother: ___ cancer, DM
Father: ___
Physical Exam:
Admission Physical Exam:
====================
Vitals: 98.7 124/43 79 16 99% RA
General: A&Ox3, NAD
HEENT: NC/AT, dry mucous membranes, no mouth ulcers
Neck: JVP flat, FROM
CV: RRR, nl s1, s2, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: +BS, soft, NT/ND/NG/NR
GU: no foley
Ext: axilla dry, signs of venous stasis in BLE without edema,
pulses 2+ throughout
Neuro: CNII-XII intact, motor and strength grossly intact.
Skin: No rashes
Discharge Physical Exam:
====================
Vitals: 97.6 66 125/53 18 100% on RA
General: A&Ox3, NAD
HEENT: NC/AT, moist mucous membranes, no mouth ulcers
Neck: JVP flat, FROM
CV: RRR, nl s1, s2, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: +BS, soft, NT/ND/NG/NR
GU: no foley
Ext: signs of venous stasis in BLE without edema, pulses 2+
throughout
Neuro: CNII-XII intact, motor and strength grossly intact.
Skin: No rashes
Pertinent Results:
Admission Labs:
==============
___ 10:30AM BLOOD WBC-5.3 RBC-3.95* Hgb-12.1 Hct-36.4
MCV-92 MCH-30.5 MCHC-33.2 RDW-13.3 Plt ___
___ 10:30AM BLOOD Neuts-72.5* ___ Monos-8.5 Eos-0.6
Baso-0.4
___ 10:30AM BLOOD Plt ___
___ 10:30AM BLOOD Glucose-84 UreaN-13 Creat-0.7 Na-136
K-5.9* Cl-101 HCO3-25 AnGap-16
___ 10:30AM BLOOD ALT-26 AST-254* LD(___)-886* AlkPhos-36
TotBili-0.2
___ 09:15PM BLOOD TotProt-6.1*
___ 10:30AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.0 Mg-1.8
Cardiac Labs:
==============
___ 10:30AM BLOOD cTropnT-<0.01
Heme Labs:
==============
___ 10:30AM BLOOD D-Dimer-901*
___ 09:15PM BLOOD PEP-HYPOGAMMAG IgG-269* IgA-33*
IgM-1421*: Thickened Beta-2 Band identified previously, by IFE,
as monoclonal IgM Kappa. In this patient, suggest following IgM
levels rather than densiotometry
___ 10:30AM BLOOD LD(LDH)-886*
___ 05:55AM BLOOD LD(LDH)-156
Endo Labs:
==============
___ 10:30AM BLOOD TSH-4.3*
___ 10:30AM BLOOD T3-88 Free T4-0.96
Urine:
===========
___ 04:23PM URINE Color-Straw Appear-Clear Sp ___
___ 04:23PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
___ 04:23PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1
___ 04:23PM URINE Mucous-RARE
___ 04:23PM URINE Hours-RANDOM Creat-25 TotProt-14
Prot/Cr-0.6*
___ 04:23PM URINE U-PEP- Abnormal band in gamma region
based on IFE (see separate report), identified as ___
kappa now representes roughly 90% of urinary protein. Based on
this sample's protein/creatinine ratio and assuming daily
cretinine excretion of 1000mg, we estimate this patient's
___ excretion as 90% * 0.6 * 1000 = 540 MG/DAY
___ 04:23PM URINE MONOCLONAL FREE (___) KAPPA
DETECTED
Discharge Labs:
============
___ 01:30PM BLOOD WBC-6.3# RBC-3.75* Hgb-11.5* Hct-34.6*
MCV-92 MCH-30.7 MCHC-33.3 RDW-13.2 Plt ___
___ 01:30PM BLOOD Plt ___
___ 05:55AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-141 K-3.6
Cl-106 HCO3-26 AnGap-13
___ 05:55AM BLOOD ALT-21 AST-177* LD(LDH)-156 AlkPhos-38
TotBili-0.1
___ 05:55AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.7 Mg-1.7
GI/Stool:
===========
___ 10:50AM STOOL Osmolal-287
___ 09:15PM BLOOD antiDGP-1
___ 09:15PM BLOOD ENTAMOEBA HISTOLYTICA ANTIBODY-NEGATIVE
___ 09:15PM BLOOD STRONGYLOIDES ANTIBODY,IGG-NEGATIVE
Micro:
===========
___ FECAL CULTURE-FINAL; CAMPYLOBACTER NEGATIVE,
YERSINIA NEGATIVE; Cryptosporidium/Giardia (___)-NEGATIVE
___ CULTURE - NEGATIVE
___ CULTURE - NEGATIVE
PRIOR STUDIES:
====================
# Colonoscopy ___ (___)
Diverticulosis of the descending ___ and ascending ___.
Previous end to side ___ anastomosis of the sigmoid
___. Otherwise normal colonoscopy to cecum and terminal ileum
# Small bowel follow-through ___ (___)
1. Slightly diminished mucosal folds in the distal jejunum and
ileum, which may reflect chronic inflammation.
2. Multiple diverticula in the proximal jejunum, which may be
seen in asymptomatic patients or may be seen in intenstinal
motility disorders, such as progressive systemic sclerosis,
visceral neuropathies and visceral myopathies. Please correlate.
NEW STUDIES:
=====================
# CXR PA/LAT ___
--FINDINGS: PA and lateral views of the chest were provided. The
heart is top-normal in size. The lungs appear clear. No pleural
effusion or pneumothorax. Mediastinal contour is normal. Bony
structures are intact. There is no free air below the right
hemidiaphragm.
--IMPRESSION: No evidence of pneumonia.
# CTA CHEST ___
--FINDINGS: The aorta and pulmonary arteries are well opacified.
The aorta maintains a normal contour without evidence of acute
aortic syndrome. There is no pulmonary embolism in the main,
right, left, lobar, or subsegmental pulmonary arteries. The
heart is normal size without pericardial effusion. The thyroid
is normal. The airways are patent to the segmental level.
Slight thickening of the bronchial walls was also seen on the
prior study and may indicate a chronic small airways
inflammatory process. There is no mediastinal, hilar, axillary,
or supraclavicular lymphadenopathy. There is no concerning
pulmonary nodule, mass, or confluent consolidation. Bibasilar
atelectasis is present. There is no pleural effusion or
pneumothorax. No suspicious lesion is seen in the visualized
osseous structures.
--IMPRESSION: Limited exam in the lung bases. No pulmonary
embolism or evidence of acute aortic syndrome. No other acute
pathology.
# SPEP ___
Hypogammaglobulinemia with IgG-269* IgA-33* IgM-___*: Thickened
Beta-2 Band identified previously, by IFE, as monoclonal IgM
Kappa. In this patient, suggest following IgM levels rather than
densiotometry
# UPEP ___
Abnormal band in gamma region based on IFE (see separate
report), identified as ___ kappa now representes roughly
90% of urinary protein. Based on this sample's
protein/creatinine ratio and assuming daily cretinine excretion
of 1000mg, we estimate this patient's ___ excretion as
90% * 0.6 * 1000 = 540 MG/DAY
EKG
===============
___ (Intern Read): Bradycardia with HR 55. Normal axis. PR
interval 154. Q wave in III, aVF. Poor R wave progression
(Unchanged from priors)
Brief Hospital Course:
___ with a PMH significant for lupus, IgA deficiency, IgM MGUS,
and chronic diverticular disease (s/p partial colectomy in ___
who presents with chronic diarrhea as well orthostasic
hypotension. She received 2L NS with improvement in her
symptoms. She had an elevated d-dimer to 900, but negative CTA
for PE. CXR was wnl as well. She had minimal diarrhea, although
several studies were sent on request of her outpatient GI
doctors. ___ was noted to have a chronic cough that was not
concerning for bacterial PNA so no treatment was pursued. She
reported weight loss and had an elevated LDH (repeat was normal)
so SPEP/UPEP were sent to evaluate progression of MGUS. Her
Metoprolol was held as she was borderline bradycardic.
ACTIVE ISSUES:
===================
# Chronic Diarrhea
This patient has a complicated history of diarrhea that has been
previously worked up extensively by her outpatient GI provider.
She has a a long history of diverticular disease s/p sigmoid
colectomy. She has been IgA deficient, but her anti-TTG was
negative as was a SIBO breath test. She was admitted following a
recent small bowel follow-through which showed evidence of
jejunal diverticula, which can actually be seen in rheumatologic
disease. She previously had a gastrinoma ruled out. She denied a
rash or flushing, making carcinoid unlikely. Her diarrhea may
also be due to Cellcept, although her dosage has been
decreasing. All of her stool cultures, including giardia,
cryptosporidia and yersinia were negative. Serum studies were
negative for Amoeba and Strongyloides. Her anti-DGT was negative
as well. She did not have diarrhea while she was admitted. Per
her outpatient GI physician recommendations, she was started on
Rifaximin for empiric treatment despite the negative bacterial
overgrowth breath test prior to discharge.
# Orthostatic Hypotension
Ms. ___ presented with ___. She appeared slightly dry
on exam with dry mucous membranes and dry axilla. Although she
was bradycardic on admission, she remained in NSR without ectopy
or pauses throughout her hospitalization. She has negative
troponins. Although patient had elevated d-dimer, CTA was
negative and suspicion is low for PE. She was treated with IVF
and her orthostasis resolved.
# Cough
CXR not concerning for PNA, although patient with 1 week hx of
dry cough with chills. DDX includes viral infection vs atypical
PNA vs bronchitis. Will not treat for now as no clear infectious
process ongoing and patient symptomatically improving.
# IgM MGUS
IgM MGUS has been stable for several years. Now presents with
elevated LDH (although repeat was normal) on this admission,
concerning for progression of disease. Weight loss concerning.
Repeat SPEP demonstrated IgM Kappa monoclonal band that had been
seen previously. UPEP significant for ___ proteins
(kappa), which have not been documented previously. Patient
should follow up with PCP and ___ regarding these new
findings.
CHRONIC ISSUES:
========================
# SLE
Diagnosed in ___. Mostly presents with arthralgias and mouth
and back sores. Of note, Cellcept dose recently decreased from
1500 to 1000 per day.
- Continued Dexamethasone for oral sores
- Continued Prednisone, Mycophenolate Mofetil,
Hydroxychloroquine Sulfate
- Continued Ibuprofen 400 mg PO Q6H:PRN pain
- Per OMR, Rheum plans to slowly taper prednisone and Cellcept
at appointment for ___.
# GERD
- Continued Omeprazole 20 mg PO BID
# AST Elevation
Unclear etiology. Seems chronic. Liver biopsy in the past
negative for cirrhosis. Denies EtOH use.
# Hypertension
- Continued Metoprolol Tartrate 25 mg PO DAILY
# Osteoporosis
- Continued raloxifene 60 mg Oral daily
# Depression/Anxiety
- Continued Citalopram 20 mg PO DAILY
- Continued Diazepam 5 mg PO QHS
Transitional Issues:
=======================
# Needs follow-up with Hematology: Please consider progression
of MGUS as patient now has ___ protein in the urine.
# Needs follow-up with PCP: ___ evaluate and consider whether
patient should restart beta blocker, which was stopped due to
bradycardia
# Needs GI follow up: Of note, all micro was negative
# Per R___ notes, plan to slowly taper Cellcept in
___
# CODE: FULL
# CONTACT: ___ Husband ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. dexamethasone 0.5 mg/5 mL Oral daily cancer sores
2. PredniSONE 5 mg PO DAILY
3. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
4. Hydroxychloroquine Sulfate 400 mg PO DAILY
5. Diazepam 5 mg PO QHS
6. Metoprolol Tartrate 25 mg PO DAILY
7. minoxidil 5 % Topical unknown alopecia
8. raloxifene 60 mg Oral daily
9. Mycophenolate Mofetil 500 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Ibuprofen 400 mg PO Q6H:PRN pain
12. Omeprazole 20 mg PO BID
13. calcium carbonate-vit D3-min (calcium-mag-vit
B6-D3-minerals) 600 mg calcium- 400 unit Oral daily
14. Rifaximin 550 mg PO TID
15. aspirin-acetaminophen-caffeine 250-250-65 mg Oral unknown
16. Citalopram 20 mg PO DAILY
17. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. dexamethasone 0.5 mg/5 mL Oral daily cancer sores
3. Diazepam 5 mg PO QHS
4. Hydroxychloroquine Sulfate 400 mg PO DAILY
5. Ibuprofen 400 mg PO Q6H:PRN pain
6. Multivitamins 1 TAB PO DAILY
7. Mycophenolate Mofetil 500 mg PO BID
8. Omeprazole 20 mg PO BID
9. PredniSONE 5 mg PO DAILY
10. raloxifene 60 mg Oral daily
11. Rifaximin 550 mg PO TID
12. calcium carbonate-vit D3-min (calcium-mag-vit
B6-D3-minerals) 600 mg calcium- 400 unit Oral daily
13. Fish Oil (Omega 3) 1000 mg PO DAILY
14. minoxidil 5 % Topical unknown alopecia
15. aspirin-acetaminophen-caffeine 250 mg ORAL Frequency is
Unknown
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Orthostatic Hypotension
Chronic Diarrhea
Secondary:
Cough
Lupus
Diverticulosis
IgM MGUS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you at ___. You were admitted
with chronic diarrhea, lightheadedness and a slow heart rate.
You were found to be dehydrated so you were treated with IV
fluids. You had a Chest X-Ray and a Chest CT that were normal.
With regard to your diarrhea, you had several studies sent that
are pending. You were started on a medication called Rifaximin
that can help with diarrhea. Your Metoprolol was stopped as your
heart rate was slow (bradycardia).
You should follow up with your PCP and your GI doctor.
Regards,
Your ___ Team
Followup Instructions:
___
|
10316648-DS-16 | 10,316,648 | 20,140,331 | DS | 16 | 2135-05-03 00:00:00 | 2135-05-03 20:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall/AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o dementia presenting after a witnessed fall yesterday
in the setting of increasing confusion. Pt is reportedly AOx1 at
baseline and is unable to provide history. Per ___
Assisted Living where patient resides, patient had "guided fall"
while getting out of bed and slipped. Aide turned away during
fall and when turned back patient was rubbing head however so
evidence of head strike and patient is known to have odd
behavior ___ dementia. After fall, patient was screened for
facial asymmetry and other focal neuro findings-there were none.
However patient was unable to ambulate after getting out of bed
which is not baseline- normally able to ambulate without
assistance.
RN from facility notes she received signout that patient vomited
once yesterday, no diarrhea or any flu-like symptoms, PO intake
normal. Today however was "off". RN also notes frequent UTIs
though unable to quantify since becoming sexually active with
one of the other residents in the assisted living facility
approximately one month ago. 3 weeks ago, she fell off the bed
after intercourse. Per RN daughter and family are aware of this
behavior and "ok with it". Left message with daughter to discuss
further details.
RN reports that there has been respiratory illness going around
facility, however patient has been entirely without symptoms- no
cough, SOB, congestion, headache.
In the ED initial vitals T100.4 82 119/58 18 99% 2L. In ED tmax
was 101.4. Pt was initially hypoxic to 80's, and had cough +
crackles in left lung base. O2 sats quickly corrected with 2L
NC. EKG showed SR NANI, ?Twave lenthening, no e/o ischemia. CXR
showed no evidence of pneumonia. Mild pulmonary vascular
engorgement without overt pulmonary edema. CT Head showed no
acute intracranial process. Labs notable for lactate 2.4, blood
gas: 7.49 pCO2 30 pO2 70 HCO3 23. Cr 1.2, WBC 10.2 w/o shift.
U/A nit +, ___, 53 WBC and many bacteria. First set of trops <
0.01, Valproate level wnl at 74. Patient was given ceftriaxone
and azithromycin for UTI and PNA. Prior to transfer, vitals were
97.7 74 123/72 16 97%RA.
On the floor, T 98.1 118/54 72 20 93%RA
Past Medical History:
Dementia
Chronic Renal Insufficiency (per PCP, but normal creatinine from
office and here)
Hyperlipidemia
Hypothyroid-goiter
Osteopenia
Hypertension
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals- T 98.1 118/54 72 20 93%RA
General- Alert, oriented to maiden name, ___,
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, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal, gait
deferred
.
Discharge Physical Exam:
Vitals: T 97.6 139/69 70 20 96%RA
General: well-appearing in NAD
HEENT: NCAT, anicteric sclera, MMM, OP clear
Neck: Supple without LAD
PULM: CTA b/l without wheeze, rhonchi, or focal dullness
COR: RRR (+)S1/S2 to m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm and well perfused, 2+ pulses, no edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission Labs:
___ 10:50AM BLOOD WBC-10.5# RBC-4.68 Hgb-13.8 Hct-42.2
MCV-90 MCH-29.4 MCHC-32.7 RDW-14.4 Plt ___
___ 10:50AM BLOOD Neuts-65 Bands-0 ___ Monos-15*
Eos-0 Baso-0 ___ Myelos-0
___ 10:50AM BLOOD Glucose-105* UreaN-20 Creat-1.2* Na-138
K-4.3 Cl-102 HCO3-22 AnGap-18
___ 10:50AM BLOOD ALT-38 AST-27 CK(CPK)-179 AlkPhos-72
TotBili-0.7
___ 10:50AM BLOOD Lipase-11
___ 07:10PM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:50AM BLOOD Albumin-4.1 Calcium-9.0 Phos-3.2 Mg-2.0
___ 10:50AM BLOOD Valproa-74
___ 04:44AM BLOOD TSH-0.89
___ 11:06AM BLOOD Lactate-2.4* K-4.2
___ 11:06AM BLOOD ___ pO2-70* pCO2-30* pH-7.49*
calTCO2-23 Base XS-0 Comment-GREEN TOP
Pertinent Labs/Imaging:
___ 10:34AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:34AM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 10:34AM URINE RBC-1 WBC-53* Bacteri-MANY Yeast-NONE
Epi-0 TransE-<1
___ URINE URINE CULTURE-PENDING
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL- NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ URINE Legionella Urinary Antigen -FINAL
NEGATIVE;
URINE CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S)}
___ CT HEAD: There is no acute intracranial hemorrhage,
edema, mass effect or major vascular territorial infarction.
The ventricles and sulci are prominent compatible with age
related involutional changes. Periventricular and subcortical
white matter hypodensities suggest chronic small vessel ischemic
disease. Bil. small hippocampi are noted. There is no shift is
normally midline structures. There is no fracture. The mastoid
air cells are well aerated ; diffuse mucosal thickening
throughout the ethmoid air cells. The sphenoid sinuses,
maxillary and frontal sinuses appear well aerated.
IMPRESSION: No acute intracranial hemorrhage or mass effect.
Correlate clinically for AD/superimposed NPH given the history
though imaging findins are not characteristic of communicating
hydrocephalus.
___ CXR: Frontal and lateral chest radiographs demonstrates
low lung volumes and mildly engorged pulmonary vasculature
compared to ___, potentially accounted for by the
lower lung volumes. There is increased opacity at the posterior
costophrenic angle on the lateral view. There is no pleural
effusion or pneumothorax. The cardiomediastinal silhouette is
normal.
IMPRESSION: Opacity seen in the posterior costophrenic angle on
the lateral view, potentially secondary to atelectasis given
very low lung volumes on this view. If persistent concern for
infection, repeat with improved insiratory effort can be
attempted.
___ CXR: FINDINGS: PA and lateral views of the chest were
reviewed. Compared to the prior study, there has been rapid
clearance of a left lower lobe opacity that was most likely due
to atelectasis or uncomplicated aspiration. Bibasilar linear
opacities likley represent minimal atelectasis. Normal heart,
mediastinal and pleural surfaces.
IMPRESSION: Rapid clearing of left lower lobe opacity, which
likley
represented atelectasis or uncomplicated aspiration
Discharge Labs:
___ 06:26AM BLOOD WBC-7.0 RBC-4.29 Hgb-12.6 Hct-38.6 MCV-90
MCH-29.3 MCHC-32.6 RDW-14.2 Plt ___
___ 07:30AM BLOOD UreaN-17 Creat-0.9 Na-140 K-3.9 Cl-103
HCO3-29 AnGap-12
___ 06:26AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
Brief Hospital Course:
The patient is a ___ with history of dementia who presented to
ED with AMS and fall, found to have UTI.
.
ACUTE ISSUES
# UTI:
Patient presented with altered mental status superimposed on
baseline dementia, found to have UTI on urinalysis/culture.
There was concern for NPH on head CT, but the findings were not
strong enough to warrant further workup. The patient has a known
diagnosis of dementia. Other labs including TSH were also found
to be normal and CXR was without infectious process. The patient
was found to have a klebsiella UTI and treated with cefpodoxime
for three days with improvement of her mental status to
baseline. Her antibiotic course was completed during the
admission.
.
# s/p fall:
Mechanical fall by history, though quite possibly related to
encephalopathy from UTI. No falls occurred while admitted. A
head CT was performed at time of admission and was without
intracranial hemorrhage or sign of injury. The patient was
evaluated by ___ with clearance for return to assisted living.
.
CHRONIC ISSUES
# Hypothyroid:
Patient is with history of hypothyroidism. TSH found to be
appropriate at time of admission. She was continued on home-dose
levothyroxine.
.
# Hyperlipidemia:
Patient is with history of hyperlipidemia. She was continued on
home-dose pravastatin.
.
# Dementia:
Patient is with history of dementia. She was continued on
home-dose donepezil, memantine, and valproic acid. A valproic
acid level was checked on admission and found to be normal at
74.
.
TRANSITIONAL ISSUES
#Patient will follow-up with PCP at assisted living facility and
work with ___ for mobility.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tolterodine 2 mg PO DAILY
2. Donepezil 10 mg PO HS
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Loratadine *NF* 10 mg Oral qday
5. Memantine 10 mg PO BID
6. Pravastatin 40 mg PO DAILY
7. Divalproex (DELayed Release) 250 mg PO BID
Discharge Medications:
1. Divalproex (DELayed Release) 250 mg PO BID
2. Donepezil 10 mg PO HS
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Memantine 10 mg PO BID
5. Pravastatin 40 mg PO DAILY
6. Tolterodine 2 mg PO DAILY
7. Loratadine *NF* 10 mg Oral qday
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: fall, UTI
Secondary diagnosis: dementia, hyperlipidemia, hypothyroidism,
osteopenia, HTN
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted after you fell and were found to have an infection in
your urinary tract. You were given IV antibiotics and were
switched to oral antibiotics which you will continue to take at
home.
You had testing done after your fall and the results were
reassuring that there was no bleeding in your brain and that
your heart was not causing the fall.
Please see the medication reconcilliation for your medication
regimen.
It was a pleasure taking care of you, thank you for choosing
___!
Followup Instructions:
___
|
10316648-DS-17 | 10,316,648 | 21,709,412 | DS | 17 | 2137-09-16 00:00:00 | 2137-09-16 14:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hip fracture
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty
History of Present Illness:
___ w/severe dementia s/p unwitnessed fall at assisted living
facility earlier today. Believed to have potentially struck her
head on couch. Found shortly after. History obtained via pt's
son ___ ___. She was cognizant when found but unable
to bear weight due to pain RLE. Brought to ___ and found to
have a right displaced femoral neck fx. Prior to fall, per son
pt was ambulatory without assistive devices at her assisted
living home at baseline, walking frequently.
Past Medical History:
Dementia
Chronic Renal Insufficiency (per PCP, but normal creatinine from
office and here)
Hyperlipidemia
Hypothyroid-goiter
Osteopenia
Hypertension
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals:98.4 68 130/50 18 100%
Right lower extremity:
- Skin intact
- No visible deformity
- Soft, non-tender thigh and leg
- TA/Gastrocs fire. Does not wiggle toes independently
- unable to assess sensation
- foot warm and well-perfused
Pertinent Results:
XR: displaced right femoral neck fracture
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 hip fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for right hip hemiarthroplasty, 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 was noted to have leukocytosis on presentation,
which was attributed to stress response. Urinalysis was
positive, and urine culture grew pansensitive citrobacter, which
was treated with a short course of ceftriaxone. A single blood
culture on admission (___) grew gram positive rods consistent
with corynebacterium or propionibacterium spp., though this was
felt to be attributable to contamination. Two sets of repeat
blood cultures on ___ showed no growth on preliminary report.
The patient remained afebrile with no signs of bacteremia or
sepsis during the hospital course. The ___ hospital
course was otherwise unremarkable. The patient worked with ___
who determined that discharge to rehab was appropriate.
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
weight bearing as tolerated on the right lower extremity with
anterior hip precautions, and will be discharged on Lovenox for
DVT prophylaxis. The patient will follow up in Dr. ___
___ per routine. The patient was discharged to rehab with
written instructions concerning post-operative care and
appropriate follow-up.
Discharge Medications:
1. Donepezil 5 mg PO QHS
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Loratadine 10 mg PO DAILY
4. Vitamin D 800 UNIT PO DAILY
5. Acetaminophen 1000 mg PO Q8H
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC DAILY Duration: 3 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
8. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*40 Tablet Refills:*0
9. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right hip fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week. - Resume your
regular activities as tolerated, but please follow your weight
bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated on the right lower extremity,
anterior hip precautions
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 3 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.
Physical Therapy:
Weight bearing as tolerated on the right lower extremity,
anterior hip precautions
Treatments Frequency:
Suture/staple removal at follow up appointment
Followup Instructions:
___
|
10316671-DS-21 | 10,316,671 | 28,910,552 | DS | 21 | 2148-09-05 00:00:00 | 2148-09-11 10:50:00 |
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:
None
History of Present Illness:
This is a ___ yo M with metastatic renal CA s/p IL-2 and Avastin
and most recently Sunitinib who recent cord compression s/p T8
laminectomy and radiation on ___ and C6 Corpectomy and C5-7
anterior fusion on ___ who presented with ___ days of
worsening back pain. Patient had been doing well since his last
surgery ~2 weeks ago but reports that this pain began earlier
this week when he was walking to the kitchen and felt he "threw
out" his back. The pain continued to escalate this week up to
the point that he was unable to move due to excrutiating pain.
He increased is dilaudid dose to 32 mg Q2H and this brought the
pain down to ___ at most. He denies any urinary or bowel
incontinence but it has been hard to get to the bathroom due to
pain. Also his appetite has been poor and he has not been eating
well.
In the ___, VS: 98.0 116 135/80 16 97% RA. The patient was unable
to tolerate MRI secondary to severe pain. He was given
hydromorphone IV. After discussion with the patient's oncologist
Dr. ___ was decided the patient could have an MRI later this
evening or in the morning once he had better pain control.
Neurosurgery was consulted and deemed no active neurosurgical
issues but recommended re-imaging and pain control. Neurology
was consulted and recommended continue adequate pain control and
MRI of the C/T/L spine to see if extension of disease. Rectal
exam was done and pt had normal tone.
Patient was given 3x 2mg IV dilaudid.
Consulting services were neurology and neurosurgery
Final vitals prior to transfer were 98.8 °F (37.1 °C), Pulse:
100, RR: 16, BP: 103/82, O2Sat: 96, O2Flow: ra
Access 20GA R hand
IVF 3L NS
Review of Systems:
(+) Per HPI. (+) Chills, diplopia (unchanged).
(-) Denies fever, night sweats, blurry vision, loss of vision.
Denies headache. Denies chest pain or tightness, palpitations.
Denies cough, shortness of breath. Denies nausea, vomiting,
diarrhea, constipation. Denies dysuria, stool or urine
incontinence. No new weakness in extremities but limited
movement due to pain. All other systems negative.
Past Medical History:
- presented to ___ in ___ c/o abdominal pain and gross
hematuria. CT scan performed and showed a 14-cm tumor on his
left kidney.
- ___: underwent a radical left nephrectomy which showed a
14 x 14 x 10 cm tumor that was of clear cell type, firm and
nuclear grade ___. There was evidence of tumor thrombus
extending
into a large muscular vein at the hilum of the kidney. His left
adrenal gland was removed and was negative for tumor. ___ hilar
lymph nodes, ___ paraaortic lymph nodes and a small bowel lymph
node obtained was negative for malignancy.
- ___: suffered a traumatic work-related fall (fell 25
feet
off a ladder). Standard trauma x-rays and a nonenhanced CT,
showed the presence of new pulmonary nodules.
- ___ CT TORSO: innumerable pulmonary metastases, bulky
mediastinal lymphadenopathy.
- ___: FNA right upper lobe lung nodules showed malignant
cells consistent with metastatic clear cell carcinoma of the
kidney
___: Started on IL-2; received 10 out of 14 doses, first
week was complicated by encephalopathy and the second week was
complicated by renal failure, transaminitis and Staph
epidermitis
bacteremia s/p Vancomycin
- ___ chest CT, no evidence of progression of metastatic
disease
- ___ CT TORSO: progression of disease
- ___: Started Avastin 10mg/kg q2 weeks; CT ___ showed
stable disease
- ___: Cyberknife to subcarinal mass; 2400 cGy in 3
fractions. Avastin on hold.
- ___: Restarted Avastin every 2 weeks.
- ___: Admitted for severe neck pain, MRI showed
degenerative
disc disease. Avastin on hold.
- ___: CT with disease progression in lytic lesions, slight
progression of chest disease
- ___: Avastin resumed 10mg/kg q2 weeks.
- ___: Admitted to ___ with progressive disease
and worsening pain, started on Sunitinib on ___ at a dose of
37.5 mg daily for 4 weeks on, 2 weeks off.
- ___: started cycle 2 of Sunitinib
- ___: presented with RLE weakness and found to have cord
compression at T8; underwent laminectomy on ___. Admitted
___.
___ MRI: new mass lesion in the right petrous apex
and clivus in close proximity to the right sixth cranial nerve.
- ___: radiation to T5-T9, C2-T3, right clivus.
- ___: C6 Corpectomy and C5-7 anterior fusion
.
PAST MEDICAL HISTORY:
GERD
s/p appendectomy at age ___ 25ft fall; suffered bilateral calcaneal fractures,
bilateral tibial fractures, L2 fracture
s/p IVC filter
Depression
Anxiety
Social History:
___
Family History:
Mother had breast cancer but died of alcohol abuse. His brother
also has alcoholic liver disease.
Physical Exam:
Vitals - 98.9 125/80 109 18 96% RA
GENERAL: Uncomfortable due to pain but NAD. Wearing ___ J
brace.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, nontender supple neck, no LAD
CARDIAC: Regular tachycardia, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: Limited due to neck brace and pain but no gross
abnormalities noted. Refused rectal exam given that it had been
done in ___.
Pertinent Results:
___ 03:10PM GLUCOSE-97 UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 03:10PM WBC-4.2 RBC-3.37* HGB-9.5* HCT-29.8* MCV-88
MCH-28.2 MCHC-32.0 RDW-18.2*
___ 03:10PM NEUTS-76* BANDS-1 LYMPHS-14* MONOS-6 EOS-3
BASOS-0 ___ MYELOS-0
___ 03:10PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 03:10PM PLT SMR-LOW PLT COUNT-162#
___ 03:10PM ___ PTT-33.8 ___
.
___ MRI of spine (prior to neurosurgery): IMPRESSION:
Marked relatively short-interval progression of the widespread,
extensive osseous metastatic disease, as detailed above. Most
concerning are:
1. Malignant compression fracture of the C6 vertebral body,
with significant collapse, angular kyphosis and retropulsion of
its dorsal cortex. There is marked canal stenosis and cord
compression at this level, without evidence of cytotoxic edema
within the cord substance at this time.
2. Extensive paraosseous soft tissue mass involving the T2
vertebral body and its posterior elements with large epidural
soft tissue component and cord displacement and effacement;
again, there is no definite abnormality of spinal cord signal at
this level.
3. Destruction of the T8 right posterior elements and
associated rib, with large paraosseous soft tissue mass.
4. Involvement of the T11 and L1 vertebrae with retropulsion of
their dorsal cortex, but no significant canal compromise or
thecal compression.
5. Large lesion in the "superior sulcus" of the right
hemithorax; brachial plexus involvement is not fully assessed on
this examination, but is a consideration.
.
___ MRI of Spine: CONCLUSION: Extensive metastatic disease.
No evidence of tumor progression in the interval since the ___ spine MR. ___ post interval cervical decompression with
no evidence of cord compression. Metastases at T2 and T11
encroach on the spinal cord, unchanged since the prior study.
Decrease in the volume of fluid at the thoracic laminectomy
site. This no longer encroaches on the spinal cord or canal.
Brief Hospital Course:
Brief Assessment: Admitted with much worse lumbosacral pain
after recent C6 corpectomy and C5-7 anterior Fusion for
malignant compression fracture and rapid progression of spinal
mets from ___ while on therapy. Presentation was worrisome for
progression of known spinal metastases and recurrent cord
compression. Initially the patient required high doses of IV
dilaudid for pain control. Because the patient was unable to
undergo MRI except under anesthesia, he was started on high dose
steroids since this would also be an effective treatment for
pain from bone metastases. MRI under anesthesia subsequently
ruled out cord compression. The patient was seen in consultation
with the palliative care service and his pain medications were
titrated up with much improved pain control.
.
# Back pain due to cancer w/o impending cord compression: No
neurologic deficits on admission exam but presentation had been
concerning for impending cord compression given the tempo of his
disease. The patient was unable to tolerate MRI without
anesthesia due to pain and anxiety. Steroids started empirically
for pain and he ruled out for cord compression on ___ by MRI
under anesthesia. He will continue Decadron 4mg Q12 given his
improved pain even though he has no cord compression. He will
taper the dose gradually with a decrease in 1 week to 3 mg Q12.
Dr. ___ primary oncology fellow) will taper his dose
further as outpatient. Methadone dose was titrated up to
40mg-40mg-30mg which he will continue as an outpatient. He will
continue po dilaudid ___ mg Q3H:PRN as well as scheduled
gabapentin. He was advised by the neurosurgery service that he
must wear an Aspen collar at all times even during meals for
next two to three months until advised otherwise b the
neurosurgical service.
.
# Urinary retention: required a foley catheter at the time of
admission (probably due to increase narcotic dose). Foley was
DC'd without difficulty prior to discharge.
.
# Pancytopenia: etiology unclear. Has received extensive XRT to
spine in the past and has extensive ___ metastases so may be
the result of decreased marrow reserve and marrow infiltration.
Did not require transfusion.
.
# HCC: Currently on afinitor (evirolimus). Discussed with
primary oncologist. The patient was restarted on his therapy as
soon as drug was procured and consent obtained. Glu was
monitored carefully without findings of hyperglycemia since MTOR
inhibitors can alter insulin uptake and cause severe
hyperglycemia in setting of steroids. The patient had no
findings of hyperglycemia on afinitor and decadron.
.
# Depression: Continued on sertraline.
.
# Hypothyroidism: continued on levothyroxine at 150mcg.
.
# GERD: continued on ppi.
.
# Hypophosphatemia: repleted po.
.
# Elevated LFTs: trended daily.
.
# PPx: bowel regimen and SQ heparin (cleared with neurosurgery)
.
# Precautions: Hx of positive MRSA screen. Kept on fall
precautions.
.
# Code status: FULL
Medications on Admission:
1. methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*126 Tablet(s)* Refills:*0*
2. sertraline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (___).
Disp:*90 Tablet(s)* Refills:*2*
4. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
Disp:*270 Capsule(s)* Refills:*2*
5. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*.
8. everolimus 10 mg Tablet Sig: One (1) Tablet PO daily ().
9. Dilaudid 8 mg Tablet Sig: ___ Tablets PO q2h as needed for
pain.
Disp:*90 Tablet(s)* Refills:*2
10.clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for Anxiety/pain.
Discharge Medications:
1. methadone 10 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day).
Disp:*240 Tablet(s)* Refills:*0*
2. methadone 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
Disp:*90 Tablet(s)* Refills:*0*
3. sertraline 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO THREE TIMES WEEKLY ON MON WED FRI ().
Disp:*20 Tablet(s)* Refills:*2*
5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
6. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
9. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for Anxiety/pain.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. everolimus 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO twice a day
for 7 days: Then take one and ___ tablets (3mg) and ask Dr.
___ when to lower the dose again.
Disp:*70 Tablet(s)* Refills:*1*
13. hydromorphone 8 mg Tablet Sig: ___ Tablets PO Q3H: PRN as
needed for pain.
Disp:*200 Tablet(s)* Refills:*0*
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Back pain due to spinal metastases
Metastatic renal cell cancer
Urinary retention
Pancytopenia (low blood counts)
Depression
Hypothyroidism
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with new severe back pain. You had an MRI
under anesthesia that did NOT show new tumor on your spinal
cord. Your pain is from renal cancer that has spread to your
bones. You were seen with the palliative care team and your
methadone and dilaudid doses were increased. While you were in
the hospital you needed a foley catheter for several days, but
this was discontinued and you have been able to urinate without
difficulty. The office is trying ot schedule an appointment with
Drs. ___ in two weeks on ___. If you have not
heard within 2 business days or have questions, please call
___.
.
You must wear your ___ neck collar at all times
.
The following changes were made to your medications:
Increase your methadone to 40 mg twice daily and 30 mg at night
Increase your Dilaudid to ___ mg every 3 hours as needed
START Dexamethasone (Decadron) 4 mg twice daily for one week
then take 3 mg twice daily. You should check with Dr. ___ to
see when to lower your dose
START Sulfamethoxazole-trimethoprim one tablet three times a
week on ___ and ___
Followup Instructions:
___
|
10317043-DS-5 | 10,317,043 | 21,515,403 | DS | 5 | 2179-09-09 00:00:00 | 2179-09-10 06:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hand pain
Major Surgical or Invasive Procedure:
___
right brachial artery embolectomy
History of Present Illness:
This is a ___ year old male with a history of atrial fibrillation
not on anticoagulation who presents as an urgent transfer from
___ with a cold, painful right hand. At
the outside hospital, pulses were noted to be absent at the
right wrist. There was significant mottling of the right hand.
He was urgently transferred to ___ for vascular surgery
evaluation. Upon arrival, he was taken to the operating room
emergently for brachial artery embolectomy.
Past Medical History:
PMH: afib (not on coumadin), CHF (EF 15% ___, HTN, R
inguinal hernia, frequent falls, BPH, CAD s/p MI
PSH: tonsillectomy
Social History:
___
Family History:
Noncontributory
Physical Exam:
on arrival
Physical Exam:
Vitals:69 112/52 15 96 RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: iregular
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, right inguinal hernia
reducible
Ext:
RUE: Cool, pale, cyanotic. weak. palpable brachial but you loose
it proximal to antecubital fossa. no radial or ulnar pulse.
diminished sensation, interossei strength ___
LUE: pink, well perfused. palpable brachial, radial and ulnar
pulses
RLE: varicosities. warm, pink well perfused. 0.5x0.5cm ulcer in
base of ___ toe (dorsal aspect). medial malleolar ulcer 1x1cm.
no
erythema or cellulitis. Fem p, Pop d, ___ venous, DP venous, ___
strength, sensation intact
LLE: varicosities. warm, pink well perfused. no ulcers, Fem p,
Pop d, ___ no signals. ___ strength, sensation intact.
On discharge:
AFVSS, non-hypertensive
Gen: NAD, AAOx2, uncertain of location
CV: Irregularly irregular
Pulm: CTAB
Abd: Soft, NT/ND, no rebound/guarding
Ext: Palpable R brachial and R radial pulses. Bilateral arms
with extensive bruising.
Lower extremities cool with pulses as follow:
Fem Pop DP ___
Right: p d venous venous
Left: p d - -
Pertinent Results:
___ ___ ___
Cardiovascular ReportECGStudy Date of ___ 2:45:36 ___
Atrial fibrillation with a controlled ventricular response.
Non-specific
intraventricular conduction delay of the left bundle-branch
block type.
Possible left ventricular hypertrophy. Possible septal
myocardial infarction,
age indeterminate. Non-specific ST-T wave abnormalities could be
due to left
ventricular hypertrophy but cannot exclude myocardial ischemia.
No previous
tracing available for comparison.
TRACING #1
Read ___.
IntervalsAxes
___
___
---------------
___ 91 ___
Cardiovascular ReportECGStudy Date of ___ 5:26:28 ___
Atrial fibrillation with a controlled ventricular response.
Non-specific
intraventricular conduction delay of the left bundle-branch
block. Poor
R wave progression. Cannot exclude a septal myocardial
infarction, age
indeterminate. Non-specific ST-T wave abnormalities. Compared to
tracing #1
the ST-T wave flattening in lead V3 is probably due to
variability in lead
placement.
TRACING #2
Read ___.
IntervalsAxes
___
___
-------------------
___ ___
___
Department of Pathology
Patient Name: ___
___ MRN: ___
___ ___ Birth Date: ___ Age: ___ Y
Sex: M
Surgical Pathology voice:
___
Surgical Pathology Facsimile:
___
Cytology voice: ___
Date of Procedure: ___ ___ #: ___
Date Specimen(s) Received: Patient Location: ___ 5- VICU
___
___
Date Reported: ___ Ordering Provider: ___
___, ___
Responsible Provider: ___
___,
___
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
Brachial artery thrombus, thrombectomy:
- Bland, lamellated, focally organizing thrombus (1.5 cm in
aggregate).
CLINICAL HISTORY: Brachial artery hematoma.
GROSS DESCRIPTION:
The specimen is received fresh labeled with the patient's name,
___, the medical record number, and is
additionally
labeled "thrombus brachial artery". It consists of multiple
fragments
of apparent thrombus measuring 1.5 x 1.0 x 0.8 cm in aggregate.
The
specimen is entirely submitted in cassette 1A.
Residents: ___, ___
By his/her signature, the senior physician certifies that he/she
personally conducted a gross and/or microscopic examination of
the
described specimen(s) and rendered or confirmed the
diagnosis(es)
related thereto.
Immunohistochemistry test(s), if applicable, were developed and
their
performance characteristics were determined by the Department of
Pathology at ___, ___.
They
have not been cleared or approved by the ___. Food and Drug
Administration. The FDA has determined that such clearance or
approval
is not necessary. These tests are used for clinical purposes.
They
should not be regarded as investigational or for research. This
laboratory is certified under the Clinical Laboratory
Improvement
Amendments of ___ (CLIA-88) as qualified to perform high
complexity
clinical laboratory testing. Unless otherwise specified, all
histochemical and immunohistochemical controls are adequate.
***** Electronically Signed Out *****
Diagnosed by: ___, ___, PhD
Signed Out: ___ 19:15
CLIA # ___
Radiology Report ART DUP EXT UP UNI OR LMTD Study Date of
___ 8:55 AM
___ VICU ___ 8:55 AM
ART DUP EXT UP UNI OR LMTD Clip # ___
Reason: RT BRACHIAL THOMBRCTOMY ? EMOBLI PAIN IN HAND
Final Report
DUPLEX DOPPLER EVALUATION OF ARTERIAL INFLOW TO THE RIGHT UPPER
EXTREMITY
HISTORY: ___ male with history of brachial thrombus.
Request is to evaluate.
TECHNIQUE: Grayscale, color and spectral Doppler were used to
evaluate the arterial inflow to the right upper extremity.
FINDINGS: Normal arterial waveforms are seen in the subclavian
and axillary arteries. The waveforms are triphasic. Velocities
in the subclavian and axillary arteries are within normal limits
at around 60 cm/sec. There is non-occlusive thrombus in the
proximal brachial artery but this becomes occlussive more
distally and no flow can be demonstrated in the mid and distal
brachial artery. No demonstrable flow can be seen in the right
ulnar or the right radial arteries.
IMPRESSION: Satisfactory arterial triphasic waveforms in the
right
subclavian, axillary arteries and proximal brachial artery.
Occlusive
thrombus is seen; however, in the mid to distal brachial artery
extending into
both radial and ulnar arteries in which no demonstrable flow can
be seen.
___. ___
___: SAT ___ 12:58 ___
___. ___ VICU ___ 8:56 AM
ART EXT (REST ONLY) Clip # ___
Reason: assess ABI/PVRs b/l ___
Final Report
EXAMINATION: Noninvasive Doppler evaluation of arterial inflow
to both lower extremities.
TECHNIQUE: Ankle brachial indices, Doppler waveform analysis
and pulse volume recordings were performed.
FINDINGS:
RIGHT SIDE: There is severe right-sided disease with a reduced
ankle-brachial index of 0.52 recorded. Monophasic waveforms are
seen in the right femoral , popliteal and posterior tibial
vessels. No dorsalis pedis waveform can be identified. Pulse
volume recordings demonstrate markedly decreased amplitude in
the right calf, ankle and metatarsal levels. Findings are in
keeping with severe right lower extremity inflow disease.
LEFT SIDE: Arterial waveforms in the left femoral, superficial
femoral and popliteal veins are monophasic. No demonstrable
pulse wave form activity could be identified in the left
posterior tibial or dorsalis pedis arteries. No ankle-brachial
index could be recorded. Pulse volume recordings are also
markedly reduced in amplitude in the left calf, ankle and
metatarsal level. Again, findings are in keeping with severe
left-sided insufficiency.
IMPRESSION: Severe peripheral arterial disease with absent
pulses noted in the left posterior tibial, dorsalis pedis and
right dorsalis pedis arteries. Right-sided ABI is significantly
reduced at 0.52.
___. ___
___: SAT ___ 12:57 ___
___ VICU ___ 2:41 ___
ART DUP EXT LOW/BILAT COMP Clip # ___
Reason: Vascular patency
Final Report
INDICATION: ___ male with peripheral vascular disease
and non-healing ulcers.
TECHNIQUE AND FINDINGS: The lower extremity arterial system was
evaluated with B mode, color and spectral Doppler ultrasound.
The right common femoral artery is patent with triphasic Doppler
waveforms. Proximal and mid segment of the right superficial
femoral artery is patent with triphasic waveforms; however, no
flow was demonstrated in the distal segment of the right
superficial femoral artery. No flow was demonstrated in the
right popliteal and posterior tibial arteries.
On the left side, triphasic Doppler waveforms are seen at the
left common
femoral artery. Triphasic Doppler waveforms are also seen at
the proximal and mid segments of the left superficial femoral
artery. Monophasic Doppler waveforms are seen at the distal
segment of the left superficial femoral artery. There is no
evidence of significant flow in the left popliteal and posterior
tibial arteries.
IMPRESSION: No evidence of flow from the distal superficial
femoral to the posterior tibial arteries bilaterally.
Findings correlate with severe peripheral arterial insufficiency
with absent pulses noted on the study performed on ___.
___. ___
___: ___ 7:44 ___
Cardiovascular Report ECG Study Date of ___ 1:53:44 ___
Atrial fibrillation with a slow ventricular response. Left
ventricular
hypertrophy with ST-T wave changes. Left axis deviation.
Compared to the
previous tracing of ___ the ventricular response has slowed.
Otherwise, no diagnostic interim change.
Read by: ___
___ Axes
Rate PR QRS QT/QTc P QRS T
56 0 ___ 0 -32 -147
___ VICU ___ 11:33 AM
CHEST (PRE-OP PA & LAT) Clip # ___
Reason: RIGHT ARM ISCHEMIA
Final Report
REASON FOR EXAMINATION: Evaluation of the patient with
congestive heart
failure and right hand weakness, with reassessment before
surgery.
AP and lateral radiographs of the chest were reviewed with no
prior studies available for comparison.
Heart size is substantially enlarged. Mediastinum is
unremarkable. There is bilateral pleural effusion, small.
There are coronary calcifications noted. Minimal vascular
engorgement cannot be excluded.
___. ___
___: WED ___ 5:47 ___
___ ___ 9:57 AM
___ DUP EXTEXT BIL (MAP/DVT) Clip # ___
Reason: Vein mapping
Final Report
EXAMINATION: Sonographic evaluation of bilateral great and
small saphenous
veins.
INDICATION: ___ year old man with popliteal occlusion RLE and
prev RUE
brachial embolectomy.
TECHNIQUE: Sonographic evaluation of bilateral great and small
saphenous
veins using B-mode and color Doppler.
COMPARISON: No similar prior examination is available for
comparison.
FINDINGS:
The right great saphenous vein measures 0.2 cm in the thigh,
0.19 cm at the popliteal fossa and up to 0.47 cm in the calf.
There are varicosities of the distal right great saphenous vein
below the knee.
The right small saphenous vein measures 0.14 cm cranially and
0.13 cm
caudally. There are calcifications within the right small
saphenous vein.
The left great saphenous vein measures 0.33 cm in the thigh,
0.27 cm at the popliteal fossa and 0.33 cm in the calf.
Calcifications are noted within the left great saphenous vein in
the mid thigh and calf.
The left small saphenous vein measures 0.41 cm cranially and
0.22 cm caudally. Calcifications are noted within the left small
saphenous vein.
IMPRESSION:
Patent bilateral great and small saphenous veins. Measurements
described
above.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___ 5:26 ___
Cardiovascular Report ECG Study Date of ___ 1:12:02 ___
Baseline artifact. Probable atrial fibrillation with a rapid
ventricular
response with a possible ventricular premature beat. Leftward
axis.
Intraventricular conduction delay. Consider left ventricular
hypertrophy with ST-T wave abnormalities of strain and/or
ischemia. Since the previous tracing of ___ the rate is now
faster. ST-T wave abnormalities are more prominent. Axis is more
leftward. ST-T wave abnormalities are more prominent. Clinical
correlation is suggested.
Read by: ___.
___ Axes
Rate PR QRS QT/QTc P QRS T
94 0 ___ 0 -38 127
___ FA5 ___ 11:48 AM
CT HEAD W/O CONTRAST Clip # ___
Reason: Intracranial bleed vs infarction
Final Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with acute mental status change,
history of
atrial fibrillation, now on heparin drip for vascular surgery.
Evaluate for
intracranial hemorrhage versus infarction.
TECHNIQUE: Noncontrast head CT with sagittal and coronal
reformatted images.
DLP 891.93 mGy-cm.
COMPARISON: None
FINDINGS:
There is no acute intracranial hemorrhage, mass effect, loss of
gray/ white matter differentiation, or pathologic extra-axial
collection. There are extensive confluent areas of low density
in the subcortical, deep, and periventricular white matter of
the cerebral hemispheres, likely sequela of chronic small vessel
ischemic disease in a patient of this age. The ventricles and
sulci enlarged secondary to cerebral atrophy. Basal cisterns are
normal in size.
The bones are unremarkable. The imaged paranasal sinuses and
mastoid air cells are essentially well aerated.
IMPRESSION:
No acute hemorrhage. No evidence for an acute major vascular
territorial
infarction. If clinically warranted, MRI would be more sensitive
for an acute infarction, particularly in the setting of
extensive supratentorial white matter abnormalities, which are
presumably sequela of chronic small vessel ischemic disease.
NOTIFICATION: Results were discussed by Dr. ___ Dr.
___ the telephone at 13:00 on ___.
___. ___
___: TUE ___ 1:03 ___
___ 02:35PM ___ PTT-150* ___
___ 02:35PM PLT COUNT-220
___ 02:35PM NEUTS-74.9* LYMPHS-15.0* MONOS-9.1 EOS-0.4
BASOS-0.6
___ 02:35PM WBC-7.1 RBC-4.33* HGB-13.8* HCT-41.8 MCV-97
MCH-32.0 MCHC-33.1 RDW-13.1
___ 02:35PM CALCIUM-9.7 PHOSPHATE-6.2* MAGNESIUM-2.6
___ 02:35PM CK-MB-54* MB INDX-2.6 cTropnT-0.15*
___ 02:35PM CK(CPK)-___*
___ 02:35PM GLUCOSE-184* UREA N-75* CREAT-2.6* SODIUM-142
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-20
___ 12:00AM PTT-68.7*
___ 12:00AM CK-MB-159* MB INDX-2.4 cTropnT-0.15*
___ 12:00AM CK(CPK)-6639*
___ 04:59AM BLOOD ___-5.3 RBC-3.59* Hgb-11.4* Hct-35.3*
MCV-98 MCH-31.7 MCHC-32.2 RDW-13.3 Plt ___
___ 07:40AM BLOOD WBC-6.3 RBC-3.66* Hgb-11.6* Hct-36.0*
MCV-98 MCH-31.6 MCHC-32.1 RDW-13.9 Plt ___
___ 07:55AM BLOOD WBC-7.4 RBC-3.95* Hgb-13.0* Hct-38.3*
MCV-97 MCH-32.9* MCHC-34.0 RDW-14.2 Plt ___
___ 05:10PM BLOOD ___ PTT-35.5 ___
___ 07:40AM BLOOD ___ PTT-130.7* ___
___ 09:00AM BLOOD ___ PTT-88.3* ___
___ 05:20AM BLOOD PTT-85.8*
___ 04:59AM BLOOD Glucose-104* UreaN-40* Creat-1.2 Na-137
K-4.7 Cl-103 HCO3-27 AnGap-12
___ 07:40AM BLOOD Glucose-105* UreaN-35* Creat-1.2 Na-140
K-4.0 Cl-100 HCO3-30 AnGap-14
___ 07:55AM BLOOD Glucose-109* UreaN-35* Creat-1.3* Na-146*
K-4.4 Cl-103 HCO3-24 AnGap-23*
___ 12:00AM BLOOD CK(CPK)-6639*
___ 07:30AM BLOOD CK(CPK)-7082*
___ 01:05PM BLOOD CK(CPK)-6931*
___ 03:57AM BLOOD CK(CPK)-4572*
___ 08:00AM BLOOD CK(CPK)-2657*
___ 07:30AM BLOOD CK(CPK)-2196*
___ 12:00AM BLOOD CK-MB-159* MB Indx-2.4 cTropnT-0.15*
___ 07:30AM BLOOD CK-MB-164* MB Indx-2.3 cTropnT-0.13*
___ 01:05PM BLOOD CK-MB-165* MB Indx-2.4 cTropnT-0.13*
___ 08:00PM BLOOD CK-MB-158* MB Indx-2.2 cTropnT-0.13*
___ 03:57AM BLOOD CK-MB-101* MB Indx-2.2 cTropnT-0.13*
___ 08:00AM BLOOD Calcium-8.7 Phos-2.5* Mg-2.0
___ 07:40AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
___ 07:55AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.0
___ 07:30AM BLOOD Digoxin-0.4*
___ 03:57AM BLOOD Digoxin-0.6*
Brief Hospital Course:
The patient was admitted to the Vascular Surgery service and was
emergently taken to the operating room on ___ for right
brachial artery embolectomy (reader referred to operative report
for details). Following, the patient was transferred to the
PACU. After an uneventful PACU course, the patient was taken to
the VICU on IV heparin.
Outside hospital lab and ECG data were reviewed and the patient
was noted to have ST segment changes in lateral leads and
elevated troponins to 0.63 at the outside hospital. Troponins
were found to be elevated at ___ and similar ECG changes were
noted. Cardiology was consulted who recommended aspirin, statin
and IV heparin for likely NSTEMI. Troponins were trended and ECG
was repeated. Echocardiogram was performed ___ that showed
ejection fraction of 15% but no focal wall motion abnormality.
The patient was also noted to have a significant elevation in
creatinine to more than 2 from a baseline <1. Acute kidney
injury likely secondary to decompensated heart failure in the
setting of NSTEMI was likely cause. With gentle hydration and
improvement of hemodynamics, Cr trended down. In agreement with
cardiology recommendations, ACE inhibitor and lasix were held in
the setting of elevated creatinine.
CK were elevated likely due to ischemia of right upper
extremity. They were trended and gentle IV fluid hydration was
carried out to minimize potential for adverse renal effects of
rhabdomyolysis. CK trended down.
IV heparin was continued postoperatively. Rate control for
atrial fibrillation was pursued with beta blocker. Digoxin was
continued.
On ___, the patient was found to have an absent brachial
pulse which had been present postoperatively ___. Ultrasound
was performed that demonstrated absent flow in the right
brachial artery with clot. The patient was taken to the
operating room ___ for repeat right brachial artery
embolectomy (reader referred to operative note for further
details). ECHO results: EF 15% (baseline), CK 7000, started
500cc fluid at 50cc/hr. A cardiology consult was called. Later
in the day, he had an absent pulse over the brachial site in the
morning and was taken emergently to the OR for embolectomy. A
heparin drip was started.
On ___ we continued the heparin drip, advanced his diet as
tolerated and locked his intravenous fluids. We increased his
heparin drip to 1050cc/hr.
On ___ his digoxin was discontinued, we started coumadin
2mg, and continued the heparin drip. His CK/BUN/Cr were
downtrending.
On ___ 2mg coumadin was given again. The patient refused a
rehabilitation disposition. His CK trend:
7084->4572->2657->2196. He also complained of right lower
extremity pain that has been present for some time. He has to
dangle his foot over the side of the bed for pain relief; this
is how he sleeps nightly. He was offered surgical intervention
if approrpriate.
On ___ he had pre-opeartive orders and was consented for
bilateral angiogram on ___. His heparin drip was discontinued,
at that time was INR 2.5. He was given coumadin 1mg x 1.
___ We restarted lasix given a Cr 1.1 (1.2), we held
enalapril. His INR = 3.4, to prepare him for the procedure, he
was given FFP x 1 which yielded an INR = 2.3. A diagnostic
angiogram revealed a right lower extremity with popliteal
occlusion and 3 vessel run-off.
On ___ the heparin drip was continued. The patient became
more agitated and paranoid per nursing report. A urinalysis was
ordered with urine culture ordered.
On ___ the results from his previous urinalysis were
positive for pseudomonas. He was started on ciprofloxacin
orally.
On ___ he was made nil per os (NPO) at midnight for an
angiogram/possible popliteal stent. He continued to have
intermittent agitation.
On ___ The patient continued to be agitated, a Geriatrics
consult was called. The recommendation was for seroquel orally
at 25 mg x 1. He continued to be agitated after this initial
dose for several hours, pulling at tubes and lines. The patient
was then given a 0.25 mg IM dose of Haldol. Following this he
became somnolent and not arousable. An EKG was non-revealing,
his vital signs were within normal limits, afebrile, making some
purposeful movements spontaneously and withdrawing to noxious
stimuli. He was ordered for 1 mg coumadin; however, the patient
was not arousable and did not take oral medications. We held all
antipsychotics after this change in mental status. His heparin
drip was started at 1000 cc/hour.
On ___ his heart rate was elevated to the 110's, his
medications were adjusted accordingly. He continued to be
somnolent, however, he was arousable and responded to voice,
noxious stimuli and mumbled incoherently with purposeful
movements.
On ___ Discussed goals of care with son and the need for
rehab. Son and older daughter agree to send patient to rehab at
this time.
___: Geriatrics stated they had no new recommendations and
signed off. Patient is discharged to rehab on ___ with
appropriate information, warnings, and follow-up on a heparin
drip with plans to continue raising his INR to therapeutic
levels with continued warfarin.
Medications on Admission:
carvedilol 12.5mg po bid, digoxin 0.125mg po daily, enalapril 10
mg po daily, lasix 40 mg po daily, aspirin daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/headache
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Bisacodyl 10 mg PO/PR BID:PRN constipation
5. Carvedilol 25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Ciprofloxacin HCl 250 mg PO Q24H
9. Heparin IV
No Initial Bolus
Initial Infusion Rate: 950 units/hr
Titrate to PTT ___
10. Warfarin 1 mg PO ONCE Duration: 1 Dose
Titrate to INR 2.0-3.0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right brachial artery embolus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Upper Extremity Thrombectomy Discharge Instructions
WHAT TO EXPECT:
It is normal to have slight swelling of the effected arm:
Elevate your arm above the level of your heart with pillows
every ___ hours throughout the day and at night
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
You ___ shower (let the soapy water run over the arm incision,
rinse and pat dry)
Your incision ___ be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow arm incision to heal)
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in the effected extremity
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from incision site
SUDDEN, SEVERE BLEEDING OR SWELLING in the effected arm
Sit down and have someone apply firm pressure to area for 10
minutes. If bleeding stops, call vascular office ___.
If bleeding does not stop, call ___ for transfer to closest
Emergency Room.
It has been a pleasure taking care of you!
Followup Instructions:
___
|
10317356-DS-5 | 10,317,356 | 25,648,527 | DS | 5 | 2186-08-20 00:00:00 | 2186-08-21 18:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Traumatic injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old gentleman with no significant past medical
who presented to ___ from ___ after a 15
foot fall from a roof. There was no LOC. Workup at ___ showed a
left frontal depressed skull fracture, subdural hematoma &
pneumocephalus, right temporal/occipital subarachnoid
hemorrhage, facial fractures, left scapular fracture, left
distal radius fracture, and left ear avulsion and he was
transferred to ___ for further management.
Past Medical History:
Past Medical History: none
Past Surgical History: none
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS: Temp 99.0, HR 83, BP 138/30, RR 16, SpO2 98% room air
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-) LAD, mucous membranes moist, trachea midline. Left
eyelid ecchymosis/edema without impairment of visual function,
extraocular movements intact, pupils equal, round and reactive
to light. Left ear avulsion repaired with interrupted sutures.
Small superficial abrasions on left forehead.
CHEST: Clear to auscultation bilaterally, (-) cyanosis. No
increased work of breathing noted.
ABDOMEN: Soft, non-tender to palpation, non-distended.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema.
Pertinent Results:
AP CXR & PELVIS PORT (___):
1. No acute cardiopulmonary process. Known left scapular
fracture better seen on CT.
2. No pelvic fracture.
CT CHEST/ABDOMEN/PELVIS (___):
Acute left scapular fracture. Otherwise no evidence of injury in
the chest abdomen or pelvis.
Horseshoe kidney.
RIGHT KNEE X-RAY (___):
No acute fracture. Possible small suprapatellar effusion.
CT SINUS/MANDIBLE/MAXILLOFACIAL (___):
1. Left paramedian frontal, left orbital roof, frontal sinus and
frontal process of the maxilla fractures, as above.
2. Pneumocephalus and known extra-axial hematoma are better
evaluated on the outside hospital CT.
3. Left preorbital hematoma without significant retro-orbital
extension.
CT HEAD/C-SPINE FROM OSH (___):
1. 6 mm left extra-axial hematoma, likely epidural, underlies
the frontal bone fracture with pneumocephalus. No evidence of
herniation.
2. Right subdural hematoma extends along the right tentorial
leaflet.
3. Small amount of right temporal-occipital subarachnoid
hemorrhage.
4. Facial bone fractures are evaluated separately.
5. Metallic foreign body in the left piriform sinus of the
hypopharynx.
6. No cervical spine fracture.
LEFT WRIST X-RAY (___):
Overlying cast obscures fine bony detail. There is an acute
impacted comminuted fracture through the distal left radius with
intra-articular extension. Mild dorsal angulation is noted.
Small osseous fragment also seen at the ulnar styloid, better
seen on prior. No new fracture seen.
REPEAT CT HEAD (___):
1. Left frontal epidural hematoma underlying the frontal bone
fracture with locules of pneumocephalus appears minimally
decreased compared to the prior study.
2. Trace right subdural hematoma along the tentorial leaflet is
unchanged.
3. Trace right temporo occipital subarachnoid hemorrhage
unchanged.
4. No new hemorrhage.
5. Facial bone fractures as better described on the prior
maxillofacial CT report.
Brief Hospital Course:
Mr. ___ was evaluated by the trauma service at ___ in the
emergency department upon arrival and admitted to the trauma ICU
for monitoring. Below is a brief summary of his ICU course:
He was monitored on telemetry and with frequent neurological
checks. He did not have any neurological deficits appreciated.
The plastic surgery service repaired his ear laceration. His
left distal radius fracture was reduced and splinted. The
neurosurgery service was consulted and recommended a week of
seizure prophylaxis with keppra. Repeat head CT showed unchanged
intracranial injuries. The ophthamology service was consulted
regarding his orbital fractures and no globe injury was
appreciated. The ENT service was consulted regarding his
temporal bone fracture and recommended outpatient followup as no
obvious facial nerve injury was appreciated.
The patient was noted to have a stable hematocrit, stable
hemodynamics, and stable neurological exam and was transferred
to the floor on hospital day 2.
He remained stable after transfer to the floor. He was evaluated
by physical therapy, who recommended discharge to home. On
hospital day 3, he was discharged home with a total 5 day course
of ciprofloxacin and with appropriate follow-up instructions.
Medications on Admission:
None
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*8 Tablet Refills:*0
2. LeVETiracetam 500 mg PO BID Duration: 9 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*12 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp
#*30 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Fall from roof leading to a left frontal depressed skull
fracture, subdural hemorrhage and pneumocephalus, right
temporal/occipital subarachnoid hemorrhage, multiple facial
fractures, left scapular fracture, left distal radius fracture
and left ear avulsion.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ after
you fell from a roof. You sustained a number of injuries,
including facial, skull and left forearm and scapular fractures.
Your left ear was avulsed, and this has been repaired. While you
were here, the orthopedic surgeons, neurosurgeons, plastic
surgeons and head and neck surgeons saw and evaluated you and
their recommendations are listed belows:
ORTHOPEDIC SURGERY
* You should follow up with Dr. ___ in the
Orthopedics clinic to plan for repair of your forearm fracture.
Please call ___ to set up an appointment.
* Do not bear weight on your left arm. Please keep the splint on
until you are seen in clinic.
NEUROSURGERY
* The neurosurgeons have recommended a medication called Keppra
(levetiracetam) for seven days. You will be discharged with a
prescription for this medication.
* Please call ___ to make a follow up appointment with
Dr. ___ in ___ weeks. He will obtain a CT scan of your
head at this time.
PLASTIC SURGERY
* Please follow up in the Plastic Surgery Chief Resident's
Clinic on ___. The phone number is ___.
HEAD AND NECK SURGERY
* Please call the ___ clinic at ___ to make
an appointment for an audiogram in ___ weeks.
COGNITIVE NEUROLOGY
* Physical therapy recommended outpatient occupational therapy
follow-up when they evaluated you. Please call the cognitive
neurology clinic at ___ to set up an appointment within
the next week.
Best wishes,
Your surgical team
Followup Instructions:
___
|
10317694-DS-18 | 10,317,694 | 26,269,966 | DS | 18 | 2135-11-04 00:00:00 | 2135-11-04 13:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year odl female known to our service for VP
shunt placement in ___ ___ NPH. She has been
doing well with her shunt, which is a ___ Delta 1.5, and
has had stable CT scans. She reports that this morning after
church she began developing a headache that she described as
being midline at the crown of her head. She has a history of
migraines in the past and this headache is different from her
normal headaches. She came to ___ for evalaution and was found
to have a 7mm right subdural hematoma. She reports a possible
headstrike 10 days ago but no significant trauma. She denies
nausea, vomiting, dizziness, difficulty ambualting, changes in
vision, hearing, or speech. She has no alteration on strength or
sensation.
Past Medical History:
1. Diabetes mellitus type 2 diagnosed ___ year ago
2. High cholesterol
3. Hypertension
4. History of uterine fibroids, last menstrual period ___. Iron deficiency anemia, on iron supplementation
Social History:
___
Family History:
No family history of colon cancer. Mother died at ___ from MI.
Father with ___, and sisters with ___.
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Coordination: normal on finger-nose-finger
On Discharge:
Alert and oriented to person, place and time
Face symmetrical, tongue midline. PERRL, EOMI
No pronator drift
Moves all extremities ___ strength, sensation intact to light
touch.
Pertinent Results:
CT HEAD W/O CONTRAST ___
Right frontal convexity hyperdense extra-axial fluid collection
most
compatible with acute subdural hemorrhage 7.8 mm in maximal
thickness. This demonstrates mild mass effect with subtle
effacement of adjacent sulci. No shift of normally midline
structures.
Stable size and configuration of enlarged ventricles. Right
frontal
ventriculoperitoneal shunt identified, unchanged in position
SHUNT SERIES AP & LAT SKULL, AP CHEST, AP ABDOMEN ___
No evidence of shunt discontinuity
Brief Hospital Course:
___ y/o F with history of VP shunt placement in ___ for NPH
presents with headaches. She reported that she hit her head on
the car door a couple days ago and head CT confirms R SDH. She
was admitted to the ICU for close monitoring. She was
neurologically intact on exam. On ___, patient remained intact.
Repeat head CT showed redistribution of R SDH. Her diet was
advanced and she was OOB with assistance. Transfer order to the
floor were written.
___, the patient remains stable. She was started on a short
course of anti-epileptic medication. She was discharged home in
stable condition after walking with her nurse who felt she
stable.
Medications on Admission:
ASA 81, cozaar, fish oil, januvia, glimepiride, metformin,
toprol xl, zocor
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Hold for sedation. Do not drive or operate machinary while
taking this medication.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
2. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
Do not exceed greater than 4g Acetaminophen in a 24-hour period.
3. Simvastatin 10 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. LeVETiracetam 500 mg PO BID Duration: 7 Days
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
8. glimepiride 2 mg Oral QHS
9. Januvia (sitaGLIPtin) 100 mg oral qdaily
10. MetFORMIN (Glucophage) 500 mg PO QAM
11. MetFORMIN (Glucophage) 1500 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Right Subdural Hematoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
not resume this medication until cleared by Dr. ___ in the
outpatient Neurosurgery office.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring. You will only need to take
Keppra for 7 days (starting ___.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10317978-DS-3 | 10,317,978 | 28,678,656 | DS | 3 | 2120-07-01 00:00:00 | 2120-07-07 16:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
___ year old female who is brought in by EMS for ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old female who is brought in by EMS
for ___. Patient was restrained driver, backing out of driveway
when accidentally stepped on the accelerator and accelerated
backwards with card dropping 20 to 25 feet into
a ravine and rolled over in the process. She self extricated and
was found ambulating on scene, covered in blood with a scalp
laceration and complaining of R knee pain. Patient is ___
speaking so could not provide full history. When
interpreter arrived to ___ patient relayed R hip, R knee
and generally R leg pain
Past Medical History:
uterine fibroids
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Temp: afebrile HR: 100 BP: 108/69 Resp: 13 O(2)Sat: 100
Constitutional: awake, Alert, non toxic
HEENT: +large laceration R parietal region.
c-collar in place
Chest: Clear to auscultation, no CW TTP
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Pelvic: pelvis stable.
Extr/Back: +patellar TTP, no eccymoses. Well-healed scar
on the left shoulder. Acute abrasion on the right scapula.
Skin: head laceration
Neuro: Speech fluent. GCS 15.
Psych: Normal mood, Normal mentation
___: No petechiae
Discharge Physical Exam:
Gen: NAD
HEENT: sutured laceration in right parietal region
Lungs: CTAB
Heart: RRR
Abd: soft, NTND, +BS
Ext: no c/c/e
Pertinent Results:
___ 01:39PM URINE HOURS-RANDOM
___ 01:39PM URINE UCG-NEGATIVE
___ 12:16PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:16PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:16PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 12:16PM URINE MUCOUS-RARE
___ 11:12AM COMMENTS-GREEN TOP
___ 11:12AM GLUCOSE-106* LACTATE-1.5 NA+-140 K+-3.9
CL--105 TCO2-21
___ 10:55AM UREA N-15 CREAT-0.5
___ 10:55AM estGFR-Using this
___ 10:55AM LIPASE-32
___ 10:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:55AM WBC-12.6* RBC-4.35 HGB-13.8 HCT-36.9 MCV-85
MCH-31.7 MCHC-37.5* RDW-12.3
___ 10:55AM PLT COUNT-299
___ 10:55AM ___ PTT-27.9 ___
___ 10:55AM ___
TECHNIQUE: Portable supine AP chest radiograph.
FINDINGS:
Within the limitation of overlying trauma board, there is no
displaced acute
fracture. The cardiomediastinal and hilar contours are within
normal limits.
The lung volumes are decreased but clear. There is no focal
consolidation,
pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
TECHNIQUE: Contiguous axial CT images were obtained through the
brain without
IV contrast. Sagittal, coronal and bone thin algorithm
reconstructions were
generated.
FINDINGS:
There is no hemorrhage, major vascular territory infarction,
edema, mass or
shift of normally midline structures. The ventricles and sulci
are normal in
size and configuration. The basal cisterns appear patent and
there is
preservation of gray-white matter differentiation.
No fracture is identified. There is complete opacification of
the left
maxillary sinus with interspersed areas of hyperdensity, which
could be
related to fungal superinfection. There is mild mucosal
thickening of the
right maxillary sinus. The left sphenoid sinus demonstrates
mucosal
thickening and sclerosis of surrounding bone, indicative of
chronic findings.
The right sphenoid sinus, ethmoidal air cells, mastoid air cells
and middle
ear cavities are clear. Scalp laceration extends from the right
frontal
region to the vertex. There are surgical clips noted overlying
the frontal
scalp, with an underlying small subgaleal hematoma. The globes
are
unremarkable.
IMPRESSION:
1. No intracerebral hemorrhage or acute fracture.
2. Scalp laceration extending from the frontal region to the
vertex on the
right with a small underlying subgaleal hematoma.
3. Chronic maxillary and sphenoid sinus.
TECHNIQUE: Axial MDCT images were obtained through the cervical
spine without
IV contrast. Sagittal and coronal reformats were generated.
FINDINGS:
There is no acute cervical fracture or subluxation. There is no
prevertebral
soft tissue swelling. CT is not able to provide intrathecal
detail comparable
to MRI, however the visualized portion of the thecal sac appears
unremarkable.
The thyroid is within normal limits. No lymphadenopathy is
present by CT size
criteria. Visualized portions of the paranasal sinuses
demonstrate extensive
mucosal thickening within the left maxillary sinus with
interspersed
hyperdensities which can be related to fungal superinfection.
There is
calcification of the nuchal ligament.
IMPRESSION:
No acute cervical fracture or subluxation.
Findings discussed with Dr. ___ the ___ team in person on
___ at
12:00 ___, time of discovery.
TECHNIQUE: ___ MD CT images were obtained through the chest,
abdomen and
pelvis after the uneventful administration of 130 cc Omnipaque
intravenous
contrast.
FINDINGS:
CT OF THE CHEST: The airways are patent to the subsegmental
level. There is
no mediastinal, hilar or axillary lymph node enlargement by CT
size criteria.
There is no evidence of acute aortic injury. The heart,
pericardium and great
vessels are within normal limits. No evidence of a concerning
opacity,
pleural effusion or pneumothorax.
CT OF THE ABDOMEN: The liver enhances homogeneously without
focal lesions or
intrahepatic biliary duct dilatation. The gallbladder is
unremarkable and the
portal vein is patent. The pancreas does not demonstrate focal
lesions,
peripancreatic stranding or fluid collections. The spleen is
homogeneous and
normal in size. The adrenal glands are unremarkable. The
kidneys enhance
symmetrically and excrete contrast without evidence of
hydronephrosis or mass.
There is no bowel obstruction or bowel wall abnormality. The
intra-abdominal
vasculature is unremarkable with normal diameter of the
abdominal aorta and
patent celiac axis, SMA, bilateral renal arteries and ___.
There is no
retroperitoneal or mesenteric lymph node enlargement by CT size
criteria. No
ascites, free air or abdominal wall hernias are noted.
CT OF THE PELVIS: The urinary bladder and terminal ureters are
normal. There
are multiple fibroids within the uterus. A 1.5 x 1.6 cm
heterogeneous lesion
in the right adnexal region could represent an exophytic fibroid
or a corpus
luteum cyst. No pelvic or inguinal lymph node enlargement is
seen. There is
no pelvic free fluid.
OSSESOUS STRUCTURES: No acute fracture is identified. No
blastic or lytic
lesions suspicious for malignancy is present.
IMPRESSION:
1. No acute traumatic injury to the intrathoracic,
intra-abdominal or pelvic
structures.
2. Uterine fibroids.
TECHNIQUE: ___ MD CT images were obtained through the chest,
abdomen and
pelvis after the uneventful administration of 130 cc Omnipaque
intravenous
contrast.
FINDINGS:
CT OF THE CHEST: The airways are patent to the subsegmental
level. There is
no mediastinal, hilar or axillary lymph node enlargement by CT
size criteria.
There is no evidence of acute aortic injury. The heart,
pericardium and great
vessels are within normal limits. No evidence of a concerning
opacity,
pleural effusion or pneumothorax.
CT OF THE ABDOMEN: The liver enhances homogeneously without
focal lesions or
intrahepatic biliary duct dilatation. The gallbladder is
unremarkable and the
portal vein is patent. The pancreas does not demonstrate focal
lesions,
peripancreatic stranding or fluid collections. The spleen is
homogeneous and
normal in size. The adrenal glands are unremarkable. The
kidneys enhance
symmetrically and excrete contrast without evidence of
hydronephrosis or mass.
There is no bowel obstruction or bowel wall abnormality. The
intra-abdominal
vasculature is unremarkable with normal diameter of the
abdominal aorta and
patent celiac axis, SMA, bilateral renal arteries and ___.
There is no
retroperitoneal or mesenteric lymph node enlargement by CT size
criteria. No
ascites, free air or abdominal wall hernias are noted.
CT OF THE PELVIS: The urinary bladder and terminal ureters are
normal. There
are multiple fibroids within the uterus. A 1.5 x 1.6 cm
heterogeneous lesion
in the right adnexal region could represent an exophytic fibroid
or a corpus
luteum cyst. No pelvic or inguinal lymph node enlargement is
seen. There is
no pelvic free fluid.
OSSESOUS STRUCTURES: No acute fracture is identified. No
blastic or lytic
lesions suspicious for malignancy is present.
IMPRESSION:
1. No acute traumatic injury to the intrathoracic,
intra-abdominal or pelvic
structures.
2. Uterine fibroids.
TECHNIQUE: Right knee, 3 views.
FINDINGS:
There is no acute fracture or dislocation. There is no sizable
suprapatellar
joint effusion. Small ossific density posterior to the patella
does not
appear acute. There is a linear density superior to the tibial
spines, which
could represent sequelae from prior injury and likely a chronic
finding.
IMPRESSION: No acute fracture or dislocation.
Brief Hospital Course:
___ is a ___ year old female who was brought to ___ on
___ by EMS for a MVC. She was a restrained driver, backing
out of driveway when accidentally stepped on the accelerator and
accelerated backwards in her car dropping 20 to 25 feet into
a ravine and rolled over in the process. She self extricated and
was found ambulating on scene, covered in blood with a scalp
laceration and complaining of R knee pain. Patient was also
experiencing R hip, R knee and generally R leg pain. Imaging was
obtained of the patient's chest, head, spine, abdomen, pelvis,
and right leg. The patients scalp laceration was closed in the
emergency room, and the patient was admitted to the acute care
surgery service for observation. She was monitored for any
additional injuries or symptoms. The patient experienced nausea
and vomiting the morning following her accident. This resolved
by the time of her discharge. Upon discharge, the patient was
ambulating independently, tolerating regular diet, and had her
pain controlled.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth
every six (6) hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
S/p MVA
Right scalp laceration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please come back to emergency department id:
Fever, nausea, vomiting, change mental status
Increasing redness, pain or discharge from incision
Respiratory distress or any other symptoms that concern you
Followup Instructions:
___
|
10318296-DS-8 | 10,318,296 | 23,857,506 | DS | 8 | 2139-08-28 00:00:00 | 2139-08-29 10:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
Right leg numbness/weakness
Hypotension/Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady with HTN, HLD, DM2 c/b neuropathy, h/o
stroke, Graves disease s/p RAI now hypothyroid, aortobifemoral
bypass who presented to an OSH with R leg numbness, now admitted
for hypotension, tachycardia, hypoxia, leukocytosis, and ___.
Per St ___ discharge summary, the pt was recently admitted to
the hospital ___. She presented complaining of right leg
pain and numbness for which she was seen by neurology who felt
it was ___ osteoarthritis. Given her vascular risks, she had
carotid ultrasoudns demonstrating known bilateral occluded
carotids, R vertebral artery occlusion, and patent L vertebral
artery. She had MRA which demonstrated no abomralities with
aortoiliac vessels. She also was found to have a cr 3.0 and CPK
800s. She had a renal u/s which was normal. Her hctz and acei
were held, and she was treated with IVF with reported resolution
___ and CKs to the 200s. Statin was dced. TSH was noted to be
11.6 and synthroid was increased from 25 to 50.
Per the pt, she has been fine since discharge, but she reports
that for the past 2 days she has had nausea, vomiting, and
diarrhea. She denies bloody stools or black stools. Due to
recurrent RLE pain and numbness on ___ morning, EMS was
called and found her with the following VS at 11:20AM: HR 110,
BP 114/64, RR 18, POx 95%on 2L NC. FSG 318 (she had not taken
insulin today). EKG reportedly showed lateral changes. She was
taken to ___.
At ___, initial VS at 6:30PM were: T 98.5, BP 128/65,
HR 122, RR 16, POx 97%2L NC. Labs were notable for WBC 17.8
(88.6% PMNs, no bands), Hct 32.2 (per OMR was 37 in ___.
BUN/Cr were 53/3.7 (baseline is 0.7), lactate 3.0. CK 843 with
CK-MB 2.4. CT abd/pelvis revealed distended stomach, thickened
& distended distal esophagus, and fluid contents in the colon
c/w diarrhea. She was hypotensive to 88/47. She received 500cc
ns, morphine 4mg, reglan 10mg, zofran 4mg and was transferred to
___ for further management.
In the ___ ED, initial VS were: T 98.5, HR 122, BP 128/69, RR
16, POx 90% on RA, 97% 2L NC. Labs here with WBC 19.4 (87.4%
PMNs, no bands), Hct 31.4 (MCV 100). Na 131, K 5.5, BUN/Cr
57/3.1, glu 534. CK 810, Trop-T <0.01. CXR unremarkable. NG
tube was placed for decompression and returned 400cc dark brown
stomach contents, no bright red blood. On rectal exam had brown
stool. She was started on PPI bolus+drip. For hyperglycemia
received insulin regular 10u IV. BP dropped as low as 90/40 in
the ED and she was given 1.5L NS. She was started on empiric
Levofloxacin and Clindamycin. Foley was placed and she had
300cc urine output. She is admitted to the MICU for
tachycardia, hypotension, concern for GI bleed.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
HTN
HLD
Insulin Dependent Diabetes
CVA ___ years ago
carotid stenosis
peripheral arterial disease
Graves disease s/p PTU/RAI now on thyroid replacement
GERD
Fibromyalgia
Restless leg syndrome
Migraines
Anxiety
Depression
Osteoporosis
Recurrent left hip bursitis
h/o tibial plateau fracture
h/o distal radius fracture
s/p hysterectomy
s/p cholecystectomy
s/p appendectomy
PVD s/p aortobifemoral bypass
Social History:
___
Family History:
One sister with "thyroid problems." No other history of thyroid
problems in the family
Physical Exam:
Admission Physical Exam:
Vitals: T 98.7, BP 92/54, HR 129, RR 16, POx 95% 3L NC
General: Ox3, but with some speech latency and inattentiveness
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, no obvious rubs/murmurs/gallops, regular rhythm
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: epigastric tenderness, mild diffuse tenderness, no
rebound, no guarding, palpable epigastric aortic pulse, multiple
well healed abdominal scars.
GU: foley in place.
Ext: warm, palpable pulses
Neuro: moving all extremities, symmetric pulses
Pertinent Results:
Admission Labs:
___ 10:59PM GLUCOSE-268* UREA N-52* CREAT-2.5* SODIUM-137
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-12
___ 10:59PM ALT(SGPT)-12 AST(SGOT)-22 ALK PHOS-62 TOT
BILI-0.2
___ 10:59PM LIPASE-8
___ 10:59PM CALCIUM-7.1* PHOSPHATE-3.3 MAGNESIUM-1.7
___ 10:59PM D-DIMER-3455*
___ 10:59PM TSH-6.2*
___ 10:59PM WBC-16.0* RBC-2.61* HGB-8.5* HCT-26.3*
MCV-101* MCH-32.4* MCHC-32.2 RDW-14.3
___ 10:59PM NEUTS-79.5* LYMPHS-13.1* MONOS-6.8 EOS-0.3
BASOS-0.3
___ 10:59PM ___ PTT-19.3* ___
___ 10:59PM ___ 08:02PM LACTATE-1.8 K+-5.1
___ 08:01PM URINE HOURS-RANDOM UREA N-333 CREAT-115
SODIUM-41 POTASSIUM-74 CHLORIDE-LESS THAN
___ 07:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:50PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-4
___ 07:50PM URINE HYALINE-14*
___ 07:50PM URINE MUCOUS-RARE
___ 07:02PM GLUCOSE-534* UREA N-57* CREAT-3.1*#
SODIUM-131* POTASSIUM-5.5* CHLORIDE-93* TOTAL CO2-25 ANION
GAP-19
___ 07:02PM ALT(SGPT)-9 AST(SGOT)-24 CK(CPK)-810* ALK
PHOS-78 TOT BILI-0.3
___ 07:02PM LIPASE-9
___ 07:02PM CK-MB-3 cTropnT-<0.01
___ 07:02PM ALBUMIN-3.3*
___ 07:02PM WBC-19.4*# RBC-3.15* HGB-10.3* HCT-31.4*
MCV-100*# MCH-32.5* MCHC-32.7 RDW-14.0
___ 07:02PM NEUTS-87.4* LYMPHS-8.2* MONOS-4.0 EOS-0
BASOS-0.4
___ 07:02PM PLT COUNT-237
___ 07:02PM ___ PTT-27.6 ___
Relevant Labs:
___ 03:40PM BLOOD WBC-13.9* RBC-3.31* Hgb-10.7* Hct-31.7*
MCV-96 MCH-32.4* MCHC-33.9 RDW-15.4 Plt ___
___ 03:30AM BLOOD WBC-8.7 RBC-3.09* Hgb-9.8* Hct-29.3*
MCV-95 MCH-31.9 MCHC-33.6 RDW-15.6* Plt ___
___ 07:02PM BLOOD Glucose-534* UreaN-57* Creat-3.1*#
Na-131* K-5.5* Cl-93* HCO3-25 AnGap-19
___ 10:59PM BLOOD Glucose-268* UreaN-52* Creat-2.5* Na-137
K-4.2 Cl-104 HCO3-25 AnGap-12
___ 03:16AM BLOOD Glucose-124* UreaN-20 Creat-0.9 Na-139
K-3.8 Cl-109* HCO3-19* AnGap-15
___ 01:20PM BLOOD calTIBC-156* Hapto-230* Ferritn-133
TRF-120*
___ 10:59PM BLOOD TSH-6.2*
___ 04:41AM BLOOD TSH-3.6
___ 04:41AM BLOOD Cortsol-25.2*
___ 04:07AM BLOOD pO2-75* pCO2-40 pH-7.30* calTCO2-20* Base
XS--5
___ 04:07AM BLOOD Hgb-9.2* calcHCT-28 O2 Sat-94
___ 01:20PM BLOOD Iron-60
___ 01:20PM BLOOD calTIBC-156* Hapto-230* Ferritn-133
TRF-120*
___ 01:20PM BLOOD LD(___)-206 TotBili-0.3 DirBili-0.2
IndBili-0.1
Discharge Labs:
___ 06:40AM BLOOD WBC-5.6 RBC-3.53* Hgb-11.4* Hct-33.0*
MCV-94 MCH-32.4* MCHC-34.6 RDW-14.9 Plt ___
___ 06:40AM BLOOD Glucose-116* UreaN-9 Creat-0.8 Na-140
K-3.5 Cl-104 HCO3-27 AnGap-13
___ 01:20PM BLOOD LD(LDH)-206 TotBili-0.3 DirBili-0.2
IndBili-0.1
Micro:
BCx ___: Pnd
UCx ___: Negative
Imaging:
TTE ___:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. The left
ventricular cavity is unusually small. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is dilated
with normal free wall contractility. Interventricular septal
motion is normal. The aortic valve is not well seen. The mitral
valve leaflets are not well seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Small hyperdynamic left ventricle. Dilated right
ventricle with preserved free wall contractility. Moderate
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of ___, a
mid-cavitary gradient was not assessed on the current study. The
right ventricle appears dilated on the current study and
estimated pulmonary pressures are higher.
CXR ___:
Single portable view of the chest. NG tube is seen with tip in
the stomach
however the side port is proximal to the GE junction and should
be advanced. There is streaky left basilar opacity most
suggestive of atelectasis. The lungs are otherwise grossly
clear. The cardiomediastinal silhouette is within normal
limits. Orthopaedic hardware seen in the right humeral head.
Osseous and soft tissue structures are otherwise essentially
unremarkable noting right upper quadrant clips.
EKG ___:
Sinus tachycardia. Baseline artifact. Non-specific lateral ST-T
wave
changes. Compared to the previous tracing of ___ the
findings are similar.
CXR ___:
The cardiac size is normal. The position of the nasogastric
tube appears
satisfactory. The lung fields are essentially clear. Some
atelectasis of the left base is again noted. There is no
evidence of failure.
Brief Hospital Course:
Ms. ___ is a ___ lady with HTN, HLD, DM2 c/b neuropathy, h/o
stroke, Graves disease s/p RAI now hypothyroid, aortobifemoral
bypass who presented to an OSH with R leg numbness, and admitted
to ___ for hypotension, tachycardia, hypoxia, leukocytosis,
and ___. She was initially admitted to the floor for several
hours but subsequently transferred to the MICU (___) and
subsequently transferred to the floor. She was treated as below
for her presenting medical problems.
#) Hypotension:
The pt presented with hypotension to the ___, persistent in
the ___ after 2L of fluid. On the floor the pt was s/p 500cc
ns at the osh, 1.5L in the ED, and an additional 8L on the
floor. Her BP is responsive to fluid up to the low 100s, and TTE
demonstrated collapsable IVC. These findings are c/w either a
hypovolemic or septic shock picture. Hypovolemia could be ___
decreased PO intake, exacerbated by diarrhea, vomiting, and
diuresis ___ glucosuria. Also concern for GI bleed (see below).
Unclear etiology of sepsis and pt has not been febrile, however
she did p/w leukocytosis with a neutrophilic predominance. Most
likely source of infection would be GI track, at risk for cdiff
given recent admission and diarrhea (though no recent abx),
viral gastroenteritis. Less likely pna given clear cxr though pt
is newly hypoxic. Also possible bacteremia given recent pIVS
(though no indwelling catheters) with hardware. Pt received
vanc/levoflox/clinda in the ED for empiric infection coverage.
Also concerning given triad of hypotension, tachycardia, and
hypoxia, +elevated d-dimer would be PE. Pt without e/o RH strain
on bedside echo, denies cp, sob. Given TTE and neg CE, warm
extremities and fluid responsiveness, unlikely cardiogenic. Pt
was s/p 10L NS total, 1u prbc, received cipro/flagyl for concern
for GI associated sepsis (DC'd on hospital day 3). Cortisol and
TSH were found to be wnl in MICU. She was monitored for 72
hours off antibiots and continued to do well. She was
normotensive to hypertensive for the remainder of her
hospitalization.
#) Tachycardia: Pt with sinus tachycardia of unclear etiology.
Relatively stable initially in the 130s without apparent
responsiveness to IVF. Possible associated with hypovolemia or
sepsis as above, though would expect some impact with IVF.
Concern for PE as above. Pt was recently increased on dose of
synthroid so possible element of thyrotoxicosis, though only on
low dose. THis resolved during her hospitalization and she was
not tachycardic by time of discharge.
#) Hypoxia: Pt with hypoxia requiring ___ nc (with pO2 ___ on
3Lnc). Unclear etiology. Possible some pulm edema with IVF,
though none seen on CXR from the ED. No known underlying pulm
disease. She was monitered on the medical floor off O2 for more
than 72 hours and she continued to do well. She worked with ___
and did not desat on ambulation. She continued to do well on
room air for the remainder of her hospitalization.
#) ___: Pt presented with Cr 3.7 with report of nl baseline cr,
though recent admission for cr 3.0 resolved with IVF. FeNa
suggestive of prerenal. Pt making good urine that appears clear.
Given elevated CK and mod blood without rbc on u/a, possible
component of rabdo. Improved with IVF and had normalized to 0.8
at time of discharge.
#) Epigastric pain/?UGIB: pt with epigastric pain on exam. Given
hx of AAA, pulsatile epigastrium on exam, and hypotension/tachy,
initial concern for dissection, though reassuring CT non-con. Pt
with hx of GERD, complaining of reflux pain. CT with e/o
distended stomach with concern for gastric outlet obstruction.
NGT in place draining dark appearing, gastrocult+ material
concerning for UGIB. Pt also with significant diabetic
associated neuropathies, could have component of gastroparesis.
GI consulted and outside records were obtained. The patient had
an endoscopy in ___ that was notable for only antral
ulceration and a hiatal hernia. Given the recent scope and that
the patient was hemodynamically stable without signs or symptoms
of bleeding, GI did not recomend repeat EGD. It was thought that
the initial gastrocult+ material was likely from NG Tube trauma.
#) Anemia: HCT trended from 32--> 26 in the setting of fluid
resuscitation. She was transfused 1 unit over concern of UGIB
(see above) and her HCt improved to 28.8 after 1u prbc. He HCT
continued to improve and was 33 at time of discharge without
further intervention. There appears to be a chronic component to
her anemia as her retic count was 2.4 and retic index of 1.4.
Her iron studies we low normal.
#) Elevated CK: potential component of rhabdo from hypovolemia
and potential immobility. Also possible hypothyroid associated
myopathy. THis trended down with fluids on this admission.
CHRONIC:
#) IDDM: no gap, no ketones on admission. THis was stable during
admission with reasonable glucose control.
#) Graves disease s/p PTU/RAI now on thyroid replacement. This
was not active on this admission.
#) Hx AAA s/p repair: recent MRA at ___ reassuring. CT non
con without e/o dissection. Not active on this admission.
TRANSITIONAL ISSUES:
The patient has a history of 2 recent hospitalizations for right
leg numbness that self resolve. Given her history of lower back
pain, outpatient repeat MRI would be warranted. At this point
vascular cause is less likely given reassuring scans.
Anemia: This appears to be chronic given labs. She is not iron
deficient on out labs. Her retic index is low indicating poor
response. This should be followed up on as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 40 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Aspirin 325 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Oxybutynin 5 mg PO DAILY
6. traZODONE 100 mg PO HS
7. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Migraine
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO TID:PRN Pain
9. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
10. cycloSPORINE *NF* 0.05 % ___ BID
11. Ditropan XL *NF* (oxybutynin chloride) 5 mg Oral Daily
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Migraine
2. Aspirin 325 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. cycloSPORINE *NF* 0.05 % ___ BID
5. Glargine 40 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
6. Levothyroxine Sodium 50 mcg PO DAILY
7. traZODONE 100 mg PO HS
8. Ditropan XL *NF* (oxybutynin chloride) 5 mg Oral Daily
9. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
10. Oxybutynin 5 mg PO DAILY
11. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO TID:PRN Pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
Three times a day Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Dehydration
Statin induced myopathy.
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 while you were in the
hospital. You were hospitalized for the numbness in your leg
that had resolved by the time you reached the hospital. You were
found to have a low blood pressure and high heart rate. You were
given 8L of IV fluids and IV antibiotics and you improved. You
were monitored off antibiotics as we were unable to find an
infection and you continued to do well. You were felt to be safe
for discharge.
Followup Instructions:
___
|
10318302-DS-12 | 10,318,302 | 21,648,564 | DS | 12 | 2156-02-20 00:00:00 | 2156-02-20 15:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Diltiazem / Keflex / Cefaclor / Cephalosporins / Zolpidem /
artificial sweeteners
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a complicated past medical history
including ESRD on HD, DM2, CAD, CHF with EF ___, and
recurrent C dif infection and ischemic bowel x 3 resections who
is presenting with abdominal pain.
He's had a very complicated course since his health started
declining in ___ when he was diagnosed with ischemic bowel and
underwent ___ resection. He's struggled with recurrent C
dif that had been refractory to PO vanc, and eventually went
into a sustained remission after being hospitalized here in
___ and getting fidaxomicin. He was admitted to ___ in
___ with ischemic bowel requiring 65cm of small bowel
resection. He was readmitted there in ___ with volume
overload, and again later that month with pulmonary infiltrates,
MRSA bacteremia. He was treated with 8 weeks of vancomycin
(since no TEE was done to confirm endocarditis or ICD lead
infiltration) and received po vanco to prevent CDI. He had
another hospitalization in early ___ with lightheadedness
and possible GI bleed. Due to continued loculated effusion, he
was evaluated by IP and underwent thoracentesis of 50cc of fluid
that was sterile on ___. He was hospitalized ___ with
ischemic colitis that was managed non-surgically, and again ___
with the same diagnosis following HD. It was felt tht he could
not tolerate drops in his BP associated with HD, causing
ischemia. He began HD 5x weekly to combat this problem. He was
again admitted ___ with hypoxia and hypoglycemia but no
infections or ischemia was discovered at that time.
He developed severe abdominal pain yesterday in his lower
quadrants. It was mild before HD, after which it intensified.
He was hypotensive at HD to ___ systolic and got a liter of
fluid back with improvement of the BP. He ate a hamburger for
lunch which further worsened his pain but presented anyways to
an ID followup where he was found to be normotensive but febrile
to 100.4 with chills. He was subsequently referred to the ED.
In the ED, initial vs were: 99.7 100 92/48 19 100% ra. Labs
were remarkable for WBC of 10.2 and lactate to 3.2. His pain
was controlled with morphine. CT of the abdomen and pelvis
without contrast revealed no definite signs of ischemia in the
bowel but ascites was present. Surgery evaluated him and did
not feel he had an acute surgical problem. He got 500cc NS, was
made NPO and admitted to medicine.
On arrival to the floor, the patient feels well. He thinks he
has gas, since his pain is considerably improved with moving his
bowels or with flatus. He does not think the pain is similar to
is ischemic pain, which tends to have accompanying diarrhea.
There is no BRBPR or melena. He feels 70% back to normal. Good
response to morphine. No recent sick contacts, N/V. Pain is in
the lower quadrants, is sore, and does not radiate. Currently
___. No exacerbating factors. No other fevers besides the one
in ___ clinic. Denies dyspnea, coughing, weakness, fatigue, sore
throat, dysuria.
Past Medical History:
1. CHF (systolic, pacemaker/defibrillator placed in ___, EF 15%
in ___
2. MI (in ___, required LAD by-pass surgery (LIMA to LAD),
stent placed in LAD in ___. Has had ___ angioplastie sin
addition to this. Denies any angina in years.
3. DM type II (diagnosed in the ___, baseline ___
140-160's, has been taking glargine insulin since ___,
has mild retinopathy, nephropathy)
4. Chronic kidney disease (baseline creatinine ~ 2.1 for the
last ___ years)
5. Intestinal ischemia ___, required multiple
transfusions, urgent colonic resection at ___, recovery has been complicated by blood
loss/anemia/transfusion requirements, most recent transfusion
occurred during hospitalization for anemia ~ 2 weeks ago)
6. C-difficile infection (___)
7. Depression
8. Herpes zoster/shingles (in ___, c/b post-herpatic
neuralgia for which he continues to have pain, requires
hydrocodone-acetaminophen prn)
9. Glaucoma - well controlled
10. Cataracts - ops on both eyes
11. Abdominal hernia repair (many years ago)
12> Gastritis and duodenitis on recent ___
.
Operative history
Laparotomy for ischemic gut in ___ (At ___ 2 staged procedure;
closed on a later day)
Abdominal hernia repair (many years ago)
CABG
Bilateral cataracts
Appendectomy
Tonsillectomy
Social History:
___
Family History:
Mother - ___ died at ___ years
Father - T2DM
Paternal uncle - T2DM
Brother and sister - well
Children x2 well
Physical Exam:
Admission:
Vitals: T98.2 BP113/59 P92 RR20 Sat94/2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: no JVD
Lungs: bibasilar crackles, worse R>L
CV: Regular rate and rhythm, normal S1 + ___ SEM at the apex
Abdomen: +distention. midline surgical scar clean with mild
scabbing. +shifting dullness. Mild TTP on deep palp of the LLQ.
No rebound or guarding.
Ext: Warm, well perfused, 1+ DP pulses. Chronic erythematous
changes seen on both legs
Neuro: AAOx3 normal strength throughout
Discharge:
Vitals: Tm99.2 BP 84-92/40-50 P85-95 RR20 Sat93% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: no JVD
Lungs: bibasilar crackles, worse R>L
CV: Regular rate and rhythm, normal S1 + ___ SEM at the apex
Abdomen: +distention. midline surgical scar clean with mild
scabbing. +shifting dullness. Mild TTP on deep palp of the LLQ.
No rebound or guarding.
Ext: Warm, well perfused, 1+ DP pulses. Chronic erythematous
changes seen on both legs
Neuro: AAOx3 normal strength throughout
Pertinent Results:
Admission:
___ 06:00PM BLOOD WBC-10.2# RBC-2.97* Hgb-9.5* Hct-30.4*
MCV-102* MCH-31.8# MCHC-31.1 RDW-18.8* Plt ___
___ 06:00PM BLOOD Glucose-213* UreaN-18 Creat-2.9*# Na-134
K-3.8 Cl-91* HCO3-28 AnGap-19
___ 06:00PM BLOOD ALT-36 AST-59* AlkPhos-522* TotBili-0.9
___ 06:00PM BLOOD Albumin-2.8* Calcium-8.5 Phos-3.1 Mg-2.1
Discharge:
___ 06:05AM BLOOD WBC-6.6 RBC-2.76* Hgb-9.0* Hct-29.3*
MCV-106* MCH-32.5* MCHC-30.6* RDW-18.3* Plt ___
___ 06:05AM BLOOD Glucose-123* UreaN-17 Creat-3.0* Na-135
K-3.7 Cl-95* HCO3-30 AnGap-14
___ 06:20AM BLOOD ALT-34 AST-42* AlkPhos-528* TotBili-1.0
___ 06:05AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0
___ 06:20AM BLOOD Digoxin-1.5
Imaging:
CT abd/pelvis:
IMPRESSION:
1. Interval increase in large intra-abdominal ascites compared
to the prior Chest CT.
2. Intact anastomoses with contrast seen passing to the proximal
colon. No evidence of wall thickening or intra-abdominal free
air to suggest ischemic bowel.
3. Interval improvement in the right sided loculated pleural
effusion.
Brief Hospital Course:
# ABDOMINAL PAIN: Patient was at an outpatient ID follow up
appointment when he developed severe lower abdominal pain after
eating a hamburger and fries for lunch. Given history of ichemic
colitis following dialysis (which he had earlier that mornin) he
was sent to the ED. In the ED he was found to have a low grade
fever to 100.3. A CT abdomen/pelvis was unconcerning for acute
changes with no signs of ischemia. He noted pain was more
cramping and different than usual abdominal pain. He received
simethicone with improvement in symptoms. On admission, he rated
his abdominal pain a ___. He continued to have well formed
bowel movements and never experienced nausea. He was placed
under observation and his blood cultures were no growth and he
had no further fevers. Pt does note he often experiences feves
following dialysis. His initial symptoms were most likely
secondary to bloating and/or ascites. His ascites his chronic
and thought to be secondary to heart failure as he has no other
signs of decompensated liver disease. His alk phos was found to
be elevated this admission but appears to have been elevated
over the last several months on outpatient labs and has been
fractionated to bone alk phos.
# ESRD on HD: He received dialysis this admission. He continues
to receive low volume dialysis 5 times per week. Midodrine was
continued 3 time daily to support blood pressure.
# CONGESTIVE HEART FAILURE: Pt has severe systolic dysfunction.
He had crackles and ascites on exam which is his recent
baseline. He was asymptomatic and had no other signs of
decompensated disease. His toresemide, metoprolol, and
lisinopril were initially held but restarted at discharge given
stable blood pressure.
#CORONARY ARTERY DISEASE: continued ASA and statin
# MRSA BACTEREMIA: s/p complete course of vanco. Never had a
TEE to r/o endocarditis. Given clinical improvement this
admission, further work up deferred to outpatient setting if ID
feels this should be completed
# RECURRENT C DIF: No current symptoms
Transitions of Care:
#Pt's midodrine should be downtitrated as tolerated to prevent
complications of CAD
#Further endocrine evaluation of his elevated alk phos
#Possible TEE for history of MRSA bactermia in past, never
received endocarditis work up.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES DAILY
3. Gabapentin 300 mg PO HS
4. Midodrine 5 mg PO TID
5. Glargine 40 Units Bedtime
6. Omeprazole 40 mg PO DAILY
7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
8. Simvastatin 20 mg PO DAILY
9. Tamsulosin 0.4 mg PO HS
10. Cyanocobalamin 1000 mcg IM/SC MONTHLY
11. Digoxin 0.125 mg PO 3X WEEKLY
12. Epoetin Alfa ___ UNIT IV AS DIRECTED
13. Lisinopril 2.5 mg PO DAILY
14. Metoprolol Succinate XL 12.5 mg PO DAILY
15. Nitroglycerin SL 0.4 mg SL PRN cp
16. Torsemide 100 mg PO 4X WEEKLY
17. Paricalcitol 0 mcg IV PER HD
18. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Abdominal bloating
Secondary Diagnosis:
Systolic heart failure
End stage renal disease on hemodialysis
Hx of ischemic colitis status post resection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came in from your clinic appointment with
abdominal pain and fever to 100.3. A CT scan of your abdomen had
no concern findings including no signs of ischemic bowel. Your
symptoms improved soon after admission. We believe your
abdominal pain was due to bloating and gas. It improved after
you passed gas. You will continue dialysis on ___. We
recommend you follow up with your PCP within the ___ week.
Followup Instructions:
___
|
10318302-DS-14 | 10,318,302 | 20,603,801 | DS | 14 | 2156-06-14 00:00:00 | 2156-06-13 17:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Diltiazem / Keflex / Cefaclor / Cephalosporins / Zolpidem /
artificial sweeteners, aspartame
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
femoral line placement
arterial line placement
History of Present Illness:
___ CAD, CHF, ESRD on HD h/o ischemic bowel s/p multiple
resections presents with one episode of grossly bloody diarrhea
and diffuse abdominal pain consistent with prior ischemic
colitic episodes, in the setting of 3 weeks watery diarrhea. The
patient reports that for the past three weeks he has been
suffering from ___ watery bowel movements daily, not reponsive
to immodium. He reports starting lomotil two days prior to
admission, with subsequent decreased stooling and onset of
mid-abdominal pain the night prior to admission. He states that
around 2am he then had a grossly bloody bowel movement with
diffuse abdominal pain that is consistent with prior episodes of
ischemic bowel disease. He reports that the abdominal pain has
been constant since that event. He also reported small amount of
vomiting clear fluids, but no blood or coffee grounds.
The patient presented to an outside hospital, where a CT was
performed and was concerning for ischemic colitis. He had blood
pressures in the ___ to ___ systolic there he received 1 L of
normal saline prior to transport. No pressors were started at
OSH. He was given IV ciprofloxacin and Flagyl prior to
transport.
In the ED, he remained afebrile, but BPs dropped to ___
systolic. He was mentating well at that time. He was given an
additional liter of normal saline with minimal response in BP.
He was then started on norepinephrine 0.06 titrated to 0.1 with
systolic BPs in 100s. Left femoral CVC was placed in addition to
3 #20 peripheral IVs. GI was notified and transplant surgery
evaluated in ED with no recommendations at this time.
On arrival to the MICU, Mr ___ was complaining of continuing
abdominal pain, but appeared comfortable lying on his back. He
reported no bowel movements since initial 2am bloody BM at home.
He denied any chest pain, dyspnea, nausea at that time. He
denied any fevers, sweats, chills at home. His initial vitals
were T: 36.7 HR: 86 BP: 105/62 RR: 14 SpO2: 97% on room air.
Past Medical History:
1. CHF (systolic, pacemaker/defibrillator placed in ___, EF 15%
in ___,
2. CAD s/p MI (in ___ CABGx1, stent placed in ___,
3. DM type II,
4. ESRD on HD since ___. Now low volume HD five
times a week since ___ ___V fistula (M/T/R/F/Sa),
5. Intestinal ischemia: First episode ___, required
urgent colonic resection at ___. Second
episode on ___ that required new surgery. Patient had
two new episodes of ischemic bowel (with intestinal pneumatosis)
in ___ and ___,
6. C-difficile infections,
7. depression,
8. hx HZV/shigles c/b post-herpetic neuralgia,
9. glaucoma, cataracts
PSgH:
1. pacemaker placement (___),
2. CABG x1 (___) with stent placement ___,
3. ex-lap/colon resection ___, ___,
4. ex-lap/? SBR for internal hernia ___, ___,
5. abdominal incisional hernia repair (___),
6. RUE brachiocephalic fistula ___, ___,
7. cholecystectomy (___)
Social History:
___
Family History:
Mother - ___ died at ___ years
Father - T2DM
Paternal uncle - T2DM
Brother and sister - well
Children x2 well
Physical Exam:
Admission exam
Vitals- T: 36.7 BP: 105/62 P: 86 R: 14 O2: 97% room air
General- Pleasant gentleman appearing older thans stated age,
pallid complexion, but breathing comfortable in no apparrent
distress
HEENT- Pupils miotic but responsive to light, EOMI, Dry mucous
membranes, OP clear
Neck- soft, supple, JVP difficult to appreciate, no LAD
CV- regular rate and rhythm, soft systolic murmur LUSB
Lungs- diminished right base, bibasilar crackles R>L
Abdomen- soft, mild tenderness low midline, no guarding
GU- no foley in place
Ext- cool to touch, no mottling, doppler pulses x3 bilateral
lower extremities, cool hands with diminished radial pulses
Neuro- A&Ox3. Moving all extremities
Discharge exam
PHYSICAL EXAM:
VS: 98.1 80-90/40s ___ 100 100% RA 79.7 kg
tele: a-v pacing
Gen: NAD, pleasant male, appears older than his age, cooperative
with exam
HEENT: NC/AT, PERRL, EOMI, sclera anicteric, no conujunctival
injection, oropharynx clear
Neck: supple, no LAD, no JVP elevation
CV: distant heart sounds, RRR, nl s1/s2, ___ SEM at R and L USB,
no rubs or gallops
Resp: decreased BS at bases b/l, crackles at b/l bases about ___
up, no wheeze or rhonchi
Abd: obese, soft, mild LLQ tenderness, no rebound or guarding,
non-distended, normoactive bowel sounds
Ext: warm, 2+ radial pulses b/l, no edema
Neuro: aaox3, moves all 4 extremities
Pertinent Results:
admission labs:
___ 01:38PM BLOOD WBC-16.4*# RBC-3.45* Hgb-10.6* Hct-32.7*
MCV-95 MCH-30.6 MCHC-32.3 RDW-17.0* Plt ___
___ 01:38PM BLOOD Neuts-85.0* Lymphs-9.4* Monos-4.8 Eos-0.5
Baso-0.3
___ 01:38PM BLOOD ___ PTT-49.3* ___
___ 01:26PM BLOOD Glucose-113* UreaN-19 Creat-4.8* Na-133
K-3.8 Cl-96 HCO3-26 AnGap-15
___ 01:26PM BLOOD ALT-22 AST-43* AlkPhos-259* TotBili-0.8
___ 01:26PM BLOOD Lipase-11
___ 07:39PM BLOOD cTropnT-0.12*
___ 01:26PM BLOOD Albumin-2.0* Calcium-7.6* Phos-4.0 Mg-1.7
___ 08:03PM BLOOD Type-ART Temp-36.7 O2 Flow-2 pO2-103
pCO2-40 pH-7.41 calTCO2-26 Base XS-0 Intubat-NOT INTUBA
Comment-NASAL ___
___ 01:47PM BLOOD Lactate-2.5*
other pertinent labs
___ 02:02AM BLOOD cTropnT-0.14*
___ 02:02AM BLOOD Hapto-109
___ 04:21AM BLOOD Cortsol-19.0
___ 09:19PM BLOOD Lactate-1.2
discharge labs
___ 08:00AM BLOOD WBC-9.4 RBC-3.22* Hgb-9.8* Hct-31.0*
MCV-97 MCH-30.3 MCHC-31.4 RDW-18.5* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-234* UreaN-14 Creat-5.4* Na-137
K-3.8 Cl-100 HCO3-26 AnGap-15
___ 08:00AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.7
micro:
-blood cultures x 2 -
-C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay. (Reference Range-Negative).
studies:
CXR:
Stable cardiomegaly, and unchanged position of pacing and ICD
leads. Pulmonary vascularity is normal. Lungs are clear except
for linear opacities in the right mid and lower lung, which may
reflect a combination of atelectasis and scarring. Small
pleural effusions are present bilaterally.
.
ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF= ___ %). The enitre septum and
true apex are akinetic with hypokinesis of most remaining
segments; the lateral segments contract best. A left ventricular
mass/thrombus cannot be excluded. The right ventricular cavity
is dilated with depressed free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
are mildly thickened (?#). There is no aortic valve stenosis.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid regurgitation is seen. [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
IMPRESSION: Dilated right and left ventricles with severely
depressed left biventricular systolic function and regional wall
motion abnormalities, as described above. Mild mitral
regurgitation. Severe tricuspid regurgitation. At least moderate
pulmonary artery systolic hypertension.
___ Cardiac Catherization
Assessment & Recommendations
1. Moderately elevated right and left heart pressures, low
normal cardiac index
2. Significant RCA lesion stented with BMS
3. No significant LCA disease
4. Aspirin indefinitely; clopidogrel minimum 1 month but
preferably 6 months
Brief Hospital Course:
___ with history of CAD, ischemic CM EF 15% s/p pacer/ICD, ESRD
on HD (5 times weekly) and ischemic colitis s/p right colonic
resection/small bowel resection admitted with ischemic colitis.
# Systolic cardiomyopathy/Cardiac Catheterization. The patient
has severely depressed EF s/p pacer/ICD with an overall left
ventricular systolic function ___. The patient was
transferred to the ___ cardiology service following resolution
of his hypotension (see below). Echocardiogram showed wall
motion abnormalities inconsistent with his prior known coronary
artery disease. He underwent cardiac catherization which showed
an 80% stenosis of his RCA for which he received a bare metal
stent. Although his prognosis with respect to his heart failure
is poor, hopefully this stent will improve his functional
abilities. Palliative care was consulted and offered support to
the patient. His hope is to live long enough to see family
milestones happening in ___. He will be discharged with plavix,
metoprolol daily as tolerated if blood pressure >100, digoxin,
and rosuvastatin as his cardiac medications. He will require an
outpatient echo to evaluate for progress.
# Hypotension - The patient reports baseline SBP 80-100.
Worsening hypotension likely in the setting of several weeks of
watery diarrhea leading to volume losses and ischemic colitis.
He also reported missing several midodrine doses. He required
pressors for < 24 hours. No clear evidence of infection, but was
started on broad-spectrum antibiotics for moderate/severe
colitis. His midodrine dose was increased and he was started on
fludricortosone for blood pressure support. On transfer out of
the ICU his SBP was in his baseline range. His blood pressure on
the floors remained ___ with two occassions with blood
pressure in the ___. One of these episodes occurred in the
setting of dialysis for which he was symptomatic. He recovered
with gentle fluids. Discharge blood pressure was stable.
# Colitis - Initially believed to be related to ischemic
colitis. For this reason his digoxin was stopped. He was given a
5 day course of cipro/flagyl for intra-abdominal prophylaxis in
the setting of ishemic colitis and GI bleed. GI was consulted,
and believed that this was more likely an infectious colitis
picture although stools studies are negative. For this reason,
digoxin was resumed once the patient was transferred to the ___
cardiology service.
# ESRD on HD 5 times weekly. Began HD in ___ secondary to
cardiorenal syndrome. He has been on HD 5 times per week because
of his labile blood pressure and was unable to tolerate larger
UF times. His EDW is 77kg. The inpatient renal team evaluated
him on a daily basis for need of dialysis. Prior to discharge he
had a session of dialysis but this session was cut short due to
symptomatic hypotension. This episode with gentle fluids.
# Anemia: Chronically anemia in the setting of end stage kidney
disease. Acutely exacerbated in the setting of bacterial GI
infection, dilution because of large volume rescusitation. His
Hct was stable prior to discharge.
# DM: Placed on sliding scale insulin while hospitalized.
Transitional Issues
- Patient saw palliative care in house for severe heart failure
- his prognosis is poor and he is amenable to palliative care
services
- The patient will require follow up echocardiogram to evaluate
progress of heart failure
- Patient knows to take home blood pressure measurements and to
take metoprolol only if SBP>100
- If there is evidence of mesenteric ischemia in the future,
removal of digoxin can be considered
- Patient is on dialysis 5 days per week due to hypotension.
- Code status in house was clarified: He is NO CPR. However,
okay for ICD to shock and okay for intubation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Gabapentin 300 mg PO HS
3. Mirtazapine 15 mg PO HS
4. Nephrocaps 1 CAP PO DAILY
5. Pravastatin 40 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Vitamin D 1000 UNIT PO DAILY
8. Artificial Tears ___ DROP BOTH EYES PRN eye dryness
9. Digoxin 0.125 mg PO 3X/WEEK (MO,TH,SA)
10. Metoprolol Succinate XL 25 mg PO 2X/WEEK (___)
11. NexIUM (esomeprazole magnesium) 20 mg Oral daily
12. Midodrine 5 mg PO TID
13. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
Discharge Medications:
1. Aspirin 325 mg PO DAILY
DO NOT STOP TAKING THIS MEDICATION BEFORE TALKING TO YOUR
CARDIOLOGIST FIRST
RX *aspirin 325 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
2. Digoxin 0.125 mg PO 3X/WEEK (MO,TH,SA)
3. Diphenoxylate-Atropine 1 TAB PO Q4H:PRN diarrhea
RX *diphenoxylate-atropine [Lomotil] 2.5 mg-0.025 mg 1 tablet(s)
by mouth every 4 hours Disp #*90 Tablet Refills:*2
4. Midodrine 7.5 mg PO QID
RX *midodrine 2.5 mg 3 tablet(s) by mouth before dialysis Disp
#*90 Tablet Refills:*3
5. Nephrocaps 1 CAP PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Clopidogrel 75 mg PO DAILY
DO NOT STOP TAKING THIS MEDICATION UNDER ANY CIRCUMSTANCES
BEFORE TALKING TO YOUR CARDIOLOGIST
RX *clopidogrel 75 mg 1 tablet(s) by mouth once per day Disp
#*30 Tablet Refills:*3
9. Fludrocortisone Acetate 0.1 mg PO DAILY
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth once per day
Disp #*30 Tablet Refills:*2
10. Artificial Tears ___ DROP BOTH EYES PRN eye dryness
11. Gabapentin 300 mg PO HS
12. Mirtazapine 15 mg PO HS
13. NexIUM (esomeprazole magnesium) 20 mg ORAL DAILY
14. Tamsulosin 0.4 mg PO HS
15. Metoprolol Succinate XL 25 mg PO 2X/WEEK (___)
Take this medication when your systolic blood pressure is
measured >100
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: colitis, coronary artery disease, heart failure
Secondary: hypotension, ESRD on dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Hello Mr. ___,
It was a pleasure taking care of you at the ___
___. You came to the hospital after having
a bloody diarrhea. This decreased your blood pressure so you
needed to stay in the ICU. You recieved IV fluids and
medications to maintain your blood pressure. Your blood
pressures improved and you were transferred to a general
medicine floor. There your midodrine dose was increased and you
were started on fludricortisone to help increase your blood
pressure. You were also given an antibiotic course to treat you
because the blood diarrhea was likely due to infection. You were
then transferred to the cardiology service for your heart. There
you received a catheterization proedure and a stent was placed
to improve the blood flow to your heart. Now you are ready to go
to rehabilitation.
New medications:
Clopidogrel 75 mg every day to keep your stents open. DO NOT
STOP UNLESS YOU TALK TO YOUR CARDIOLOGIST FIRST
Fludrocortisone Acetate: 0.1 mg by mouth daily for your blood
pressure
Medication changes:
Aspirin 325 mg once per day instead of 81 mg once per day
Lamotil 1 pill every 4 hours as needed for diarrhea
Midodrine 7.5 mg before dialysis
Please continue to take the rest of your medications and follow
up with your doctors.
Followup Instructions:
___
|
10318555-DS-11 | 10,318,555 | 20,623,686 | DS | 11 | 2189-01-06 00:00:00 | 2189-01-06 18:55:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Doxycycline / Citalopram / bee venom (honey bee) /
antihistamines
Attending: ___.
Chief Complaint:
confusion, falls, weakness
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ woman with HCV cirrhosis (s/p Harvoni and
Ribavarin) decompensated by ascites, PHG, HE s/p TIPS and recent
embolization of her portosystemic collaterals, on the transplant
list, who presented from clinic with altered mental status,
recent falls, and failure to thrive.
Per ED Dashboard: "Patient reports worsening cough for the last
couple of days. With your PCP last week and was given antibiotic
and thought cough was ultimately due to postnasal drip. She
states this cough is now returned. No shortness of breath no
chest pain."
Per Dr. ___ clinic note ___: "She has recently
had TIPS and embolization of her portosystemic collaterals and
this has resulted in significant improvement in her
encephalopathy, however she did have an episode of nausea and
vomiting which lasted this a few days. This occurred a few days
ago. Since then she has had increasing shaking of her hands and
increasing falls. Her bowel movements have been at their
baseline with 5 bowel movements per day. She has had one
episode
of black stool. This has not continued. She had no hematemesis
or melena. In the past few days she is had multiple falls. In
addition she has had myoclonic jerks and was unable to drink a
hot chocolate this morning without spilling it and necessitate
the use of a straw."
Past Medical History:
Cirrhosis, hypertension, hypothyroidism, and depression.
Cholecystectomy, prior C-sections.
Social History:
___
Family History:
Sister passed away from complication of hepatitis C mediated
cirrhosis
Physical Exam:
ADMISSION PHYSICAL EXAM:
==============================
VITALS:98.0, 104 / 63, 83, 18, 93% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: RRR. +SEM heard best at RUSB.
LUNGS: CTAB - No wheezes, rhonchi or rales.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Alert, oriented x3. Slow to respond to questions.
+Asterixis
DISCHARGE PHYSICAL EXAM:
=========================
24 HR Data (last updated ___ @ 1132)
Temp: 97.8 (Tm 98.2), BP: 108/72 (94-108/57-72), HR: 63
(55-63), RR: 18 (___), O2 sat: 95% (94-97), O2 delivery: Ra,
Wt: 158.4 lb/71.85 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: RRR. +SEM heard best at ___.
LUNGS: CTAB - No wheezes, rhonchi or rales.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: Alert, oriented x3. Slow to respond to questions.
+Asterixis
Pertinent Results:
ADMISSION LABS:
==================
___ 03:52PM BLOOD WBC-1.9* RBC-2.31* Hgb-9.7* Hct-29.0*
MCV-126* MCH-42.0* MCHC-33.4 RDW-16.4* RDWSD-75.1* Plt Ct-42*
___ 03:52PM BLOOD ___ PTT-33.4 ___
___ 03:52PM BLOOD Glucose-112* UreaN-13 Creat-0.6 Na-135
K-4.3 Cl-102 HCO3-22 AnGap-11
___ 03:52PM BLOOD ALT-20 AST-47* AlkPhos-106* TotBili-2.4*
DirBili-0.9* IndBili-1.5
___ 06:59AM BLOOD Albumin-2.6* Calcium-8.2* Phos-3.4 Mg-1.9
___ 03:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:52PM BLOOD TSH-3.6
___ 03:52PM BLOOD VitB12-830 Folate-6
___ 04:02PM BLOOD Lactate-1.0
DISCHARGE LABS:
===================
___ 05:54AM BLOOD WBC-2.2* RBC-2.26* Hgb-9.5* Hct-27.9*
MCV-124* MCH-42.0* MCHC-34.1 RDW-15.1 RDWSD-69.0* Plt Ct-38*
___ 05:54AM BLOOD Glucose-99 UreaN-13 Creat-0.6 Na-136
K-4.0 Cl-102 HCO3-27 AnGap-7*
___ 05:54AM BLOOD Calcium-8.3* Phos-4.0 Mg-1.7
PERTINENT IMAGING:
===================
CXR
IMPRESSION:
No acute cardiopulmonary abnormality.
CT HEAD
IMPRESSION:
No acute intracranial abnormality.
RUQUS
IMPRESSION:
1. Patent TIPS.
2. Cirrhotic liver, with interval increase in splenomegaly, now
measuring 18.6
cm, previously 15.0 cm. No ascites or worrisome hepatic lesions
PERTINENT MICRO:
=================
___ 3:52 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to datE
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
=========================
Ms. ___ is a ___ woman with HCV cirrhosis (s/p Harvoni and
Ribavarin) decompensated by ascites, PHG, HE s/p TIPS and recent
embolization of her portosystemic collaterals, on the transplant
list, who presented from clinic with altered mental status,
recent falls, and failure to thrive.
Her lactulose was briefly uptitrated to every 2 hours and her
encephalopathy improved. There is concern that she may not be
taking her medications as ordered. She is also on several
sedating medications including morphine. and compro. She was
also evaluated by ___ and will be be discharged with home
physical therapy.
Her infectious work-up was negative, right upper quadrant
ultrasound without infection and stable hemoglobin with grade 1
varices seen on EGD in ___ and continued on her nadolol.
TRANSITIONAL ISSUES:
=========================
[] ___ sent this admission for elevated MCV wtih normal
B12/folate; f/u results as outpatient
[] Titrating her sedating meds including Compro and morphine as
needed. To reduce her risk of falls
ACUTE ISSUES:
=============
# Hepatic encephalopathy
# HCV Cirrhosis decompensated by ascites, PGH and HE s/p TIPS
and
splenorenal embolization
___ B, Meld-Na 17 on admission, currently on transplant
list. Has h/o refractory HE s/p TIPS and splenorenal shunt
embolization. She reports initial improvement in HE after these
procedures, however over the past several weeks she endorsed
myoclonus of her legs/arms as well as worsening confusion. Exam
notable for mild asterixis, but was cognitively intact (alert
and oriented x3 and able to say the days of the week backwards).
Unclear underlying trigger, as
patient states that she has been having ~4 BMs/day without the
use of lactulose and she continues to use Rifaxamin. Her RUQUS
demonstrated
Doppler with patent TIPS, no obvious source of infection on
CXR/no ascites seen on RUQUS.Her sedating medications including
morphine and Compro were initially held. Her lactulose was
uptitrated briefly and the hepatic
# Chronic Pancytopenia
# Macrocytosis
Underlying etiology has been explored during prior
hospitalizations, with consideration of hypersplenism as the
underlying cause. Not currently neutropenia (___ 1270) however
with notable decrease in ANC compared to prior hospitalization.
Vitamin B12 and folate normal thyroid-stimulating hormone 3.6
(normal)
CHRONIC ISSUES:
===============
# HTN
- Continue home furosemide 60mg qd, spironolactone 200mg qd, and
nadolol 40mg qd as per above
# GERD
- Continue home pantoprazole
# Hypothyroidism
- Check TSH given AMS, as per above
- Continue home levothyroxine
# Depression
- Continue home fluoxetine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO BID
2. FLUoxetine 20 mg PO BID
3. Furosemide 60 mg PO DAILY
4. Hydroxychloroquine Sulfate 200 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Morphine SR (MS ___ 15 mg PO Q12H
7. Nadolol 40 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - First
Line
10. rifAXIMin 550 mg PO BID
11. Spironolactone 200 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. Ursodiol 250 mg PO QID
14. Magnesium Oxide 250 mg PO BID
15. Potassium Chloride 20 mEq PO DAILY
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN wheezing, shortness of breath
17. ValACYclovir 500 mg PO Q24H
Discharge Medications:
1. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 ml by mouth three times a day
Disp #*1 Bottle Refills:*0
2. Ferrous Sulfate 325 mg PO BID
3. FLUoxetine 20 mg PO BID
4. Furosemide 60 mg PO DAILY
5. Hydroxychloroquine Sulfate 200 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Magnesium Oxide 250 mg PO BID
8. Morphine SR (MS ___ 15 mg PO Q12H
9. Nadolol 40 mg PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. Potassium Chloride 20 mEq PO DAILY
Hold for K > 4.5
12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN wheezing, shortness of breath
13. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - First
Line
14. rifAXIMin 550 mg PO BID
15. Spironolactone 200 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. Ursodiol 250 mg PO QID
18. ValACYclovir 500 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
___
Discharge Diagnosis:
PRIMARY DIANGOSIS:
===========================
hepatic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
-You are admitted to the hospital for altered mental status and
recent falls
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
-You were given extra lactulose which helped improve your mental
status
-Infectious work-up was negative
-We are concerned that some of the medications you are taking
including morphine Compazine and hydroxyzine can contribute to
feeling dizzy and cause falls
-You were evaluated by our physical therapists and will continue
to receive physical therapy at home
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
- Continue to take lactulose 3 times daily to have at least ___
bowel movements daily
Please discuss with your outpatient doctor how to adjust your
medication regimen to avoid drugs that can cause you to be dizzy
and fall
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10318893-DS-21 | 10,318,893 | 23,961,375 | DS | 21 | 2190-06-17 00:00:00 | 2190-06-19 15:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
multifocal pneumonia, lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ stage IV pancreatic ca s/p C1 Gemcitabine/Cisplatin (last
chemo given ___, C2 was supposed to start today) found to be
lethargic in ___ when presenting for chemo appt. Per
sisters, he was drowsy this AM however becoming progressively
more difficult to arouse. Also seen in the ED ___ for
confusion thought to be due to ativan.
In the ED, initial vitals: 99.8 88 141/75 16 92% 4l.
Pupils were pinpoint, he was lethargic and intermittently only
responsive to sternal rub. Labs showed normal chemistry, ANC
4500, HCT 30, PLT 460, LFTs normal, lacate 1.1, pCO2 44 on VBG,
UA with 9wbc only, urine pos for opiates and methadone, serum
tox negative. Got 1L NS. CT head unremarkable, CXR showed
possible LLL opacity suspicious for atelectasis more than
infection. Woke up spontaneously later around 4pm and stated he
had been taking "methadone, morphine and ativan TID" according
to ED, thinks he may have taken the wrong pill this AM. Then
spiked to 102 and received a dose of ceftriaxone before
triggering for hypoxia (80s on 4L), came up to ___ on NRB.
Admitted to MICU for ongoing O2 requirements.
On transfer, vitals were: 98.0 84 110/51 17 94% 6L NC.
On arrival to the MICU, he is sleepy but oriented and
cooperative, complains of mild chronic diffuse headache. No
shortness of breath. Coughing but says he doesn't remember
coughing before arrival.
Past Medical History:
- poorly differentiated squamous cell cancer with rare mucinous
differentiation invoving the pancreas, liver and splenic hilum.
- bipolar, IVDA, depression
- chronic hepatitis C genotype ___ s/p partial 20-wk therapy with
pegylated interferon and ribavir in ___. Therapy
incomplete due to loss to follow-up. +HCV RNA but no signs of
decompensated cirrhosis
- Asthma
Social History:
___
Family History:
Non-contributory
Physical Exam:
Discharge Exam:
Vitals- Tm 98.3, 98.0, 114/65, 75, 20, 95%RA, ___
GENERAL: NAD
HEENT: EOMI, pupils 3mm and reactive, Sclera anicteric,
LUNGS: CTA B
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no ankle edema bilaterally
SKIN: warm and dry
NEURO: A&Ox3, ambulatory
PSYC: Appropriate mood
Pertinent Results:
Admission Labs:
___ 10:50AM BLOOD WBC-6.5 RBC-3.52* Hgb-9.7* Hct-30.0*
MCV-85 MCH-27.7 MCHC-32.5 RDW-19.4* Plt ___
___ 10:50AM BLOOD Neuts-71.1* Lymphs-14.5* Monos-12.0*
Eos-2.2 Baso-0.2
___ 03:09AM BLOOD ___
___ 10:50AM BLOOD ___ ___
___ 10:50AM BLOOD UreaN-12 Creat-0.7 Na-137 K-4.4 Cl-102
___ 10:50AM BLOOD ALT-41* AST-35 AlkPhos-73 TotBili-0.3
___ 10:50AM BLOOD Phos-4.2 Mg-2.1
___ 10:50AM BLOOD CEA-16*
___ 12:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:17PM BLOOD ___ pO2-49* pCO2-44 pH-7.39
calTCO2-28 Base XS-0
___ 01:17PM BLOOD Glucose-103 Lactate-1.1
___ 10:50AM BLOOD CA ___: 45 H (normally <34 U/mL; last
90*)
Microbiology:
___ Blood culture pending at time of discharge
MRSA SCREEN (Final ___: No MRSA isolated.
Imaging:
___ CT head: No evidence of hemorrhage or acute territorial
infarction.
___ CXR: IMPRESSION: Lower lung volumes with crowding of
the bronchovascular markings and left base opacity, potentially
due to atelectasis, although infection is not entirely excluded.
___ CXR: Frontal and lateral views of the chest demonstrate
increased opacification in the left retrocardiac region and
right lower lobe consistent with multifocal pneumonia. The
cardiomediastinal and hilar contours are normal. There is
slight blunting of the left costophrenic angle which may
represent a small pleural effusion. There is no pneumothorax.
IMPRESSION: Left and right lower lobe opacities consistent with
multifocal pneumonia.
Brief Hospital Course:
___ with metastatic pancreatic cancer, s/p C1
gemcitabine/cisplatin, admitted for lethargy and multifocal
pneumonia.
1. Multifocal Pneumonia: Hypoxia resolved. Patient presented
with hypoxia requiring nonrebreather, fevers to ___, and chest
radiograph showing multifocal pneumonia involving both right and
left lower lungs. Given lethargy, there may have additionally
been a component of hypoventilation in setting of narcosis.
Presentation was not felt to be consistent with volume overload
or pulmonary embolism, despite risk factor of metastatic
pancreatic cancer (Well's score 1 for active malignancy).
Patient was monitored in the MICU overnight, given vancomycin
and cefepime (given patient is receiving chemotherapy). Blood
cultures pending. Not producing sputum for culture during MICU
stay. On transfer from the MICU to OMED, patient was satting in
the mid-high ___ on 4L NC, which were subsequently weaned off.
Fevers resolved x 48h. Vancomycin and cefepime transitioned to
PO levaquin ___.
- Will be DC'd home on levaquin 500 mg BID x5 day course
(___).
2. Toxic metabolic encephalopathy: Primary cause was initially
felt to be overmedication with methadone, morphine and ativan.
Sedating medications were held and patient was monitored
overnight in the ICU with resolution to baseline mental status.
Home pain, appetite stimulation (remeron) and insomnia (ativan)
were restarted 3 days prior to discharge, which were well
tollerated without further AMS. AMS now thought to be primarily
due to multilobar pneumonia.
Chronic inactive issues:
3. Pancreatic cancer: Patient was transferred to the oncology
service once his acute issue of altered mental status and
hypoxia were stabilized in the MICU. His home Creon was given
with meals and mirtazipine for appetite stimulation.
4. Chronic Hep C virus: No evidence of decompensation during
admission.
5. Chronic pain: Controlled. Patient's methadone, gabapentin and
morphine were initially held given mental status/lethargy on
presentation, and concern for sedation related to these
medications. ___ care gave recommendations to restart
above meds on ___, which were subsequently well tollerated.
5. Asthma: Patient was written for albuterol prn.
Transitional Issues:
1. Communication: Patient; HCP sister ___
___
Alternate HCP: ___, niece (___)
2. Code: Full
3. F/U Bcx from ___ (pending at ___)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob or wheeze
2. Gabapentin 600 mg PO TID
3. Ibuprofen 600 mg PO Q8H:PRN pain
4. Creon ___ CAP PO TID W/MEALS
5. Methadone 30 mg PO TID
6. Mirtazapine 15 mg PO HS
7. Prochlorperazine 10 mg PO Q8H:PRN nausea
8. Acetaminophen 650 mg PO Q8H:PRN pain
9. Senna 8.6 mg PO BID:PRN constipation
10. Lorazepam 0.5-1 mg PO HS:PRN sleep or nausea
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 5 Days (until ___
2. Acetaminophen 650 mg PO Q6H:PRN pain or fever
3. Creon ___ CAP PO TID W/MEALS
4. Methadone 20 mg PO BID and 30 mg QHS
5. Mirtazapine 15 mg PO HS
6. Senna 8.6 mg PO BID:PRN constipation
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob or wheeze
8. Gabapentin 600 mg PO TID
9. Ibuprofen 600 mg PO Q8H:PRN pain
10. Trazodone 25 mg PO HS:PRN sleep or nausea
11. Prochlorperazine 10 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Multi-lobar pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for lethargy and found to have a multi-lobar
pneumonia. You were treated with IV antibiotics, which were
transitioned to levofloxacin on ___, which you will need to
continue until ___.
Followup Instructions:
___
|
10318966-DS-5 | 10,318,966 | 25,072,131 | DS | 5 | 2145-04-20 00:00:00 | 2145-04-20 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
ERCP w/ biliary stent
___ for internal-external biliary stents x 2, then drains upsized
in ___ procedure
History of Present Illness:
___ male with hx of CAD, afib on warfarin, who recently
developed painless jaundice. Per pt and family, since ___ he
has been undergoing eval for weakness. There is concern about a
biliary issue (unclear from family if it is cancer) and
initially they were monitoring the area, but since the pt
developed jaundice the plan is for ERCP and possible stenting on
___.
Today, the pt has become weaker than usual with difficulty
getting out of bed on his own. He almost fell ___ yesterday and
after almost falling today they felt that he should come into
the hospital. Pt denies cp,sob, lightheadedness, palp. He
reports 30 lb weight loss over the past few months. He denies
abd pain, n/v/d, he does report dark urine. denies black or
bloody stools.
10 systems reviewed and are negative except where noted in the
HPI above
Past Medical History:
Hypertension
Hyperlipidemia
afib, on warfarin
Left Bundle Branch Block
CAD, s/p CABG x 4 in ___ (LIMA-LAD, SVG-OM1, SVG-OM2, SVG-dRCA)
CAD s/p PCI ___ with BMS Stenting to RCA and POBA to 80%
Diag.
Aortic valve replacement with bioprosthetic valve
h/o Cholecystitis
Hernia repair ___
Prostate ca s/p hormone shots
Reports "hole in stomach" that was going to be repaired by Dr.
___ the past year, but was held given risks from CAD
Social History:
___
Family History:
no gallstone dz known
Physical Exam:
Physical Exam
Afeb VSS
Cons: NAD, lying in bed
Eyes: EOMI, severe sclera icterus
ENT: MMM
Neck: nl ROM, no goiter
Lymph: no cervical LAD
Cardiovasc: irreg, iii/vi sem, no edema
Resp: CTA B
GI: +bs, soft,nt, nd
MSK: no significant kyphosis
Skin: no rashes, a few scattered ecchymosis on ___
severe jaundice noted
Neuro: no facial droop
follows commands, gets confused with orientation questions
Psych: normal range of affect, pleasant
Pertinent Results:
___ 12:18PM LACTATE-1.3
___ 12:10PM GLUCOSE-171* UREA N-46* CREAT-0.9 SODIUM-134
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-19* ANION GAP-18
___ 12:10PM ALT(SGPT)-51* AST(SGOT)-106* ALK PHOS-344*
TOT BILI-19.5*
___ 12:10PM LIPASE-119*
___ 12:10PM ALBUMIN-2.9*
___ 12:10PM WBC-11.3*# RBC-1.98*# HGB-7.4* HCT-21.8*
MCV-110*# MCH-37.4*# MCHC-34.0 RDW-20.6*
___ 12:10PM NEUTS-86.3* LYMPHS-6.7* MONOS-5.9 EOS-0.5
BASOS-0.6
___ 12:10PM ___ PTT-105.6* ___
___ 12:10PM PLT COUNT-369#
EKG - I viewed- afib, LAD, LBBB no significant changes compared
to ___
ERCP:
Evidence of a previous sphincterotomy was noted in the major
papilla
A single periampullary diverticulum with small opening was found
at the major papilla
A single very tight stricture that was 5 mm long was seen at the
common hepatic duct; this correlated with the hilar mass
findings on the MRCP.
There was moderate post-obstructive dilation. Right and left
intrahepatic ducts were dilated, but it was difficult to assess
if the right anterior duct was opacified.
A 4mm balloon was introduced for dilation of the CHD stricture
successfully.
Cytology samples were obtained for histology using a brush.
Biliary double pigtail stent was placed in the L intrahepatic
ductal system. The stricture was very tight even after dilation
with the 4 mm balloon, therefore, it was not possible to place
another biliary stent and drain the R system after multiple
attempts.
Common hepatic duct:
POSITIVE FOR MALIGNANT CELLS,
consistent with adenocarcinoma.
Cell block, common hepatic duct brushings (A):
Positive for malignant cells, consistent with adenocarcinoma.
Brief Hospital Course:
CC/HPI synopsis:
___ y/ man with hx. Afib, CAD/CABG and AVR, originally presented
with painless jaundice to ward, found to have porta hepatis mass
with biliary compression/invasion - went to ___, had pigtail
drain, bx (positive for adenocarcinoma) - but this not
alleviating obstruction, so had to have ___ perc drains times two
- the latest of which pt. intubated for and suffered hypotension
in this setting considered due to hemodynamic effects of PPV,
sedation, ? transient bacteremia from biliary manipulation.
Once stable hemodynamically, off pressors, pt. transferred back
to the general medical ward, but still but massively jaundiced,
encephalopathic (due to severe illness, uremia, ? hepatic
encephalopathy contributing) with occasional agitation requiring
restraints to prevent self removal of percutaneous drains,
uremic with likely ATN from hypotension.
Long discussion with family in ICU ___ evening given severe
illness, advanced age, and adenocarcinoma (likely
cholangiocarcinoma) - pt. made DNR/DNI. One percutaneous drain
was leaking, and ___ team may need to upsize as able to try to
resolve this. On ___ - no leakage, appears to be
draining appropriately- so unclear if ___ will redo any
procedures ___ or this week.
Using very low dose of hydromorphone for pain/discomfort, or
agitation felt due to same (avoiding morphine given renal
failure). Noticed a lt sided, large, easily reducible inguinal
hernia ___ incidentally.
Active issues:
1. Biliary obstruction, concerning for
cholangiocarcinoma/cholangitis: drained internally (pigtail at
ERCP) and externally (two percutaneous biliary drains by ___, rt
and left biliary trees) - preliminary path from ERCP reveals
adenocarcinoma - primary site unknown, but concerning for
cholangiocarcinoma. Further pathology pending, revealed adeno
CA. Biliary drain leakage from Rt sided drain in ICU - seemed
to have resolved on ___, draining appropriately (externally
to gravity) - 2. Hypotension post instrumentation of biliary
system concerning for gram negative sepsis/bacteremia - on
Zosyn. Cultures remained negative
3. Encephalopathy with agitation, due to severe illness, uremia,
? hepatic encephalopathy: controlled with family presence,
redirection, low dose of hydromorphone for pain or apparent
discomfort prn. A trial of lactulose was administered, but pt
frequently unable to safely swallow.
4. Acidosis with slight anion gap, likely due to uremia: urine
output improved, and Cr and acidosis was stable.
5. ARF c/w ATN from hypotension with uremia and acidosis:
Creatinine peaked at 3.9 and then remained stable. Renal
consult deferred given goals of care
6. Anemia, multifactorial (illness, malignancy, malnutrition)
without evidence of active bleeding.
7. Coagulopathy, likely due to malnutrition, ? sc heparin, and
likely impaired liver synthetic function due to obstructive
injury: pts home warfarin held for procedures. Vitamin K
administered and SC heparin dose-reduced from TID to BID
regimen.
Stable, chronic issues:
CAD with hx CABG and bioprosthetic AVR, usually on warfarin
(held given procedures - see above)
HTN
HCL
Hx hernia repair
Hx prostate cancer
Palliative care was consulted and family meeting held,
explaining overall grave prognosis and significant clinical
deterioration. They expressed that his wishes would be to focus
on comfort/hospice care. Thus, we agreed that there would be no
escalation of care, ICU transfer, procedures, vitals, or labs
drawn.
For agitation we started low dose Zydis HS and prn with good
effect. For pain we started concentrated oxycodone Sl q2 prn
with good effect. The Foley catheter was kept in place for
comfort. His biliary drains were capped, but could be put to
gravity should his pain increase. He was somnolent but
arousable with family, mumbling. He breathes through his mouth
and was given humidified air. He had mild cough.
Medications on Admission:
1. Ascorbic Acid ___ mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Ferrous GLUCONATE 324 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Niacin 500 mg PO BID
6. Ranitidine 150 mg PO DAILY
7. Metoprolol Tartrate 50 mg PO DAILY
8. Pravastatin 20 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Warfarin Dose is Unknown PO DAILY
Discharge Medications:
1. OLANZapine (Disintegrating Tablet) 5 mg PO HS agitation
2. OLANZapine (Disintegrating Tablet) 5 mg PO TID:PRN acute
agitation
3. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q2H:PRN pain
RX *oxycodone 20 mg/mL ___ MG by mouth every 2 hours Disp #*1
Vial Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cholangiocarcinoma
Bile obstruction with cholangitis
Acute renal failure/ATN
CAD/CABG
Atrial fibrillation
Delirium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Admitted with obstructive jaundice due to new dx
cholangiocarcinoma. Required percutaneous decompression.
Complicated by hypotension and acute renal failure with
confusion and progressive decline. Family ultimately decided on
focus of comfort care and hospice. PCP ___.
Followup Instructions:
___
|
10318991-DS-12 | 10,318,991 | 27,322,682 | DS | 12 | 2162-06-18 00:00:00 | 2162-06-18 17:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ with a history of hypertension,
dilated cardiomyopathy (last EF 30% in ___ and CKD ___
to PCKD who was sent in by her cardiologist for chest pain. She
first noted the pain about 2 weeks ago and descibes it as a
pinprick, but over the course of two weeks, it has progressed to
a sharp knife-like stabbing pain. The pain is left-side and
always in the same location, to which she can point with her
finger, with no radiation or inspiratory variation, worse with
movement and better with rest. There are no clear triggers to
onset, and they occur about ___. She has not tried anything
for the pain. She has not experienced any associated SOB or
dizziness, but does note that when she stands up, she feels very
nauseated and sometimes has an "out of body experience."
Regarding her PCKD, she notes that she makes very little urine
daily, and it is always bright red in color. She has the urgency
to go but does not actually void at times. She notes having some
swelling in her hands and feet which fluctuates. Recently, she
was Cardiology was consulted when the patient was in the ED and
recommended a pMIBI to evaluate cardiac function. Her referring
cadiologist recommended evaluation by a nephrologist for PCKD
and HTN management.
Past Medical History:
-Polycystic kidney disease with cystic involvement of liver &
ovaries (all first diagnosed in ___
-Hypertension
-Dilated Cardiomyopathy ___ EF 30%)
-Migraines
-Possible cerebral aneurysm
Social History:
___
Family History:
Polycystic kidney disease in an autosomal dominant pattern and
with cerebral aneurysms on her mother's side. There is no known
family history specifically of cardiomyopathy or early coronary
artery disease. No known history of sudden death.
Physical Exam:
Physical Exam on Admission:
VS - Temp 97.6F, BP 135-148/91-110, HR 72, O2-sat 100% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no thyromegaly, no JVD,
LUNGS - CTA bilat, no r/rh/wh, decreased breath sounds on the
right ling base,
HEART - RRR, no MRG, loud P2
ABDOMEN - +BS, soft/NT/ND, enlarged liver can be felt halfway
down right side of abdomen, firm flank masses can be palpated
EXTREMITIES - WWP, 1+ edema,
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
PHYSICAL EXAM ON DISCHARGE:
VS - Temp 98.6F, BP 104-120/70s, HR 71-87, RR 18, O2-sat 100% RA
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no thyromegaly, no JVD
LUNGS - CTAB, no r/rh/wh, decreased breath sounds on the right
ling base,
HEART - RRR, no MRG, loud P2
ABDOMEN - +BS, soft/NT/ND, enlarged liver can be felt halfway
down right side of abdomen, firm fl
Pertinent Results:
Labs on Admission:
___ 04:15PM BLOOD WBC-4.0 RBC-3.66* Hgb-11.0* Hct-35.3*
MCV-97 MCH-30.1 MCHC-31.2 RDW-12.9 Plt ___
___ 04:15PM BLOOD Neuts-70.8* ___ Monos-3.4 Eos-1.7
Baso-0.2
___ 08:30AM BLOOD ___ PTT-32.4 ___
___ 04:15PM BLOOD Glucose-90 UreaN-32* Creat-4.1* Na-140
K-4.4 Cl-108 HCO3-22 AnGap-14
___ 08:30AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.1
Cardiac Enzymes:
___ 04:15PM BLOOD cTropnT-<0.01
___ 12:41AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:30AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:41AM BLOOD CK(CPK)-22*
___ 08:30AM BLOOD CK(CPK)-21*
CXR ___:
FINDINGS: PA and lateral views of the chest were obtained
demonstrating
clear, well-expanded lungs without focal consolidation,
effusion, or
pneumothorax. Stable elevation of the right hemidiaphragm noted.
Cardiomediastinal silhouette is unchanged and within normal
limits. Bony
structures are intact.
IMPRESSION: No acute intrathoracic process.
Stress Echo ___:
PROTOCOL /
STAGETIMESPEEDELEVATIONWATTSHEARTBLOODRPP
(MIN)(MPH)(%) RATEPRESSURE
1 ___
TOTAL EXERCISE TIME: 4% MAX HRT RATE ACHIEVED: 49
SYMPTOMS:NONE
ST DEPRESSION:NONE
INTERPRETATION: ___ year old female with a h/o HTN, inactivity,
and
syncope presents for evaluation of chest pain, shortness of
breath, and
palpitations. Over the course of 4 minutes, patient was given
.142
mg/kg/min of IV Persantine. This was reversed 5 minutes into
recovery
with 125 mg of IV Aminophylline. No discomforts were noted in
the
chest, back, neck, or arms. In the presence of baseline
abnormalities,
no ST segment or T wave changes were noted. Rhythm was sinus
with
occasional, isolated VPBs. Heart rate and blood pressure
responded
appropriately to infusion.
IMPRESSION: No anginal symptoms or ST changes. Heart rate and
blood
pressure responded appropriately. Nuclear report sent
separately.
pMIBI ___:
IMPRESSION: Abnormal LVEF at 25% with normal myocardial
perfusion suggesting non-ischemic cardiomyopathy.
Liver and Gallbladder ultrasound ___:
IMPRESSION: Innumerable liver and renal cysts, which severely
limit the
ability of ultrasound to assess for pathology. No gross biliary
dilatation is seen. Patent portal vein. No splenomegaly and no
ascites identified.
Labs on Discharge:
___ 07:55AM BLOOD WBC-3.6* RBC-2.97* Hgb-9.3* Hct-29.0*
MCV-98 MCH-31.3 MCHC-32.0 RDW-13.1 Plt ___
___ 07:55AM BLOOD Glucose-86 UreaN-36* Creat-4.6* Na-141
K-4.0 Cl-108 HCO3-20* AnGap-17
___ 07:40AM BLOOD ALT-3 AST-9 AlkPhos-75 TotBili-0.2
___ 07:55AM BLOOD Calcium-9.0 Phos-5.1* Mg-2.1
___ 07:40AM BLOOD PTH-432*
Brief Hospital Course:
Primary Reason for Hospitalization:
Ms. ___ is a ___ y/o female with a history of
hypertension, dilated cardiomyopathy (last EF 30% in ___ and CKD secondary to to polycystic kidney disease who was
sent in by her cardiologist due to chest pain.
Active Diagnoses:
#Chest Pain: Patient has stabbing chest pain that is at one
location and related to movement that does not sound anginal in
nature. CE negative x2 in the ED. However, given nonischemic
cardiomyopathy with low EF and hypervolemia from PCKD, pain
warranted serious evaluation for ischemia. Of note, patient
relates that she experiences significant anxiety at home with
her son reintegrating into gang life and unemployment which may
she believes may contribute to her pain. P-MIBI stress test
yesterday showed EF 25%, no perfusion abnormality. Her cardiac
output could benefit from afterload reduction with blood
pressure control and diuresis. Patient was initially switched
from metoprolol to labetalol on admission, then started on
lisinopril 5mg daily (also for her PCKD), and diuresed with IV
lasix. Patient complained about feeling worse on these various
medications, feeling more short of breath, and thus labetalol
was switched back to metoprolol. Patient did not experience
further episodes of stabbing chest pain while in the hospital.
# Polycystic Kidney Disease: Patient has Stage V renal failure
with current Cr 4.1 (an increase from 2.1 in ___. Patient
notes decreased urine output and has been showing evidence of
volume overload with peripheral edema, but no SOB or PND. She
was being followed by Nephrologist at ___ however had been lost
to follow up. She was seen in Nephrology consult this
admission, who recommended checking a PTH and performing vein
mapping, as patient is trending toward dialysis. She was given
IV lasix for diuresis per the renal team, as this would improve
her volume status and her cardiac function. As patient was not
tolerating starting many medications at once (felt short of
breath, weak), she was not perscribed PO lasix at discharge and
will follow up with nephrology as an outpatient for further
management.
# Hypertension: Patient has had difficult to control blood
pressure and was only on Toprol XL at the time of admission. She
apparently had been on multiple antihypertensives in the past
that were stopped because she felt fatigued/malaise and PCP was
hoping to re-initiate them one at a time. At admission, Toprol
XL was switched to Labetalol, and SBP has been running in the
100s-120s. After initiating lisinopril and some diuresis,
patient once again felt fatigued, so Labetalol was switched back
to Toprol. She will follow up with her PCP and nephrologist
regarding long-term blood pressure management.
# History of Hematemesis: Patient endorses that she has had ___
episodes of nausea with associated hematemesis. She has a
picture of blood-streaked emesis on her cell phone. Two nights
into admission, patient had another episode of hematemesis,
which was pink-streaked fluid with emesis. Patient has
polycystic liver disease as well, but no known portal
hypertension or varices. She received a RUQ US that showed
numerous cysts, but was unable to characterize hypertension due
to obscuration by cysts. Patient was seen by hepatology consult
who recommended outpatient liver follow-up and possible
outpatient EGD.
Transitional Issues:
Appointments were made for the patient for follow-up:
Patient will follow-up with Neprhology for care of PCKD and
transition toward dialysis (vein mapping performed this
hospitalization).
Patient will follow-up with Hepatology regarding management of
polycystic liver disease.
Patient will follow-up with PCP regarding blood pressure
management.
Medications on Admission:
Metoprolol Succinate 150mg PO daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Nonischemic cardiomyopathy
Polycystic Kidney Disease
Polycystic Liver Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___ for left-sided chest pain for
which you have been seeing your primary cardiologist. During
your admission, you had some images taken of your heart (called
myocardial perfusion stress imaging), which showed that your
chest pain is not the result of poor blood flow to your heart.
Additionally, you were seen by the nephrology team, who
recommended some changes to your blood pressure medications.
You were also seen by the liver specialists for the cysts in
your liver, and they have recommended you follow-up with them as
an outpatient.
Please note the following changes have been made to your
medications:
- please START taking Aspirin 325mg daily
- please START taking Lisinopril 5mg daily
Followup Instructions:
___
|
10318991-DS-15 | 10,318,991 | 23,628,450 | DS | 15 | 2164-03-02 00:00:00 | 2164-03-04 22:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / aspirin / Oxycodone
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ year old woman whose past medical
history is significant for dilated cardiomyopathy (likely
secondary to HTN with an EF of 20% on last echocardiogram in
___, severe polycystic kidney disease with chronic
renal insufficiency, who presents with chest pain.
She usually has one episode of exertional angina per month and
she normally is able to control the angina with sublingual
nitroglycerin. She came to the ER today after having three
anginal episodes within a week. Today she had left-sided chest
pain that radiated to the neck and was associated with nausea
and dizziness. The most recent episode lasted approximately ___
min. She is still having some mild residual pain. She has been
off ASA since esophageal tear approx 8 months earlier. She
states that she has been evaluated for worsening kidney function
and will likely require dialysis soon. The mild left-sided chest
pain is worse with coughing, breathing deeply, and is
reproducible on palpation. She sleeps with 4 pillows and she
can only stand 15 minutes at a time before feeling lightheaded
and nauseated. Of note, her previous anginal episodes have
correlated with elevated blood pressures.
ROS: As per HPI. She also endorses having palpitations,
itchiness, rash on her neck, insomnia, and occasional tremors.
She denies confusion, somnolence, buttock pain after walking,
edema, paroxysmal nocturnal dyspnea, syncope, and weight gain.
In the ED initial vitals were T 98.8, P 93, BP 188/118, RR 18,
O2 sat 100% RA
Her physical exam in the ER was unremarkable. Her first set of
troponins was negative. Her Chem7 was consistent with chronic
kidney disease and a baseline creatinine of 6.3 in ___ of this
year. Chest x-ray showed no acute cardiopulmonary processes. She
was given carvedilol 25mg.
Vitals on transfer to the floor: P 80, BP 150/95, RR 18, O2 Sat
95% RA
Past Medical History:
- Dilated cardiomyopathy, EF 20% by echocardiogram in ___. Thought to be ___ to long standing poorly controlled HTN.
MIBI ___ showed Mild to moderate anteroseptal and
inferolateral fixed defects .
- Hypertension: poorly controlled
- Polycystic kidney disease: There is cystic involvement of the
liver and ovaries as well. Had been rejected for transplant at
___ due to her heart disease and poor compliance. Baseline Cr
5.4-5.8.
- Migraine headaches.
- Questionable history of cerebral aneurysm: MRI
done here in ___ did not see any cerebral aneurysms.
- h/o UGIB requiring PRBC ___: EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to NSAID use.
Social History:
___
Family History:
Polycystic kidney disease in an autosomal dominant pattern and
with cerebral aneurysms on her mother's side. There is no known
family history specifically of cardiomyopathy or early coronary
artery disease. No known history of sudden death.
Physical Exam:
Admission Physical Exam:
VS: 97.6, 86, 171/119 improved to 150/100, 99%RA
General: WD/WN, NAD, appears younger than stated age
HEENT: oropharynx clear, EOMI, MM
Neck: supple, no JVD
CV: RRR, S4, ___ holosystolic murmur at apex
Lungs: CTAB
Abdomen: soft, diffusely mildly TTP, has midline bulge when she
contracts her abdominal muscles, non-distended
GU: no foley
Ext: no c/c/e
Neuro: AOx3, MAE
Skin: mild xerosis and erythema posterior neck on R>L
PULSES: 2+ DP's
.
Discharge Physical Exam:
VS: AF/98, 123/81 (110s-160s/80s-110s), 83 (70s-80s), 18, 100%
RA
Weight 159.8 lbs from 160.8 lb on admission
I/O 24h ___
General: WD/WN, NAD, appears younger than stated age
HEENT: oropharynx clear, EOMI, MM
Neck: supple, no JVD
CV: RRR, S4, ___ holosystolic murmur at apex
Lungs: CTAB
Abdomen: soft, diffusely mildly TTP, has midline bulge when she
contracts her abdominal muscles, non-distended
GU: no foley
Ext: no c/c/e
Neuro: AOx3, MAE
Skin: mild xerosis and erythema posterior neck on R>L
PULSES: 2+ DP's
Pertinent Results:
Admission Labs:
___ 05:00PM ___ PTT-36.5 ___
___ 05:00PM PLT COUNT-197
___ 05:00PM NEUTS-55.9 ___ MONOS-5.4 EOS-3.6
BASOS-0.7
___ 05:00PM WBC-4.9 RBC-3.20* HGB-9.9* HCT-31.5* MCV-99*
MCH-31.1 MCHC-31.5 RDW-12.8
___ 05:00PM CALCIUM-8.9 PHOSPHATE-5.0* MAGNESIUM-2.2
___ 05:00PM cTropnT-<0.01
___ 05:00PM estGFR-Using this
___ 05:00PM GLUCOSE-82 UREA N-46* CREAT-6.9* SODIUM-141
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-21* ANION GAP-19
___ 07:05PM URINE RBC-2 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-1
___ 07:05PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 07:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:05PM URINE GR HOLD-HOLD
___ 07:05PM URINE UCG-NEGATIVE
.
Interval Labs:
___ 06:46AM BLOOD WBC-3.9* RBC-3.03* Hgb-9.4* Hct-29.8*
MCV-98 MCH-31.1 MCHC-31.6 RDW-12.8 Plt ___
___ 06:46AM BLOOD ___
___ 06:46AM BLOOD Glucose-83 UreaN-45* Creat-6.7* Na-140
K-3.9 Cl-106 HCO3-19* AnGap-19
___ 06:46AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:46AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.0 Iron-55
___ 06:46AM BLOOD calTIBC-265 Ferritn-34 TRF-204
.
Discharge Labs:
___ 07:20AM BLOOD WBC-3.7* RBC-2.80* Hgb-8.8* Hct-27.8*
MCV-99* MCH-31.5 MCHC-31.8 RDW-12.8 Plt ___
___ 07:20AM BLOOD ___
___ 07:20AM BLOOD Glucose-86 UreaN-47* Creat-6.5* Na-139
K-4.0 Cl-104 HCO3-21* AnGap-18
___ 07:20AM BLOOD Calcium-8.4 Phos-5.1* Mg-2.0
.
Microbiology: None.
.
Pathology: None.
.
Imaging/Studies:
# ECG (___): Sinus rhythm. Left axis deviation. Left
ventricular hypertrophy. Non-specific repolarization
abnormalities. Compared to the previous tracing of ___ no
significant difference.
# CXR (___/___): No acute cardiopulmonary process. No
significant interval change.
# TTE (___): The left atrium is normal in size. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is severe global left
ventricular hypokinesis (LVEF = 20 %). Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The left ventricular
inflow pattern suggests impaired relaxation. The left
ventricular diastolic filling patterns is markedly abnormal,
with almost complete absence of early diastolic filling and
almost complete dependence on late diastolic/atrial systolic
filling. The pulmonary artery systolic pressure could not be
determined. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
severe systolic dysfunction persists, now with evidence of
markedly impaired diastolic function.
# ECG (___): Sinus rhythm. Left atrial abnormality. Left
axis deviation. Left ventricular hypertrophy. Non-specific
repolarization abnormalities are due to left ventricular
hypertrophy or ishemia. Clinical correlation is suggested. No
significant difference when compared with previous tracing.
# ECG (___): Sinus rhythm. Left atrial abnormality. Left
axis deviation. Left ventricular hypertrophy with repolarization
abnormalities consistent with left ventricular hypertrophy or
ischemia. No significant difference when compared with previous
tracing.
# Vein Mapping for Dialysis (___): IMPRESSION: Patent
cephalic and basilic veins bilaterally, with diameters as
described above.
Brief Hospital Course:
Ms. ___ is a ___ with a history of dilated cardiomyopathy
(LVEF 20% in ___ secondary to hypertension, and autosomal
dominant polycystic kidney disease with stage V CKD, who
presents with worsening exertional angina and uncontrolled
hypertension.
.
Active Diagnoses:
# Exertional Angina: Her past anginal episodes were associated
with elevated blood pressures. Her blood pressure on this
admission was 188/118. She was given sublingual nitroglycerin.
Her admission ECG showed evidence of left ventricular
hypertrophy but was not significantly different than her last
ECG in ___ of this year. Her chest x-ray was unremarkable. She
was ruled out for acute coronary syndrome after her cardiac
enzymes did not elevate in 24 hours and she had no changes
suggestive of ischemia on repeat ECGs. She was started on
isosorbide mononitrate. She would likely benefit from cardiac
catheterization, since her anginal episodes are increasing in
frequency. She wanted to pursue this option as an outpatient.
She will follow up with the cardiology clinic on ___.
.
# Autosomal Dominant Polycystic Kidney disease with Stage V CKD.
Per her recent clinic notes, she is considering dialysis. Her
creatinine remained near her baseline of 6.3 during this
admission. She underwent venous mapping for an AV fistula (to be
used in hemo-dialysis). Nephrology was consulted to assess the
utility of preforming cardiac catheterization during this
admission, given her worsening renal function. It was explained
to her that although IV contrast may expedite the deteriation of
her renal function, her CKD was not a barrier to angiography. In
the event she chooses to pursue cardiac catheterization before
she begins dialysis, nephrology recommended increasing her
sodium bicarbonate, continuing her home dose of lasix, avoiding
volume overload in the setting of poor systolic function,
avoiding renin-angiontensin antagonists, and closely monitoring
urine output and creatinine post-procedure. She will follow up
with the transplant clinic on ___.
.
# Dilated cardiomyopathy (likely secondary to poorly controlled
HTN): Last ECHO in ___ showed poor systolic function with an
LVEF of 20%. In the setting of worsening renal function, she was
started on isosorbide mononitrate and hydralazine. Her home
carvedilol and lasix were continued. ECHO on ___ showed an
LVEF of 20% with worsening diastolic function, with near
complete absence of early diastolic filling, compared to the
ECHO in ___. She will likely need cardiac catheterization in
order to further characterize her worsening heart function.
.
# Poorly controlled hypertension: Her home lasix and carvedilol
were continued. ACE-inhibitors were avoided in the setting of
poor renal function. Hydralazine and Isosorbide mononitrate were
started.
.
CODE STATUS: Full Code (confirmed)
CONTACT: Mother, ___ ___
.
___ Issues:
# Due to several social stressors, including current litigation
involving her ___ company, a son with special needs, and
being unemployed; she has not been able to keep all of her
healthcare appointments and did not want to stay in the hospital
for cardiac catheterization. She will need to arrange this an
outpatient.
# She will follow up with cardiology clinic on ___ and the
transplant clinic on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Carvedilol 25 mg PO BID
3. Furosemide 40 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. Sodium Bicarbonate 650 mg PO TID
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth Twice daily Disp #*30
Tablet Refills:*0
3. Furosemide 40 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. Sodium Bicarbonate 1300 mg PO BID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth Twice daily
Disp #*30 Tablet Refills:*0
6. HydrALAzine 20 mg PO TID
RX *hydralazine 10 mg 2 tablet(s) by mouth Every 8 hours Disp
#*30 Tablet Refills:*0
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet extended release 24
hr(s) by mouth Daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Compensated CHF with anginal chest pain
Secondary: ESRD (Stage V)
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 for chest pain. Your cardiac enzymes
were normal, and your EKG showed no evidence that you were
having a heart attack. You had an ultrasound of your heart
(echocardiogram), which showed that your heart failure has not
changed significantly since ___. You had ultrasound studies of
your arm to evaluate you for future AV fistula for dialysis.
Please follow up with Dr. ___ in the ___ clinic on
___ and the transplant clinic on ___. Please call your
PCP, ___, to schedule an appointment within 1 week.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best in the recovery process.
Followup Instructions:
___
|
10318991-DS-16 | 10,318,991 | 25,403,207 | DS | 16 | 2164-03-25 00:00:00 | 2164-03-25 19:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / aspirin / Oxycodone
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with dilated cardiomyopathy ___ HTN, EF 20% in ___, known mild to moderate inferoseptal and inferolateral
fixed deficits, poorly controlled hypertension, severe
polycystic kidney disease with chronic renal insufficiency, p/w
chest pain.
Of note, the patient was admitted approximately 2 weeks ago with
worsening chest pain on exertion. Patient had a negative cardiac
rule out at that time, discussed possible cardiac
catheterization. It was decided to defer this to the outpatient
setting given her CKD. In the interim, she was ordered for
cardiac MRI, but this has not yet occurred.
The patient states that she typically gets chest discomfort with
exertion or with lengthy activity, such as standing in line for
more than 20 minutes, or walking distances. The day prior to
admission she stood in line for about 15 minutes and had some
discomfort and headache. This resolved with SL NTG and rest at
home.
The day of presentation she woke feeling fine. At around 11:30
or noon, she began to feel this sensation of chest discomfort
again. More troubling, she felt intense air hunger, a new
symptom for her. She also felt nauseous and dizzy, woozy as
though she might faint, "out of it" and confused. This is a
typical constellation of symptoms when she has chest discomfort.
She describes these symptoms as uncomfortable more than
painful, save the air hunger which she found extremely
distressing. Her chest pressure is slightly left-sided but not
consistently. It typically happens with exertion or effort, but
sometimes can occur at rest. She used no NTG or other
medications. Her symptoms did not resolve and she presented for
evaluation and possible cardiac MRI/cardiac catheterization as
previously discussed.
In the ED, initial vitals were ___ 82 102/62 16 100% RA.
Troponin negative. Cardiology was consulted for possible
transfer to the cath lab given the prior plans, however they
recommended admission for workup and discussion of
catheterization. She was given no medications in the ED.
On the floor, she complains of headache, R hip bursitis
(chronic), and slight rash on her R inner thigh. She denies air
hunger or chest pressure since arrival to the ED.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. Cardiac
review of systems is notable for absence of paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope. All of
the other review of systems were negative.
Past Medical History:
- Dilated cardiomyopathy, EF 20% by echocardiogram in ___. Thought to be ___ to long standing poorly controlled HTN.
MIBI ___ showed Mild to moderate anteroseptal and
inferolateral fixed defects .
- Hypertension: poorly controlled
- Polycystic kidney disease: There is cystic involvement of the
liver and ovaries as well. Had been rejected for transplant at
___ due to her heart disease and poor compliance. Baseline Cr
5.4-5.8.
- Migraine headaches.
- Questionable history of cerebral aneurysm: MRI
done here in ___ did not see any cerebral aneurysms.
- h/o UGIB requiring PRBC ___: EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to NSAID use.
Social History:
___
Family History:
Polycystic kidney disease in an autosomal dominant pattern and
with cerebral aneurysms on her mother's side. There is no known
family history specifically of cardiomyopathy or early coronary
artery disease. No known history of sudden death.
Physical Exam:
On Admission:
Vitals: 98.7 154/90 90 18 97% RA ___ pain
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM
NECK: nontender and supple, no LAD, no JVD
BACK: no spinal process tenderness, CVA tenderness L>R
CARDIAC: RRR, nl S1 S2, ___ holosystolic murmur
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-distended, no rebound or guarding, no
HSM. Diffuse mild TTP. Midline bulging with sitting forward
without clear ventral herniation
EXT: warm and well-perfused, no cyanosis, clubbing or edema.
Tenderness over R hip trochanter.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal
On Discharge:
Vitals: 98.2 137/82 (110-140s/70-101) 78 18 99%RA
Orthostatics from ___: laying 111/73 sitting 110/81 standing
111/80
GENERAL: NAD, pleasant and comfortable
HEENT: EOMI, PERRLA, sclerae anicteric, pink conjunctiva, MMM
NECK: nontender and supple, no LAD, no JVD
BACK: no CVA tenderness, palpable kidneys bilaterally
CARDIAC: RRR, nl S1 S2, s4 heard best over LLSB
LUNG: CTAB, no rales wheezes or rhonchi
ABDOMEN: +BS, soft, non-distended, no rebound or guarding, no
HSM.
EXT: warm and well-perfused, no cyanosis, clubbing or edema.
Tender over R hip trochanter.
PULSES: 2+ DP pulses bilaterally
NEURO: moving extremities grossly
SKIN: warm and well perfused.
Pertinent Results:
On Admission:
___ 02:58PM BLOOD WBC-5.2 RBC-2.69* Hgb-8.4* Hct-26.5*
MCV-99* MCH-31.3 MCHC-31.8 RDW-12.0 Plt ___
___ 02:58PM BLOOD Neuts-77.8* Lymphs-16.0* Monos-3.4
Eos-2.6 Baso-0.3
___ 02:58PM BLOOD Glucose-88 UreaN-45* Creat-6.6* Na-139
K-4.3 Cl-106 HCO3-19* AnGap-18
___ 07:14AM BLOOD CK(CPK)-21*
___ 07:14AM BLOOD CK-MB-1 cTropnT-<0.01
___ 02:58PM BLOOD cTropnT-<0.01
On Discharge:
___ 06:38AM BLOOD WBC-4.1 RBC-2.58* Hgb-8.3* Hct-25.4*
MCV-98 MCH-32.2* MCHC-32.7 RDW-11.9 Plt ___
___ 07:43AM BLOOD ___ PTT-32.6 ___
___ 06:38AM BLOOD Glucose-91 UreaN-49* Creat-6.4* Na-139
K-4.3 Cl-103 HCO3-23 AnGap-17
IMAGING:
====================
Renal U/S ___:
1. Limited exam due to innumerable renal cysts in the setting
of polycystic kidney disease. Both kidneys contain at least one
hemorrhagic cyst.
2. Punctate calcifications in the left kidney may be stones or
calcifications within cyst walls. These were better
characterized on the prior CT.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
___ with dilated cardiomyopathy ___ HTN, EF 20% in ___, known mild to moderate inferoseptal and inferolateral
fixed deficits, poorly controlled hypertension, severe
polycystic kidney disease with chronic renal insufficiency, who
presented with new chest pain at rest.
ACTIVE ISSUES:
===================
# Chest pain: Patient was normotensive on arrival, and chest
pain resolved in the emergency department without any
interventions. She had negative troponins x2 and no new findings
on ECG. Imdur was initially increased, but given episode of
relative hypotension, she was returned to initial 30mg daily
dose. She was not considered for cardiac catheterization or
inpatient MRI because of her very poor renal function (Cr 6.6).
Patient will follow up with Dr. ___ team as an outpatient
for cardiac MRI.
# Hematuria: Patient noted bloody urine on ___. This was
thought to be due to hemorrhagic renal cyst in context of
heparin administration. Heparin was discontinued, she was
observed, and hematuria resolved by time of discharge. A urine
culture grew out mixed bacterial flora. A second culture was
pending at discharge.
CHRONIC ISSUES:
=======================
# Hypertension: Patient was maintained on her home
antihypertensive regimen of carvedilol and hydralazine. She
maintained pressures in the 110-140s systolic and ___
diastolic throughout her hospitalization.
# Hip bursitis: Patient complained of chronic right hip
bursitis, for which she was given aspirin.
TRANSITIONAL ISSUES:
=======================
[] Patient will need to follow up with a non-contrast cardiac
MRI to evaluate the cause of her systolic and diastolic heart
failure. Dr. ___ be following up with her to discuss
treatment options.
[] Please follow-up on patient's pending urine culture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Carvedilol 25 mg PO BID
3. Furosemide 40 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. Sodium Bicarbonate 1300 mg PO TID
6. HydrALAzine 25 mg PO TID
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Carvedilol 25 mg PO BID
3. Furosemide 40 mg PO DAILY
4. HydrALAzine 25 mg PO TID
5. Sodium Bicarbonate 1300 mg PO TID
6. Nitroglycerin SL 0.3 mg SL PRN chest pain
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Angina
Seconary diagnosis:
-Hematuria
-Systolic and diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital because you had chest pain and difficulty
breathing. Although your chest pain may be related to stress on
your heart, it was determined that you did not have a heart
attack.
We recommend that you get evaluated with an MRI of your heart.
You already have an appointment scheduled for this. Dr. ___,
___ cardiologist, will continue to work with you to figure out
what is causing your heart problems. You should weigh yourself
every morning, and call Dr. ___ if your weight goes
up more than 3 lbs.
You also had bloody urine while you were in the hospital. This
happened because you were given a blood thinner. We stopped your
blood thinner, and the bleeding slowed down.
Please contact your primary care doctor if you have any changes
in your urination, including any pain, burning, or difficulty
urinating, or feeling that you have to go "right away" or much
more often. These symptoms could indicate that you have a
urinary tract infection.
Followup Instructions:
___
|
10318991-DS-19 | 10,318,991 | 23,703,291 | DS | 19 | 2167-12-20 00:00:00 | 2167-12-20 20:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / aspirin / Oxycodone /
tramadol
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Paracentesis x 2
Re-initiation of HD
History of Present Illness:
Ms. ___ is a ___ female with a history of
hypertension-induced cardiomyopathy EF ___, CKD V (from
ADPKD) no longer on HD who presented with dizziness and fall.
The patient reports that she has had dizziness and difficulty
walking over the past few months. On ___ at 1030 reported
dizziness, and fell backwards off of one step landing on her
lower back and head. Presented to the ED for further evaluation.
In the ED noted mild neck pain. Severe coccyx pain. No neuro
symptoms. No fecal/urinary incontinence. No n/v/d/c, dysuria,
fevers/cough. Last HD was on ___, which was discontinued
because she felt it was making her feel worse.
In the ED, initial vitals were: 96.3 83 148/69 18 100% RA. She
had a nonfocal neuro exam. Her labs were notable for: K 5.1, Cre
16, BUN 128, HCO3 13, Trop 0.18, MB 3, Phos 10.1, Hgb 5.4.
Non-contrast CT Abd/pelvis showed extensive ascites, massively
enlarged polycystic liver and kidneys, moderate pericardial
effusion w/out evidence of acute intrathoracic or intraabdominal
injury. CT head and spine were without evidence of intracranial
abnormalities or acute fracture.
Past Medical History:
- HTN-induced dilated cardiomyopathy, EF ___
- Hypertension
- Autosomal Dominant Polycystic Kidney Disease: cystic
involvement of the liver and ovaries as well.
- Migraine headaches
- Questionable history of cerebral aneurysm: MRI done here in
___ did not see any cerebral aneurysms
- h/o UGIB requiring PRBC ___: EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to NSAID use
- Colelithiasis
- GERD
- Hyperparathyroidism ___ kidney disease. On Zemplar)
Social History:
___
Family History:
8 family members with ___ kidney disease in an autosomal
dominant pattern on paternal side. Two sisters and one brother
with ESRD ___ PCKD
Physical Exam:
ADMISSION EXAM
Vitals:98.7 135 / 90 79 1898Ra
General: Lying comfortably on back, alert, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP not appreciated.
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, ___ systolic murmur w/ prominent S3
gallop
Abdomen: distended w/ abdominal striae; RUQ firm with palpable
nodularity; mild tenderness surrounding paracentesis wound, no
erythema
GU: no foley
MSK: extremities warm, well perfused, no cyanosis, no edema;
hematoma and swelling noted over R iliac crest/lower back
improved from yesterday
Fistula: On lower left arm, fistula with palpable thrill. Bruit
on auscultation.
Neuro: No focal deficits, motor function grossly normal
DISCHARGE EXAM
Vitals: 97.9 147/97 82 18 97 RA
Pulsus: 9 cm H20
General: Lying supine, alert, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP elevated.
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, ___ systolic murmur.
Abdomen: distended w/ abdominal striae; RUQ firm with palpable
nodularity; mild tenderness surrounding paracentesis wound, no
erythema.
GU: no foley
MSK: extremities warm, well perfused, no cyanosis, no edema;
Fistula: On lower left arm, fistula with palpable thrill. Bruit
on auscultation.
Neuro: No focal deficits, motor function grossly normal
Pertinent Results:
============================
ADMISSION LABS
============================
___ 11:50PM BLOOD WBC-4.4 RBC-1.84* Hgb-5.4* Hct-17.7*
MCV-96 MCH-29.3 MCHC-30.5* RDW-13.3 RDWSD-46.6* Plt ___
___ 11:50PM BLOOD Neuts-70.3 Lymphs-17.0* Monos-8.6 Eos-3.2
Baso-0.2 Im ___ AbsNeut-3.10# AbsLymp-0.75* AbsMono-0.38
AbsEos-0.14 AbsBaso-0.01
___ 11:50PM BLOOD Plt ___
___ 11:50PM BLOOD Glucose-99 UreaN-128* Creat-16.0* Na-141
K-5.1 Cl-104 HCO3-13* AnGap-29*
___ 11:50PM BLOOD ALT-<5 AST-6 LD(LDH)-157 CK(CPK)-108
AlkPhos-64 TotBili-0.3
___ 11:50PM BLOOD CK-MB-3 cTropnT-0.18*
___ 11:50PM BLOOD Albumin-3.8 Calcium-8.2* Phos-10.1*
Mg-1.8 Iron-53
___ 11:50PM BLOOD calTIBC-182* Ferritn-876* TRF-140*
___ 10:44AM BLOOD PTH-1547*
___ 10:44AM BLOOD 25VitD-9*
___ 10:44AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative
___ 10:44AM BLOOD HCV Ab-Negative
___ 12:47AM BLOOD Lactate-1.3
============================
DISCHARGE LABS
============================
___ 06:45AM BLOOD WBC-4.7 RBC-2.46* Hgb-7.4* Hct-24.2*
MCV-98 MCH-30.1 MCHC-30.6* RDW-14.1 RDWSD-49.0* Plt ___
___ 07:45AM BLOOD Neuts-62.7 ___ Monos-11.6 Eos-2.6
Baso-0.2 Im ___ AbsNeut-2.92 AbsLymp-1.05* AbsMono-0.54
AbsEos-0.12 AbsBaso-0.01
___ 06:45AM BLOOD Glucose-88 UreaN-54* Creat-8.5* Na-136
K-5.1 Cl-97 HCO3-25 AnGap-19
___ 06:30AM BLOOD CK-MB-2 cTropnT-0.16*
___ 06:45AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.0
___ 07:45AM BLOOD Albumin-2.9* Calcium-8.3* Phos-4.1 Mg-1.8
============================
IMAGING
============================
___ CXR (PORTABLE)
IMPRESSION:
Low lung volumes with possible small left pleural effusion and
persistent
moderate cardiomegaly. Otherwise, no acute cardiopulmonary
process. Chronic elevation right hemidiaphragm.
___ PELVIS (AP ONLY)
IMPRESSION:
No evidence of fracture or dislocation.
___ CT C SPINE w/o CONTRAST
IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. Within limits of study, no definite acute fracture.
3. Multilevel degenerative changes as described, including
minimal asymmetric
widening of right C3-4 facet joint, which may have been present
on ___ prior
brain MRI, and may be degenerative. If concern for ligamentous
injury or
occult fracture, consider dedicated cervical spine MRI for
further evaluation.
4. Limited imaging lungs demonstrate bilateral nonspecific
ground-glass
opacities. Please see concurrently obtained CT of the chest
abdomen pelvis
for further description of thoracic findings.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. No acute intracranial abnormality.
3. No evidence acute intracranial hemorrhage or fracture.
4. Minimal right frontal supraorbital scalp soft tissue
swelling.
5. Paranasal sinus disease , as described.
6. Probable periodontal disease of multiple maxillary teeth, as
described.
NOTIFICATION: The impression and recommendation above was
entered by Dr.
___ on ___ at 11:16 into the Department of
Radiology critical
communications system for direct communication to the referring
provider.
___ CT CHEST/ABD/PELVIS W/O
IMPRESSION:
1. Extensive ascites is seen throughout the abdomen pelvis.
2. No evidence of acute intrathoracic or intraabdominal injury
within the
limitation of an unenhanced scan.
3. Massively enlarged polycystic liver and kidneys.
4. Moderate pericardial effusion.
___ ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is moderate global left ventricular
hypokinesis (Quantitative (biplane) LVEF = 35 %). Right
ventricular chamber size is normal with normal free wall
contractility. The ascending aorta is mildly dilated. 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. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is a
moderate sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Moderate circumferential pericardial effusion
without 2D echo evidence of tamponade. Moderately dilated left
ventricular cavity with mild symmetric hypertrophy and moderate
global systolic dysfunction. Ascites is present.
Compared with the prior study (images reviewed) of ___
global left ventricular systolic function is more vigorous. A
moderate pericardial effusion is now present.
___ PELVIS (AP ONLY)
IMPRESSION:
No evidence of acute traumatic injury in the lumbar spine or
pelvis. If
patient has continued symptoms a CT could be obtained.
___ LUMBO-SACRAl SPINE (AP ONLY)
IMPRESSION:
No evidence of acute traumatic injury in the lumbar spine or
pelvis. If
patient has continued symptoms a CT could be obtained.
___ CT ABD&PELVIS W/O CON
IMPRESSION:
1. No evidence retroperitoneal bleed.
2. Enlarged and multicystic liver and kidneys.
3. Large volume simple ascites tracking down to the pelvis.
4. Moderate simple pericardial effusion.
5. Diffuse anasarca of the subcutaneous fat.
============================
MICRO
============================
2 blood cultures negative (final)
urine culture (final)
2 peritoneal fluid cultures (one final, one NGTD)
Brief Hospital Course:
Ms. ___ is a ___ female with a history of HTN
induced HFrEF (EF ___ and CKD V ___ ADPKD) who initially
presented after a fall, later found to have anemia(hgb 5.4),
uremia, and a moderate pericardial effusion (presumed uremic).
She was admitted for dialysis re-initiation and
management/work-up of volume overload. She had Ultrasound-guided
paracentesis x2 (total 5.5L removed). Her hospital course was
complicated by unwitnessed fall in the setting of unsteady gait
(no fractures or hematomas on CT) with bruising, no fractures.
She has been seen by social work and dialysis social work for
complex social home situation.
======================================
Summary by problem:
# ADPKD, ESRD, Uremia: Now back on HD (___ schedule), managing
nausea and hypotension during HD with Zofran pre-treatment and
holding antihypertensives on HD days. Uremia improving (BUN 54,
down from 128 on admission).
# Volume overload, Ascites: Fluid studies from ascites
suggestive of cardiac ascites (SAAG >1.1 and total protein >3)
likely worsened by ESRD. Patient had symptomatic relief with
improved SOB and decreased abdominal pressure following
paracentesis and volume removal at HD.
# HTN, Chronic Dilated cardiomyopathy/CHF: Repeat echo ___
showed mildly dilated left atrium, moderate global systolic
dysfunction (LVEF=35%). Outpatient records indicate BP has been
difficult to control I/s/o her kidney disease. Also had some
hypotension during/following dialysis to SBPs low ___, improved
when holding BP meds on HD days. Not on ___ at this time
given trying to use residual renal function for diuresis in
between dialysis sessions.
# Moderate pericardial effusion: CT w/ evidence of moderate
pericardial effusion likely ___ uremia I/s/o Stage V CKD. There
were no echocardiographic signs of tamponade and she remained HD
stable without tachycardia or hypotension suggestive of cardiac
tamponade. Pulsus paradoxus remained normal throughout admission
at 7-9 mm H20.
# Unsteady gait, Lower back pain, s/p Fall x2:
Presented with a fall and experienced a fall in the hosptial.
Worked with ___ during this admission. Unclear if gait
abnormalities seen in the hospital are due to the soft
tissue/MSK injuries she experienced from her falls, or were
present prior to (and possibly precipitated) these falls. Will
need reassessment when exam no longer limited by pain. She does
not want narcotics on discharge as her family has a history of
going through her belongings and stealing drugs with street
value. She taken a few PO doses of dilaudid while inpatient.
# Anemia: Fe studies suggest secondary to chronic renal disease.
S/p 4U PRBCs and Epo x4 with improvement in clinical appearance
and H/H.
#Complex social issues: She had been living temporarily with her
mother, however pt was notified the weekend prior to discharge
that she wouldn't be allowed to stay there in the future. Pt has
also had problems with getting rides to and from dialysis in the
past, so was set up with/provided information for new
transportation company in order to get to and from dialysis as
an outpatient. Of note, pt also with food insecurity as well. Is
already on SNAP.
===============================
TRANSITIONAL ISSUES
===============================
- No BP meds on HD days
- will need activated vit d+/- cinacalcet as outpatient (through
renal provider)
- when stable on HD and open to referral, consider non-urgent
liver referral regarding ADPKD involvement of liver (recommended
from previous hepatology assessment several years ago)
- ongoing assessment of gait as her traumatic pain improves to
evaluate for other etiologies of unsteady gait
- needs outpatient ___
- Patient should follow up with outpatient cardiologist to
review heart failure meds. Pt currently only on carvedilol and
isosorbide mononitrate.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Carvedilol 25 mg PO BID
2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
3. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
4. Sodium Bicarbonate 1300 mg PO TID
5. Omeprazole 20 mg PO DAILY
6. Calcium Acetate ___ mg PO TID W/MEALS
Discharge Medications:
1. Carvedilol 25 mg PO BID FOUR DAYS A WEEK
Take BID on ___ and do not take on HD days.
2. HYDROmorphone (Dilaudid) ___ mg PO DAILY:PRN BREAKTHROUGH
PAIN
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth
daily:prn Disp #*6 Tablet Refills:*0
3. Isosorbide Mononitrate (Extended Release) 60 mg PO 4X/WEEK
(___)
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Nephrocaps 1 CAP PO DAILY
6. nitroglycerin 400 mcg/spray translingual ___ sprays q5min up
to 3 times PRN chest pain
7. Ondansetron ODT 4 mg PO BID:PRN Take prior to dialysis
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Torsemide 20 mg PO 4X/WEEK (___)
10. Acetaminophen 1000 mg PO Q6H
11. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Autosomal dominant polycystic kidney disease
ESRD on HD
Ascites
Pericardial effusion
Fall
Abnormal gait
Discharge Condition:
Activity Status: Ambulatory - Independent however below her
baseline.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. ___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- fall, fluid overload, management of your kidney disease, low
energy
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- you were found to have excess fluid in your legs, abdomen, and
around your heart
- you were monitored closely
- fluid was removed from you abdomen (paracentesis)
- hemodialysis was restarted and arrangements made for a new
center and new transportation
- pain was treated
- you were seen by ___
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- work with ___ at rehab
- Go to HD and work with your new renal doctor
- review your new medications list and take as prescribed
- Weigh yourself every morning, talk to your renal doctor if
weight goes up more than 3 lbs.
It was a pleasure being a part of your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10318991-DS-20 | 10,318,991 | 28,578,832 | DS | 20 | 2168-01-07 00:00:00 | 2168-01-07 21:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / aspirin / Oxycodone /
tramadol
Attending: ___
Chief Complaint:
Abdominal distention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ YO F with history of hypertension-induced cardiomyopathy EF
___, CKD V (from ADPKD) recently restarted hemodialysis this
month presents with increasing abdominal distention and mild
shortness of breath over the last week in the setting of missing
HD this week.
Per patient her last HD was last ___. She has been trying to
go to a new place to have this performed but has had some issues
setting that up. Her visiting nurse saw her today and was
concerned about a 4 pound weight gain and some shortness of
breath and referred her to the ED.
Patient states she otherwise feels well. She does not complain
of significant shortness of breath or chest pain. No fevers. She
denies any abdominal pain and just feels like her abdomen has
grown in size. She has been constipated but no additional
bleeding per rectum. She denies any urinary symptoms. She has
not noticed any swelling in her legs.
In the ED, initial VS were 4 98.1 90 138/90 18 97% RA.
Exam notable for not recorded
Labs showed K+ 5.7
Imaging showed CXR w/ Streaky right basilar opacity could
reflect atelectasis, but infection is not excluded in the
correct clinical setting.
Received Lasix 20
Transfer VS were 4 98.1 90 138/90 18 97% RA
On arrival to the floor, patient reports that she is having
abdominal tightness. She denies any shortness of breath. She has
not had HD in 1 week, vomited afterwards. She does make urine
but did not put out to the Lasix in the ED.
She denies F/C, N/V, SOB, chest pain/dizziness,
constipation/diarrhea, numbness/weakness.
Per patient, her rehab is not able to accommodate her HD. Per
rehab notes, she has refused HD x 3.
Past Medical History:
- HTN-induced dilated cardiomyopathy, EF ___
- Hypertension
- Autosomal Dominant Polycystic Kidney Disease: cystic
involvement of the liver and ovaries as well.
- Migraine headaches
- Questionable history of cerebral aneurysm: MRI done here in
___ did not see any cerebral aneurysms
- h/o UGIB requiring PRBC ___: EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to NSAID use
- Colelithiasis
- GERD
- Hyperparathyroidism ___ kidney disease. On Zemplar)
Social History:
___
Family History:
8 family members with ___ kidney disease in an autosomal
dominant pattern on paternal side. Two sisters and one brother
with ESRD ___ ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.5 PO 158 / 89 R Sitting 94 16 99 RA
GENERAL: NAD, sitting comfrotably
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, JVD to earlobe
HEART: RRR, +blowing murmur
LUNGS: Decreased breath sounds in RLL
ABDOMEN: distended, nontender in all quadrants, no
rebound/guarding,
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.0 134 / 88 86 18 100 Ra
General: Calm, NAD
Neck: JVP slightly above clavicle
CV: RRR, systolic ejection murmur
Pulm: CTAB
Abd: Moderately distended, NT, soft
MSK: No ___ edema
Neuro: speech fluent, moving all extremities with purpose
Pertinent Results:
ADMISSION LABS:
===============
___ 02:45PM BLOOD WBC-3.7* RBC-2.56* Hgb-7.6* Hct-25.4*
MCV-99* MCH-29.7 MCHC-29.9* RDW-14.5 RDWSD-52.4* Plt ___
___ 02:45PM BLOOD Neuts-62.2 ___ Monos-9.7 Eos-4.0
Baso-0.3 Im ___ AbsNeut-2.32 AbsLymp-0.87* AbsMono-0.36
AbsEos-0.15 AbsBaso-0.01
___ 02:45PM BLOOD ___ PTT-28.7 ___
___ 02:45PM BLOOD Glucose-85 UreaN-65* Creat-11.3*# Na-137
K-6.3* Cl-99 HCO3-22 AnGap-22*
___ 02:45PM BLOOD ALT-<5 AST-14 AlkPhos-61 TotBili-0.3
___ 02:45PM BLOOD Albumin-3.1* Calcium-8.6 Phos-4.8* Mg-2.2
___ 02:57PM BLOOD Lactate-1.2 K-5.7*
___ 04:58PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-SM
___ 04:58PM URINE RBC-4* WBC-11* Bacteri-FEW Yeast-NONE
Epi-5
MICROBIOLOGY:
=============
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
___ Cardiovascular ECHO
LEFT VENTRICLE: Depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
PERICARDIUM: Moderate pericardial effusion. Effusion
circumferential. No echocardiographic signs of tamponade.
Conclusions
LV systolic function appears depressed. Right ventricular
chamber size and free wall motion are normal. There is a
moderate sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
___ Cardiovascular Cath Physician ___
Dominance: Right
Left main coronary artery: Normal
Left anterior descending coronary artery: There was a high
diagonal branch without disease. The
proximal, mid, and distal LAD were free of significant disease.
Left circumflex coronary artery: The LCx was a large vessel and
gave rise to a large OMB without
disease. It terminated in a medium sized posterolateral branch
without disease.
Right coronary artery: There was marked tortuosity of the RCA.
The proximal, mid, and distal RCA had
minor irregularities. The RCA terminated in a small PDA and
posterolateral branch.
Impressions:
1. Insignificant coronary artery disease
INTERMITTENT PERTINENT LABS:
============================
___ 10:31AM BLOOD CK-MB-1 cTropnT-0.14*
___ 03:00AM BLOOD TSH-9.7*
___ 01:39PM ASCITES TNC-378* RBC-286* Polys-1* Lymphs-46*
___ Mesothe-27* Macroph-26*
___ 01:39PM ASCITES TotPro-3.8 Glucose-108 LD(LDH)-70
Amylase-114 Albumin-1.9
DISCHARGE LABS:
===============
___ 03:20PM BLOOD WBC-3.7* RBC-2.74* Hgb-8.3* Hct-26.5*
MCV-97 MCH-30.3 MCHC-31.3* RDW-14.2 RDWSD-50.0* Plt ___
___ 03:20PM BLOOD Glucose-113* UreaN-17 Creat-3.7*# Na-138
K-4.3 Cl-101 HCO3-25 AnGap-16
___ 03:20PM BLOOD TotProt-6.4 Albumin-3.1* Globuln-3.3
Calcium-8.4 Phos-2.7 Mg-1.8
Brief Hospital Course:
PATIENT SUMMARY:
Ms. ___ is a ___ woman with history of
hypertension-induced cardiomyopathy EF ___, CKD V (from
ADPKD) recently restarted hemodialysis this month who presented
with increasing abdominal distention and mild shortness of
breath over the last week in the setting of missing HD.
ACUTE ISSUES
#Volume overload:
#ESRD on HD
Dyspnea on presentation likely due to volume overload in the
setting of missing HD. Missing HD was due to patient feeling
that was not receiving treatment of her symptoms such as nausea
from HD. Improved with volume removal during HD this admission.
She was set up with new ___ facility that could better manage her
symptoms such as nausea during HD
#Ascites:
Fluid studies from ascites on previous admission suggestive of
cardiac ascites (SAAG >1.1 and total protein >3), likely
worsened by ESRD. Repeat diagnostic paracentesis showed findings
again consistent with cardiac ascites. Renal suggested
outpatient liver US with Doppler to evaluate for vascular
compression contributing to ascites.
#Tooth pain:
Possible abscess seen on panorex. Dental recommending several
tooth extractions. ___ was working on appointment at time of
discharge and OMFS would call ___ house to confirm
appointment when made. Was started on augmentin on ___ for ___fter concern for possible odontogenic infection.
Course to complete on ___.
#Intermittent dizziness and visual changes:
Pt reports seeing "floaters" and intermittent vertiginous
symptoms. Orthostatics negative. The intermittent, rare nature
(<2 times per week) suggests less likely a CVA. Opthalmology
appointment as outpatient was pending at time of discharge.
#Chest pain, CAD:
Episode of CP during HD thought to be stable angina. Trop at
baseline with normal CK-MB, suggesting ACS less likely. Elective
cath ___ showed non-obstructive CAD. Medical management.
#Pericardial effusion:
#Hypothyroidism:
Known chronic effusion, likely due to uremia in the setting of
ESRD. TTE showed no signs of tamponade. Remained hemodynamically
stable. Started on levothyroxine 25mcg for elevated TSH.
TRANSITIONAL:
=============
[]Augmentin course for suspected odontogenic infection to
complete on ___
[]Recheck TSH in ___ months and consider adjusting Synthroid
dose as needed
[]please help arrange patient to have ophthalmology eval for
floaters reported while in-patient
[]please help arrange patient to have ___ outpatient work-up
for possible abscess seen on panorex imaging -- ___ was still
scheduling appointment at time of discharge and said would call
rehab center when appointment made
[]consider liver US with Doppler to evaluate for possible
contribution from venous compression contributing to ascites
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Nephrocaps 1 CAP PO DAILY
4. Ondansetron ODT 4 mg PO BID:PRN Take prior to dialysis
5. sevelamer CARBONATE 800 mg PO TID W/MEALS
6. Carvedilol 25 mg PO BID FOUR DAYS A WEEK
7. Isosorbide Mononitrate (Extended Release) 60 mg PO 4X/WEEK
(___)
8. HYDROmorphone (Dilaudid) ___ mg PO DAILY:PRN BREAKTHROUGH
PAIN
9. nitroglycerin 400 mcg/spray translingual ___ sprays q5min up
to 3 times PRN chest pain
10. Acetaminophen 1000 mg PO Q6H
11. Vitamin D ___ UNIT PO 1X/MONTH
12. Senna 8.6 mg PO BID
13. Milk of Magnesia 30 mL PO DAILY:PRN constipation
14. Fleet Enema (Saline) ___AILY:PRN constipation
15. Docusate Sodium 100 mg PO BID
16. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
17. Heparin 5000 UNIT SC BID
18. Ondansetron 4 mg PO 3X/WEEK (___)
19. Ondansetron 4 mg PO BID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q24H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth daily Disp #*7 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Acetaminophen 1000 mg PO Q6H
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Carvedilol 25 mg PO BID FOUR DAYS A WEEK
10. Docusate Sodium 100 mg PO BID
11. Fleet Enema (Saline) ___AILY:PRN constipation
12. HYDROmorphone (Dilaudid) ___ mg PO DAILY:PRN BREAKTHROUGH
PAIN
13. Isosorbide Mononitrate (Extended Release) 60 mg PO 4X/WEEK
(___)
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Milk of Magnesia 30 mL PO DAILY:PRN constipation
16. Nephrocaps 1 CAP PO DAILY
17. Nitroglycerin 400 mcg/spray translingual ___ SPRAYS Q5MIN
UP TO 3 TIMES PRN CHEST PAIN chest pain
18. Omeprazole 20 mg PO DAILY
19. Ondansetron ODT 4 mg PO BID:PRN Take prior to dialysis
20. Ondansetron 4 mg PO 3X/WEEK (___)
21. Senna 8.6 mg PO BID
22. sevelamer CARBONATE 800 mg PO TID W/MEALS
23. Vitamin D ___ UNIT PO 1X/MONTH
24. HELD- Heparin 5000 UNIT SC BID This medication was held. Do
not restart Heparin until decided appropriate by rehab
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
End stage renal disease on hemodialysis
Hypertension
Chronic pericardial effusion
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for increased fluid in your body from
missing dialysis. After resuming dialysis this overload of fluid
improved. We arranged for a new dialysis ___ you.
We also examined your painful tooth and set you up with a
followup appointment to have this tooth and other diseased ones
removed.
You will also need to followup with an eye doctor for your
visual changes. Please ask your PCP to help you arrange this.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10318991-DS-21 | 10,318,991 | 23,862,662 | DS | 21 | 2168-03-01 00:00:00 | 2168-03-01 16:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / aspirin / Oxycodone /
tramadol
Attending: ___.
Chief Complaint:
Weakness, Hematuria, Flank Pain, Ascites
Major Surgical or Invasive Procedure:
___ - Paracentesis
History of Present Illness:
___ y/o F h/o of ___ on dialysis (missed ___, missing today),
hypertensive CM (EF 20%), hypothyroidism, and cardiac ascites
requiring frequent therapeutic paracentesis, who presents with
hgb of 5.6 in the setting of 3 days of hematuria and R flank
pain with concern for acute on chronic anemia in the setting of
blood loss from nephrolithiasis, complicated by persistent large
volume ascites.
The patient reports that over the last three days she has
developed sharp R flank pain and red urine. She feels fatigued
but no dyspnea, light-headedness, CP. No fevers/chills. Right
flank pain was sharp and does not radiate, blood in urine is red
and intermittent. Also associated with nausea and a few episodes
of nausea. She has been living at the ___. They
checked labs which showed hgb 5.6 and her urine had large blood,
so they decided to have her bypass HD today and be sent to the
___ ED. Also, the patient reports that her abdomen is more
distended than usual, normally gets therapeutic taps but has not
been tapped recently.
Of note, the pt was due for HD on ___ and today and missed
both sessions.
The patient was last admitted to ___ in ___ for large
volume ascites and volume overload in the setting of missing an
HD appointment. She had a large volume paracentesis, with fluid
studies SAAG >1.1 and total protein >3 suggestive of cardiac
ascites. She was discharged to ___ for rehab and has
remained there awaiting housing placement given that she would
be otherwise homeless.
In the ED, initial VS were: 98.7 84 120/74 18 99% RA
Exam notable for: Exam: R CVAT, grossly distended abdomen with
bulging flanks, dull to percussion over flanks, liver palpable 6
cm below costal margin, no tenderness, no lower extremity edema,
rectal exam with brown stool heme negative
Labs showed: H/H 6.6/21.9, INR 1.2, AP 153, LFTs otherwise wnl
w/ Tb 0.5, albumin 3.5, Lipase 226, creatinine 10.2 (on HD), BUN
66, lactate 0.5, UA >182 RBC, 4 epis, WBC 18, sm Leuk.
Imaging showed:
-CT w/o contrast:
1. Unchanged cystic replacement of the bilateral kidneys with
marked
enlargement without new renal calcifications identified.
2. Unchanged large pericardial effusion.
3. Grossly stable large volume ascites.
Received:
-1 unit ___
Decision was made to admit for pain control and treatment of
anemia
Transfer VS were: 85 149/95 16 100% RA
On arrival to the floor, patient reports improved flank/CVA
pain. She reports that initially 3 days ago her flank pain was
sharp and now it is more dull. She also reports that she
initially had dark red/purple urine, and now she reports her
urine is the color of "pink lemonade", most recently with a void
15 minutes prior to my interview with her. Otherwise reporting
mild shortness of breath since missing HD but denies chest pain.
She did have one episode of feeling quite warm three days ago
but her temperature has remained within normal range.
Past Medical History:
- HTN-induced dilated cardiomyopathy, EF ___, with cardiac
ascites
- Hypertension
- Autosomal Dominant Polycystic Kidney Disease: cystic
involvement of the liver and ovaries as well.
- Migraine headaches
- Questionable history of cerebral aneurysm: MRI done here in
___ did not see any cerebral aneurysms
- h/o UGIB requiring PRBC ___: EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to NSAID use
- Colelithiasis
- GERD
- Hyperparathyroidism ___ kidney disease. On Zemplar)
Social History:
___
Family History:
8 family members with ___ kidney disease in an autosomal
dominant pattern on paternal side. Two sisters and one brother
with ESRD ___ ___
Physical Exam:
ADMISSION EXAM
==========================
VS: 98.1 155 / 87 87 18 99 Ra
GENERAL: NAD , lying comfortably inbed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: JVD difficult to examine given very strong carotid pulse
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB but with bibasilar reduced breath sounds
ABDOMEN: distended but soft with flank bulging. Nontender,
normal BS
BACK: +CVAT on R side
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
===========================
VS: 98.3, 116/83, HR 101, RR 16, 98 Ra
General: Pleasant, well appearing woman in no distress
HEENT: Normocephalic, sclera anicteric
Pulmonary: Normal work of breathing on RA, equal chest rise
Abdomen: Hepatomegaly with cystic masses palpable several cm
below the diaphragm. Bilateral flank tenderness. Much improved
distension following paracentesis.
Extremities: Warm, well perfused, no edema
Neuro: Alert, oriented, answers questions appropriately
Pertinent Results:
ADMISSION LABS
==============================
___ 04:40PM BLOOD WBC-4.0 RBC-2.23* Hgb-6.6* Hct-21.9*
MCV-98 MCH-29.6 MCHC-30.1* RDW-14.4 RDWSD-51.1* Plt ___
___ 04:40PM BLOOD Neuts-62.0 ___ Monos-9.3 Eos-4.8
Baso-0.5 Im ___ AbsNeut-2.46 AbsLymp-0.91* AbsMono-0.37
AbsEos-0.19 AbsBaso-0.02
___ 04:40PM BLOOD ___ PTT-29.1 ___
___ 04:40PM BLOOD Glucose-85 UreaN-66* Creat-10.2* Na-141
K-4.6 Cl-99 HCO3-24 AnGap-18*
___ 05:53AM BLOOD Ret Aut-0.9 Abs Ret-0.02
___ 04:40PM BLOOD ALT-11 AST-12 AlkPhos-153* TotBili-0.5
___ 05:53AM BLOOD Albumin-2.9* Calcium-8.4 Phos-5.6* Mg-2.0
Iron-34
___ 05:53AM BLOOD calTIBC-137* VitB12-951* Folate-19
Ferritn-579* TRF-105*
___ 05:00PM BLOOD Lactate-0.5
___ 10:00PM URINE RBC->182* WBC-18* Bacteri-FEW* Yeast-NONE
Epi-4
___ 10:00PM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM*
PARACENTESIS LABS
===============================
___ 03:31PM ASCITES TNC-275* RBC-164* Polys-4* Lymphs-14*
___ Mesothe-8* Macroph-74*
___ 03:31PM ASCITES TotPro-3.8 Glucose-91 LD(LDH)-86
Albumin-2.1
MICROBIOLOGY
===============================
Blood, urine, and peritoneal cultures with no growth at time of
discharge
DISCHARGE LABS
===============================
___ 07:00AM BLOOD WBC-5.1 RBC-3.22* Hgb-9.3* Hct-29.5*
MCV-92 MCH-28.9 MCHC-31.5* RDW-16.0* RDWSD-54.2* Plt ___
___ 07:00AM BLOOD Glucose-86 UreaN-41* Creat-6.9* Na-137
K-4.8 Cl-95* HCO3-27 AnGap-15
___ 07:00AM BLOOD Calcium-9.1 Phos-5.3* Mg-2.2
IMAGING
===============================
CT Abd/Pelvis ___. Unchanged cystic replacement of the bilateral kidneys with
marked
enlargement without new renal calcifications identified.
2. Unchanged large pericardial effusion.
3. Somewhat increased large volume ascites.
Brief Hospital Course:
___ y/o F h/o of Polycystic Kidney Disease on dialysis,
hypertensive CM (EF 20%), hypothyroidism, and cardiac ascites
requiring frequent therapeutic paracentesis, who presents with
hematuria, flank pain, anemia, weakness, and worsened ascites.
ACTIVE ISSUES
===============================
# Hematuria and Flank Pain:
# Ruptured Renal Cyst
# H/o Polycystic Kidney Disease
She presented with hematuria and flank pain, with CVA tenderness
on exam. These symptoms were likely due to a ruptured renal
cyst. She reports that she has had similar presentations in the
past that were due to cyst rupture. She had initially had dark
red urine, "blood colored." Prior to admission however, this had
cleared up to more of a "pink lemonade" color. CT scan was none,
showing no evidence of renal stone or pyelonephritis. There was
no pyuria or UA, and no fever or leukocytosis to suggest urinary
infection. Her post-void residual was checked and normal, and
she had no evidence of urinary obstruction. Her symptoms were
stable on the day of discharge, and she will continue to monitor
for signs of worsening bleeding or urinary obstruction.
# Acute on chronic Anemia: Has a baseline anemia with Hgb
typically in the 7's, related to ESRD. On presentation, she had
a somewhat worsened Hgb of 6.6 (though was <6 when checked at
her facility), but this was not far outside the range of her
prior values. She received 2 units of packed red blood cells
this admission, with appropriate response. Her hematuria was
felt to be unlikely to be a major contributor
# ESRD ___ PKD on HD: She had missed two dialysis sessions prior
to admission, which was likely in part contributing to her
weakness. She received dialysis while admitted. She received Epo
while admitted, and should continue to take this as an
outpatient at her outpatient dialysis center. Continued
compliance with dialysis will be essential. Continue nephrocaps
and sevelamer.
# Large volume ascites: Thought to be Cardiac in the past. She
received a paracentesis on ___, with 6 liters of fluid removed.
There was no evidence of peritoneal infection.
CHRONIC ISSUES
==============================
# HTN and Hypertensive CM: Continue home Carvedilol and Imdur
# Chronic pain and nausea: Continue home dilaudid and zofran
# Constipation: Continue home bowel regimen
# Hypothyroidism: Continue home levothyroxine
# Anxiety: Continue home lorazepam as needed
# Insomnia: Continue home trazadone as needed
TRANSITIONAL ISSUES
================================
[ ] Continued compliance with dialysis will be essential
[ ] Monitor for signs/symptoms of urinary obstruction due to
blood clot, such as suprapubic pain, inability to urinate,
fever, and worsening flank/back pain
[ ] No changes to her home/chronic medications were made
[ ] Discharge Hgb: 9.3
[ ] Consider arranging for periodic outpatient paracentesis for
ascites
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron ODT 4 mg PO Q8H:PRN nausea
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Carvedilol 25 mg PO BID
5. Bisacodyl ___AILY:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. Senna 8.6 mg PO BID
8. Fleet Enema (Saline) ___AILY:PRN constipation
9. Atorvastatin 40 mg PO QPM
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. nitroglycerin 400 mcg/spray translingual q5 minutes up to
three times in 15 minutes prn chest pain
12. HYDROmorphone (Dilaudid) ___ mg PO DAILY:PRN Pain - Severe
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Omeprazole 20 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Levothyroxine Sodium 25 mcg PO DAILY
17. Nephrocaps 1 CAP PO DAILY
18. Vitamin D ___ UNIT PO QMONTH ON THE ___
19. LORazepam 0.5 mg PO BID:PRN anxiety
20. Lactulose 30 mL PO DAILY:PRN constipation
21. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Carvedilol 25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Fleet Enema (Saline) ___AILY:PRN constipation
8. HYDROmorphone (Dilaudid) ___ mg PO DAILY:PRN Pain - Severe
RX *hydromorphone 2 mg ___ tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Lactulose 30 mL PO DAILY:PRN constipation
11. Levothyroxine Sodium 25 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. LORazepam 0.5 mg PO BID:PRN anxiety
14. Nephrocaps 1 CAP PO DAILY
15. nitroglycerin 400 mcg/spray translingual q5 minutes up to
three times in 15 minutes prn chest pain
16. Omeprazole 20 mg PO DAILY
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
18. Senna 8.6 mg PO BID
19. sevelamer CARBONATE 800 mg PO TID W/MEALS
20. TraZODone 50 mg PO QHS:PRN insomnia
21. Vitamin D ___ UNIT PO QMONTH ON THE ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
End Stage Renal Disease on dialysis
Hematuria due to ruptured kidney cyst
Ascites
Acute on chronic anemia
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
after low blood counts, belly pain, dark urine, and fatigue.
You were given 2 units of blood, and we drained 6 liters of
fluid from your belly. You also received dialysis sessions
while here.
Your low blood counts are likely due to poor kidney function.
When you go to dialysis, they will administer a medication to
help your body keep its blood counts up. Be sure to attend your
dialysis appointments so that they can give you this medication.
Furthermore, please continue to monitor to make sure you have no
urinary obstruction from a blood clot. If you develop worsening
pain in your bladder, or an inability to urinate at all, please
seek medical attention.
We wish you all the best,
___ Team
Followup Instructions:
___
|
10318991-DS-22 | 10,318,991 | 29,983,708 | DS | 22 | 2168-05-21 00:00:00 | 2168-05-21 21:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / aspirin / Oxycodone /
tramadol
Attending: ___.
Chief Complaint:
chest pain, missed dialysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with h/o ___ on dialysis (___) ,hypertensive CM (EF
30%), hypothyroidism, and cardiac ascites requiring frequent
therapeutic paracentesis, anemia, who presents for clearance for
dialysis after having missed over a week of sessions (last had
dialysis ___.
Per ED report:
She also states she has been having a "squeezing" left anterior
chest pain for the past week associated with diaphoresis and
dyspnea. The pain comes and goes and is not necessarily
exertional. She does have increasing exertional dyspnea. She has
a dry cough. This chest pain has happened to her in the past,
though not for several months, and she has been taking nitro
(last took it yesterday), but the pain continues to occur. She
has had some nausea and one episode of emesis two days ago. She
has increased abdominal distention. Denies abdominal pain,
fevers, diarrhea. Denies lower extremity edema. She has had
orthopnea for months. She does make urine and has had "a lot" of
urinary output, no dysuria or hematuria. Cardiac cath done in
___, no significant CAD.
Past Medical History:
- HTN-induced dilated cardiomyopathy, EF ___, with cardiac
ascites
- Hypertension
- Autosomal Dominant Polycystic Kidney Disease: cystic
involvement of the liver and ovaries as well.
- Migraine headaches
- Questionable history of cerebral aneurysm: MRI done here in
___ did not see any cerebral aneurysms
- h/o UGIB requiring PRBC ___: EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to NSAID use
- Colelithiasis
- GERD
- Hyperparathyroidism ___ kidney disease. On Zemplar)
Social History:
___
Family History:
8 family members with ___ kidney disease in an autosomal
dominant pattern on paternal side. Two sisters and one brother
with ESRD ___ ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VS: 2357 98.3 PO ___ Ra
GENERAL: NAD, pleasant, well groomed and in NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple
HEART: RRR, S1/S2, no murmurs, gallops, or rubs. no rub
appreciated
LUNGS: CTAB, mild crackles noted L lung base, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. AVF L arm.
NEURO: A&Ox3, moving all 4 extremities with purpose, strength
___
in UE and ___ bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: 98.9PO 137 / 68R Lying 51 18 96 Ra
GENERAL: No acute distress
HEENT: NCAT, EOMI, MMM, oropharynx clear
NECK: supple, no LAD, no JVP
CV: RRR, S1S2 normal, no MRG, 2+ radial pulses b/l
RESP: lungs CTAB, breathing comfortably
GI: normoactive bowel sounds, soft, NDNT, no organomegaly
EXTREMITIES: no edema, cyanosis, or clubbing
SKIN: No rashes or petechiae
NEURO: AAOx3, strength and sensation grossly normal throughout
PSYCH: normal affect
Pertinent Results:
ADMISSION LABS
-------------------
___ 04:50PM BLOOD WBC-4.3 RBC-3.39* Hgb-9.9* Hct-33.1*
MCV-98 MCH-29.2 MCHC-29.9* RDW-16.6* RDWSD-60.3* Plt ___
___ 04:50PM BLOOD Neuts-58.7 ___ Monos-10.3 Eos-4.2
Baso-0.5 Im ___ AbsNeut-2.50 AbsLymp-1.11* AbsMono-0.44
AbsEos-0.18 AbsBaso-0.02
___ 04:50PM BLOOD ___ PTT-32.2 ___
___ 04:50PM BLOOD Glucose-81 UreaN-99* Creat-14.2*# Na-142
K-5.7* Cl-101 HCO3-20* AnGap-21*
___ 04:50PM BLOOD ALT-9 AST-9 CK(CPK)-53 AlkPhos-132*
TotBili-0.4
___ 04:50PM BLOOD CK-MB-2
___ 04:50PM BLOOD cTropnT-0.11*
___ 09:05PM BLOOD CK-MB-2 cTropnT-0.11*
___ 04:50PM BLOOD Albumin-3.7 Calcium-9.1 Phos-9.1* Mg-2.1
___ 09:14PM BLOOD K-5.3*
DISCHARGE LAB
-------------------
___ 05:28AM BLOOD WBC-4.0 RBC-3.17* Hgb-9.3* Hct-29.9*
MCV-94 MCH-29.3 MCHC-31.1* RDW-16.1* RDWSD-56.9* Plt ___
___ 05:22AM BLOOD Glucose-105* UreaN-101* Creat-14.9*
Na-140 K-5.6* Cl-101 HCO3-19* AnGap-20*
___ 05:22AM BLOOD Calcium-8.9 Phos-9.2* Mg-2.0
Brief Hospital Course:
PATIENT SUMMARY:
================
This is a ___ year old woman with a PMH of ESRD ___ ___ on
dialysis (___), hypertensive CM (EF 30%), hypothyroidism, and
cardiac ascites requiring frequent therapeutic paracentesis,
anemia, who presented with chest pain and elevated troponin
after having missed medication doses and a full week of HD due
to transportation issues (last had dialysis ___.
#ESRD ___ ___ on dialysis (___)
#Hyperkalemia
#Hyperphosphatemia
Patient on ESRD but with missed sessions x10 days in setting of
move, social issues. BPs and electrolytes now improved s/p HD.
Patient states that she has now re-established with
transportation via Mass Health. Social work will follow up with
patient after d/c to ensure she continues to have access to
outpt dialysis.
#HTN
Patient with HTN to 180s in ED and on arrival to floor.
Improved to sBP 130s after HD, although continued to fluctuate.
Continued home carvedilol, imdur.
#Troponinemia
#Chest pain
RESOLVED. On arrival, <1mm STE and initial TWI that resolved
with improved BP control in ED; troponin
elevated to 0.11 and stable. Prior cardiac cath ___ notable
for insignificant coronary artery disease. Troponin leak likely
___ ESRD vs type II NSTEMI from missed HD sessions. Continued
home carvedilol, atorvastatin, ASA.
#Social Barriers
Patient with housing instability and difficulty taking
medications/getting to appointments and HD. WIll require close
care coordination upon discharge as above.
TRANSITIONAL ISSUES:
====================
[ ] F/u with PCP
[ ] Transportation to hemodialysis, per pt resolved, will have
SW follow up.
[ ] Ensure patient can get her medicines (consider PACT
pharmacy)
[ ] continue to titrate antihypertensive regimen
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Carvedilol 25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. HYDROmorphone (Dilaudid) ___ mg PO DAILY:PRN Pain - Severe
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Ondansetron ODT 4 mg PO Q8H:PRN nausea
13. Senna 8.6 mg PO BID
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. TraZODone 50 mg PO QHS:PRN insomnia
16. nitroglycerin 400 mcg/spray translingual q5 minutes up to
three times in 15 minutes prn chest pain
17. Vitamin D ___ UNIT PO QMONTH ON THE ___
18. Lactulose 30 mL PO DAILY PRN constipation
19. Temazepam ___ mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Carvedilol 25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Lactulose 30 mL PO DAILY PRN constipation
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. nitroglycerin 400 mcg/spray translingual q5 minutes up to
three times in 15 minutes prn chest pain
12. Omeprazole 20 mg PO DAILY
13. Ondansetron ODT 4 mg PO Q8H:PRN nausea
14. Senna 8.6 mg PO BID
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Temazepam ___ mg PO QHS:PRN insomnia
17. TraZODone 50 mg PO QHS:PRN insomnia
18. Vitamin D ___ UNIT PO QMONTH ON THE ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Electrolyte disturbances due to missed hemodialysis
Troponinemia
SECONDARY DIAGNOSIS
Hypertension
End Stage Renal Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for chest pain after having missed dialysis
for 1 week.
What was done for me in the hospital?
- You received dialysis on ___.
- We made sure you can continue getting outpatient dialysis at
your original center.
What should I do when I leave the hospital?
- Please take all of your medicines as prescribed.
- Please follow up with your PCP.
- Please try to attend all your dialysis sessions as scheduled.
When should I return to the hospital?
- Please return to the hospital if you miss ___ dialysis session,
if you have severe chest pain, if you have fever, if you stop
being able to feel the thrill in your fistula, or for any other
symptoms that concern you.
We wish you the best of luck in your health!
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10318991-DS-24 | 10,318,991 | 20,136,521 | DS | 24 | 2168-08-31 00:00:00 | 2168-09-01 07:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / aspirin / Oxycodone /
tramadol
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
___ Therapeutic Paracentesis
History of Present Illness:
___ woman with ADPKD previously on HD (discontinued in
___ because of nausea/malaise), hypertensive CM (EF 30%),
hypothyroidism, cardiac ascites presenting with two weeks of
nausea, bilious, vomiting, malaise, visual concerns. Patient
reports that she discontinued dialysis in ___ because of
nausea and general malaise like symptoms. Reports that for past
two weeks has been experiencing worsening vomiting of bilious
liquid with limited PO intake. Also with diffuse abdominal pain.
Denies fevers or chills. Reports visual changes with "worm like"
flashes across both of her eyes and ocular pain at her inferior
orbits. Increasing abdominal distension with new soft growth at
her right femoral region. Denies chest pain, SOB, syncope. No
hematemesis, melena or hematochezia. No fevers/chills.
In the ED, initial VS were: T 97.2 HR 100 BP 181/103 R 17 SpO2
100% RA
Exam notable for:
+SEM loudest at RSB, +S3 gallop, abdomen distended, diffusely
TTP, +fluid wave, +right femoral hernia, reducible
EKG: Sinus Rate 83. L axis. QTc 436. PRWP. No ST-T wave changes
Labs showed:
Ascites: WBC 480, 5% Polys
140|100|155
------------<123
5.7|12|24.0
Ca: 8.0 Mg: 1.7 P: 10.7
ALT: <5 AP: 57 Tbili: 0.4 Alb: 3.3
AST: <5 Lip: 148
5.5
3.7>----<123
18.4
Imaging showed:
___ Liver Or Gallbladder Us
1. Patent portal vein.
2. Cholelithiasis and no sonographic evidence of acute
cholecystitis. Gallbladder wall edema is likely due to third
spacing.
3. Moderate volume ascites.
4. Polycystic liver and kidney disease with massive enlargements
better evaluated on the CT from ___.
___ Chest (Pa & Lat)
IMPRESSION:
No focal consolidation, edema or pleural effusion.
Consults:
Seen by renal dialysis who stated no need for acute dialysis
Patient received:
___ 08:56 PO/NG Nephrocaps 1 CAP
___ 08:56 PO sevelamer CARBONATE 800 mg
___ 08:56 PO/NG Carvedilol 25 mg
___ 08:56 PO/NG Levothyroxine Sodium 25 mcg
___ 09:19 IV Ondansetron 4 mg
___ 10:49 PO/NG HYDROmorphone (Dilaudid) 2 mg
___ 10:49 PO/NG Acetaminophen 1000 mg
___ 12:00 PO sevelamer CARBONATE
___ 13:45 IV DiphenhydrAMINE 50 mg
___ 16:00 IV Epoetin Alfa 8000 UNIT
___ 16:52 PO/NG HYDROmorphone (Dilaudid) 2 mg
2 units of blood and hemodialysis
On arrival to the floor, patient reports improved malaise with
continued abdominal distention.
Past Medical History:
- Autosomal Dominant Polycystic Kidney Disease on HD ___.
Cystic involvement of the liver and ovaries as well.
- HTN-induced dilated cardiomyopathy, EF ___, with cardiac
ascites
- Hypertension
- Migraine headaches
- Questionable history of cerebral aneurysm; MRI in ___ did not
see any cerebral aneurysms
- h/o UGIB requiring PRBC ___ EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to
NSAID use.
- Colelithiasis
- GERD
- Hyperparathyroidism ___ kidney disease
Social History:
___
Family History:
8 family members with ___ kidney disease in an autosomal
dominant pattern on paternal side. Two sisters and one brother
with ESRD ___ ___
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
VS: T 97.6 BP 178/95 HR 90 R 16 SpO2 95 Ra
GEN: Tired, NAD. Low muscle mass, mild temporal wasting
HEENT: Sclerae anicteric, no uremic ___, moist mucous
membranes
___: Regular, II/VI SEM with pericardial friction rub. JVP at
angle of jaw while sitting at 90 degrees
RESP: No increased WOB. No crackles, wheezing or rhonchi.
ABD: Large, distended with +fluid wave. R soft, reducible
femoral mass without bowel sounds on auscultation
EXT: warm, no edema. Fisutla in LUE with palpable thrill
NEURO: CN II-XII grossly intact. AAOx3
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
24 HR Data (last updated ___ @ 802)
Temp: 98.4 (Tm 98.7),
BP: 122/78 (85-122/52-78),
HR: 101 (95-103),
RR: 18,
O2 sat: 99% (96-100), O2 delivery: Ra, Wt: 155 lb/70.31 kg
GEN: Well-appearing woman sitting up in bed, watching TV and
speaking with me comfortably. AAO ×3, pleasant and
conversational.
HEENT: Moist mucous membranes. No scleral icterus or injection.
Dobhoff in R nostril with tape in place.
___: Regular, II/VI systolic murmur, stable. JVP 12cm
RESP: Clear to auscultation bilaterally, no basilar crackles, no
use of accessory muscles
ABD: Distended, fluid filled abdomen. Her abdomen is softer
than last week. No tenderness to palpation. Palpable enlarged
liver. Diffuse nodularity in the L and R upper quadrants.
Moderate R inguinal hernia that is soft and painless to
palpation. Significant ventral hernia visible with increased
abdominal pressure.
EXT: warm, no edema, fistula in LUE with palpable thrill
NEURO: CN II-XII grossly intact, AAOx3
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 10:38PM WBC-3.7* RBC-1.96* HGB-5.5* HCT-18.4* MCV-94
MCH-28.1 MCHC-29.9* RDW-16.6* RDWSD-56.6*
___ 10:38PM NEUTS-70.0 LYMPHS-16.9* MONOS-10.7 EOS-1.6
BASOS-0.3 IM ___ AbsNeut-2.61 AbsLymp-0.63* AbsMono-0.40
AbsEos-0.06 AbsBaso-0.01
___ 10:38PM ALBUMIN-3.3* CALCIUM-8.0* PHOSPHATE-10.7*
MAGNESIUM-1.7
___ 10:38PM ALT(SGPT)-<5 AST(SGOT)-<5 ALK PHOS-57 TOT
BILI-0.4
___ 10:38PM LIPASE-148*
___ 10:38PM GLUCOSE-123* UREA N-155* CREAT-24.0*#
SODIUM-140 POTASSIUM-5.7* CHLORIDE-100 TOTAL CO2-12* ANION
GAP-28*
___ 02:25AM ASCITES TNC-480* RBC-706* POLYS-5* LYMPHS-11*
___ MESOTHELI-2* MACROPHAG-82*
___ 09:13AM ALT(SGPT)-<5 AST(SGOT)-<5 CK(CPK)-44 ALK
PHOS-60 TOT BILI-0.5
___ 09:13AM LIPASE-164*
___ 09:13AM cTropnT-0.33*
___ 01:44PM CK-MB-3 cTropnT-0.30*
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 07:05AM BLOOD WBC-5.0 RBC-2.67* Hgb-8.0* Hct-25.4*
MCV-95 MCH-30.0 MCHC-31.5* RDW-16.6* RDWSD-57.6* Plt ___
___ 04:35AM BLOOD Glucose-102* UreaN-52* Creat-5.6*# Na-139
K-4.4 Cl-96 HCO3-30 AnGap-13
___ 09:13AM BLOOD cTropnT-0.33*
___ 01:44PM BLOOD CK-MB-3 cTropnT-0.30*
___ 04:35AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.5
===========================
REPORTS AND IMAGING STUDIES
===========================
___ Small Bowel Follow-Through Study
FINDINGS:
ESOPHAGUS:
Limited views of the esophagus demonstrate no esophageal
dilatation. There was no esophageal web, ring, or stricture.
There was no esophageal mass. The esophageal mucosa appears
within normal limits.
The primary peristaltic wave was normal, with contrast passing
readily into the stomach. The lower esophageal sphincter opened
and closed normally.
There was no gastroesophageal reflux. There was no hiatal
hernia.
STOMACH:
Limited views of the stomach show appropriate distention. No
focal lesion is identified. No evidence of gastric outlet
obstruction, and barium passes freely into the duodenum.
SMALL BOWEL:
Barium passes through the small bowel, reaching the colon at
just
greater than 120 minutes which is within normal limits. The
duodenum, jejunum, and ileum appear within normal limits in
caliber. There is normal fold pattern, with no masses,
stricture, or mucosal abnormality. The terminal ileum appears
within normal limits.
IMPRESSION:
Normal small bowel follow through.
___ Transthoracic Echocardiogram
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to
moderate global left ventricular hypokinesis (LVEF = 35-40%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a moderate sized
pericardial effusion. The effusion appears circumferential.
There
are no echocardiographic signs of tamponade. No right atrial or
right ventricular diastolic collapse is seen.
IMPRESSION: Moderate pericardial effusion without echo signs of
tamponade. Mild to moderate global left ventricular systolic
dysfunction.
Compared with the prior study (images reviewed) of ___,
the
findings are similar.
___ CT ABDOMEN AND PELVIS WITHOUT CONTRAST
FINDINGS:
LOWER CHEST: There is mild dependent atelectasis. A large
pericardial effusion is again seen, similar to ___. No
pleural effusion.
ABDOMEN:
HEPATOBILIARY: Innumerable hepatic cysts in hepatomegaly is
again
seen, in this patient with history of polycystic kidney disease.
Some of the hepatic cysts appear partially rim calcified. The
gallbladder is not clearly identified.
PANCREAS: The pancreas has normal attenuation throughout,
without
evidence of focal lesions within the limitations of an
unenhanced
scan. There is no pancreatic ductal dilatation. There is no
peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: Innumerable renal cysts are noted in the majority of
which appear simple, although hemorrhagic cysts and partially
rim
calcified cysts are noted as well.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops
demonstrate normal caliber and wall thickness throughout. The
colon and rectum are within normal limits. The appendix is not
visualized. There is a moderate amount of intra-abdominal
simple
fluid
PELVIS: The bladder is under distended, and not well seen.
There
is a moderate amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: Fibroid uterus. No adnexal abnormalities
are identified, within limitations of this noncontrast enhanced
study.
LYMPH NODES: No definite lymphadenopathy is identified, although
assessment is limited due to the presence of extensive hepatic
and renal cysts.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute
fracture.
SOFT TISSUES: Fluid containing right inguinal hernia is
unchanged
from prior
IMPRESSION:
1. Moderate volume ascites.
2. Large pericardial effusion is again seen, unchanged from
prior
studies.
3. Cystic replacement of the kidneys and liver, which
demonstrate
marked enlargement, compatible with the patient's history of
polycystic kidney disease.
4. Right inguinal hernia containing fluid, unchanged from prior
___ PORTABLE ABDOMEN
FINDINGS:
There is an overall paucity of bowel gas throughout the abdomen.
There is a small amount of stool and gas project over the low
pelvis. There are no abnormally dilated loops of bowel. No
diffuse haziness throughout the abdomen likely reflects ascites.
Mineralized densities to the left of the L4
vertebral body may reflect calcification within a renal cyst as
seen on the prior CT. Calcifications within the pelvis reflect
calcified fibroids. There is no free intraperitoneal gas. The
osseous structures are unremarkable.
IMPRESSION:
Nonspecific bowel gas pattern. No dilated loops of bowel are
seen within the abdomen or pelvis.
___ CHEST PA AND LATERAL
FINDINGS:
The lung volumes are low, however no focal consolidation is
seen.
No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable.
IMPRESSION:
No focal consolidation, edema or pleural effusion.
___ RIGHT UPPER QUADRANT ULTRASOUND
IMPRESSION:
1. Patent portal vein.
2. Cholelithiasis and no sonographic evidence of acute
cholecystitis. Gallbladder wall edema is likely due to third
spacing.
3. Moderate volume ascites.
4. Polycystic liver and kidney disease with massive enlargements
better evaluated on the CT from ___ with
re-demonstration of variable-sized cysts throughout the liver
and
both kidneys.
============
MICROBIOLOGY
============
___ URINE CULTURE = NEGATIVE
___ BLOOD CULTURE = NEGATIVE
___ BLOOD CULTURE = NEGATIVE
___ URINE CULTURE = NEGATIVE
___ 2:25 am PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
Ms. ___ is a ___ year old woman with polycystic kidney
disease, end stage renal disease on hemodialysis, and heart
failure with reduced ejection fraction who presented with
nausea, vomiting, abdominal pain and malaise in the setting of
having not been to hemodialysis in several weeks. She had a
prolonged hospital course due to refractory nausea and vomiting
and inability to get adequate oral nutrition. Due to the the
refractory nature of her nausea, transplant surgery was
consulted and offered L nephrectomy and partial hepatectomy in
order to relieve suspected gastric and intestinal pressure
thought to be contributing to her nausea. However, given her
poor nutrition, the surgical team requested re-evaluation after
four weeks of adequate nutrition.
====================
ACUTE MEDICAL ISSUES
====================
#Nausea and vomiting:
#Severe malnutrition:
Ms. ___ presented with severe refractory nausea and vomiting,
similar to prior presentations. She correlates these symptoms
with hemodialysis, and therefore discontinued dialysis for
several weeks prior to presentation. However, our observation
was that she also had nausea and vomiting on days where she did
not do dialysis, though it did appear to worsen after dialysis.
A ___ CT scan showed massive renal and hepatic cyst burden. A
small bowel follow-through series did not reveal any
abnormalities. An EGD was only significant for a small hiatal
hernia. Trials of PRN and scheduled zofran and reglan did not
provide any relief. IV and PO ativan did eventually provide some
relief, and oral ativan was scheduled prior to all of her meals,
which did provide some relief. However, she was still unable to
get nearly enough caloric intake, estimated by the nutritionist
as less than a third of her necessary caloric intake.
On ___ her medicine team met with with hepatology, nephrology,
transplant surgery. The decision was made to offer L nephrectomy
and L hepatic lobe resection, but patient would need ___ weeks
of enteral nutrition prior to this. Ms. ___ was amenable to
this plan. A dobhoff NG was placed on ___ and advanced
post-pyloric with fluoroscopy. Tube feeds were initiated, first
continuously and then intermittently as the patient preferred to
have tube feeds for the shortest time period possible. She was
monitored for refeeding syndrome and did not demonstrate
significant electrolyte abnormalities, but her sevalemer was
stopped due to a minor decrease in her serum phosphate.
#Abdominal distension
#Ascites
Ms. ___ has had known abdominal ascites of unclear etiology.
The ascites have been presumed to be of cardiac origin
previously. Although she did have a therapeutic 5.5L
paracentesis after admission, fluid studies were not sent and a
SAAG could not be obtained. Subsequent attempt at paracentesis
with interventional radiology could not be obtained due to
obstruction by her abdominal cysts. Per hepatology, strongest
suspicion is that ascites is not from liver disease, and
therefore vascular imaging is not indicated. Ms. ___ did have
transient abdominal pain at points during her hospitalization,
but it typically resolved without further intervention.
#End Stage Renal Disease on HD:
Ms. ___ has end stage renal disease secondary to her polycystic
kidney disease. At least three weeks prior to her presentation,
she stopped going to hemodialysis sessions. This decision was
multifactorial. She explained that this was in part due to her
thinking that her nausea was worsened by HD. However, she also
elaborated that she knew HD would interfere with her goals to
have a good job and to achieve her goal of going to nursing
school and becoming a ___. She presented with severe uremic
symptoms and BUN of 155. She was re-initiated on three times
weekly hemodialysis.
#Large Pericardial effusion and HFrEF
Patient has known HFrEF due to long standing hypertension. LVEF
___ with MIBI from ___ demonstrating fixed defects in the
anteroseptal and inferolateral areas. No signs of ischemia on
presenting ECG. Pericardial effusion dating back several years.
Seen to be large on CT abdomen pelvis, but follow-up TTE shows
moderate effusion without tamponade, so no indication for
drainage at this point aside from diagnostic purposes.
Cardiology was consulted for pre-operative evaluation and
concluded no contraindication to surgery from cardiology
perspective at this time. They did say that cardiology would be
willing to drain effusion if anesthesiology is worried about
safety of induction. She was continued on her home aspirin,
statin, carvedilol and nitrate.
#Anemia
Hgb 5.5 on presentation, decreased from baseline. Patient does
have a prior history of UGIB. Likely from progression of her
ESRD due to anemia of chronic disease, iron deficiency and
decreased EPO production. Received one tranfusion in ED and one
on the floor. She developed blood streaked stool on ___
associated with straining in a painful bowel movement. Her iron
stores were adequate on ___. Her last transfusion was on ___
and hemoglobin has been greater than 7 since that time. She also
received EPO with HD.
#Hypothyroidism: Continued home levothyroxine.
#Hypertension: Continued carvedilol and imdur. Her blood
pressures typically ran with systolics in the 90's to 110's.
===================
TRANSITIONAL ISSUES
===================
[ ] Patient should have at least weekly checks of her phosphate
level for two weeks after discharge due to the risk of refeeding
syndrome.
[ ] Patient needs tube feeds every day at least until she is
re-evaluated by transplant surgery.
[ ] Patient will need monitoring of phosphate and if it rises,
sevelamer can be added back on.
[ ] Patient needs assistance with housing as she will lose her
housing at the end of ___. She has recently received a
letter from ___ saying that she is high on a wait
list and needs to arrange a meeting with ___ to set up an
in-person interview.
[ ] Patient has had some relief from her nausea with oral and IV
ativan at doses of 0.5-1mg. This she be continued as needed.
[ ] Patient has known moderate pericardial effusion without
hemodynamic compromise. Although this does not post a
contraindication to surgery, it can be drained if there is any
concern this would pose a risk during her surgery.
[ ] Holding sevelamer in setting of hypophosphatemia. Please
continue to assess need.
- New Meds:
-----> Ativan 0.5-1mg PO 30minutes before every meal
-----> Simethicone 80 mg TID
- Stopped/Held Meds:
----> Sevelamer HELD given low phosphate levels, can restart if
phosphate levels rise
----> Zofran STOPPED as it was not effective and patient refused
it
- Changed Meds:
----> Temazepam ___ PO QHS:PRN changed to 15mg PO QHS:PRN
----> Bowel regimen medications changed to PRN
----> Trazodone 50mg PO QHS:PRN STOPPED as it was not needed
- Discharge weight: ___ (155 pounds)
- Code Status: Full
- Contact Information: ___ (Daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Carvedilol 25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Lactulose 30 mL PO DAILY PRN constipation
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Senna 8.6 mg PO BID
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Temazepam ___ mg PO QHS:PRN insomnia
15. TraZODone 50 mg PO QHS:PRN insomnia
16. nitroglycerin 400 mcg/spray translingual q5 minutes up to
three times in 15 minutes prn chest pain
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
18. Vitamin D ___ UNIT PO QMONTH ON THE ___
Discharge Medications:
1. LORazepam 0.5-1 mg PO ASDIR
RX *lorazepam [Ativan] 0.5 mg 0.5-1 mg by mouth AS DIR Disp #*45
Tablet Refills:*0
2. Simethicone 80 mg PO TID
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Senna 8.6 mg PO BID:PRN constipation
5. Temazepam 15 mg PO QHS:PRN insomnia
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Bisacodyl ___AILY:PRN constipation
10. Carvedilol 25 mg PO BID
11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
12. Lactulose 30 mL PO DAILY PRN constipation
13. Levothyroxine Sodium 25 mcg PO DAILY
14. Nephrocaps 1 CAP PO DAILY
15. nitroglycerin 400 mcg/spray translingual q5 minutes up to
three times in 15 minutes prn chest pain
16. Omeprazole 20 mg PO DAILY
17. Vitamin D ___ UNIT PO QMONTH ON THE ___
18. HELD- sevelamer CARBONATE 800 mg PO TID W/MEALS This
medication was held. Do not restart sevelamer CARBONATE until
your doctor tells you to restart it.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Refractory nausea and vomiting
===================
SECONDARY DIAGNOSES
===================
Acute on chronic anemia requiring transfusion
Pericardial effusion
Abdominal ascites
Systolic heart failure with reduced ejection fraction
End stage renal disease on hemodilaysis
Polycystic kidney disease
NSTEMI
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 while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because you were having
vomiting and nausea, and because you needed dialysis.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We got you back on a regular dialysis schedule.
- We gave you blood through an IV because your blood counts were
low.
- We tried a lot of medications to help your nausea, but we
found you still weren't getting enough calories.
- We started giving you nutrition through tube feeds.
- We discussed your nausea with the surgeons who recommended
that you have a surgery to remove one of your kidneys and part
of your liver. Before they do this, they want to make sure your
nutrition is better. Because of this, they want to meet with you
after about four weeks of you getting your tube feeds.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Carefully review the attached medication list as we made
changes to your medications.
- Keep eating small meals to give you nutrition in addition to
your tube feeds.
- Tell your doctor right away if you have any of the warning
signs listed below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10318991-DS-25 | 10,318,991 | 23,594,795 | DS | 25 | 2168-12-29 00:00:00 | 2168-12-29 19:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / Oxycodone / tramadol
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
A ___ yo F with history of ESRD ___ ADPKD on HD (MWF),
hypertensive cardiomyopathy (EF 35-40%) and large volume ascites
thought to be secondary to organomegaly requiring frequent
paracentesis, who presents with acute right flank pain.
Pertinent
history includes 1 month of foul-smelling, painless hematuria
s/p
empiric ABX treatment for presumed UTI (though pt not convinced
that she had a UTI). Note that she has had hematuria off and on
over the last ___ years. Her hematuria improved yesterday to only
a
few drops of blood but she subsequently developed severe right
flank pain. Pain is dull, aching in nature like someone stabbing
on her back with frequent flares of severe pain. The pain is far
worse than prior episodes of cystic ruptures. Acetaminophen was
not helpful and the lidocaine patched provided minimal relief.
Associated with nausea and occasional vomiting. She denies any
hx
of trauma, injury or heavy lifting except holding her ___
grandson 2 weeks ago. She denies fever, chills, diarrhea,
constipation or urinary symptoms. Her appetite has been decent
and she is now off tube feeding.
Past Medical History:
- Autosomal Dominant Polycystic Kidney Disease on HD ___.
Cystic involvement of the liver and ovaries as well.
- HTN-induced dilated cardiomyopathy, EF ___, with cardiac
ascites
- Hypertension
- Migraine headaches
- Questionable history of cerebral aneurysm; MRI in ___ did not
see any cerebral aneurysms
- h/o UGIB requiring PRBC ___ EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to
NSAID use.
- Colelithiasis
- GERD
- Hyperparathyroidism ___ kidney disease
Social History:
___
Family History:
8 family members with ___ kidney disease in an autosomal
dominant pattern on paternal side. Two sisters and one brother
with ESRD ___ ___
Physical Exam:
ADMISSION EXAM:
================
VITALS: 99.1 150/84 100 18 91 RA; pulsus ___ mmHg
GENERAL: Appears uncomfortable and in some distress. Lying on
left side.
HEENT: Bilateral eyelids are twitching. Sclera anicteric and
without injection. dry lips. constricted pupils bilaterally
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. Pulsatile neck veins
CARDIAC: Tachycardic, regular rhythm. Loud S1 and S2. Rumbling
diastolic murmur? Early systolic murmur?
LUNGS: Left lung with inspiratory crackles at the base to the
mid
lung field. Right lung with basilar crackles.
BACK/HIP: No spinous process tenderness. No CVA tenderness but
severe point tenderness along the right iliac crest. Left
groin/hip tenderness non-reproducible.
ABDOMEN: Severely distended and diffusely tender to minimal
palpation, especially in the lower quadrants, without rebound or
guarding.
PELVIS: right sided inguinal hernia, soft and reducible
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. Pulsus of ___ mmHg
NEUROLOGIC: AOx3, facial symmetry, moving extremities with
purpose
DISCHARGE EXAM:
=================
Vitals: 24 HR Data (last updated ___ @ 540)
Temp: 98.3 (Tm 98.6), BP: 133/81 (101-159/61-96), HR: 76
(72-89), RR: 18, O2 sat: 99% (93-99), O2 delivery: Ra, Wt: 153.4
lb/69.58 kg
GENERAL: Lying in bed for dialysis, NAD
HEENT: Sclera anicteric and without injection. MMM.
CARDIAC: RRR. Loud S1 and S2. Systolic murmur noted
LUNGS: CTAB
BACK/HIP: No CVAT
ABDOMEN: Mild tenderness to palpation over RLQ, similar to
yesterday and much improved since admission
EXTREMITIES: Warm, no edema
NEUROLOGIC: AOx3, facial symmetry, moving extremities with
purpose
Pertinent Results:
ADMISSION LABS:
=================
___ 05:00AM BLOOD WBC-4.8 RBC-3.76* Hgb-10.3* Hct-35.7
MCV-95 MCH-27.4 MCHC-28.9* RDW-16.7* RDWSD-58.0* Plt ___
___ 05:00AM BLOOD Neuts-58.6 ___ Monos-9.6 Eos-3.1
Baso-0.4 Im ___ AbsNeut-2.82 AbsLymp-1.35 AbsMono-0.46
AbsEos-0.15 AbsBaso-0.02
___ 05:28AM BLOOD ___ PTT-29.9 ___
___ 05:00AM BLOOD Glucose-82 UreaN-57* Creat-10.2*# Na-137
K-6.0* Cl-95* HCO3-26 AnGap-16
___ 05:00AM BLOOD ALT-7 AST-32 CK(CPK)-49 AlkPhos-78
TotBili-0.4
___ 11:38PM BLOOD cTropnT-0.16* ___
___ 12:40PM BLOOD Calcium-9.1 Phos-5.5* Mg-2.1
___ 11:38PM BLOOD TSH-7.2*
___ 11:38PM BLOOD RheuFac-<10 ___ Titer-PND
CRP-68.6*
___ 05:13AM BLOOD Lactate-1.1
IMAGING:
========
CT ABD & PELVIS W & W/O
1. Unchanged cystic replacement of bilateral kidneys with marked
enlargement without new renal calcifications identified.
2. Unchanged large pericardial effusion.
3. Slightly increased moderate to large volume ascites compared
to ___.
BILAT HIPS (AP, LAT)
1. No acute fracture or dislocation.
2. No significant degenerative changes
PELVIS, NON-OBSTETRIC
Small uterus with multiple calcified fibroids. No adnexal mass
is seen on
transabdominal imaging. Moderate volume ascites and markedly
enlarged
polycystic kidneys noted. The lower pole the right kidney
extends into the right hemipelvis and was quite tender and
painful during scanning.
DISCHARGE LABS:
===============
___ 06:40AM BLOOD WBC-3.6* RBC-3.44* Hgb-9.7* Hct-32.3*
MCV-94 MCH-28.2 MCHC-30.0* RDW-16.6* RDWSD-57.3* Plt ___
___ 06:26AM BLOOD Neuts-68.8 Lymphs-17.8* Monos-10.2
Eos-2.5 Baso-0.5 Im ___ AbsNeut-3.05 AbsLymp-0.79*
AbsMono-0.45 AbsEos-0.11 AbsBaso-0.02
___ 06:40AM BLOOD Glucose-83 UreaN-43* Creat-8.8*# Na-142
K-4.6 Cl-98 HCO3-26 AnGap-18
___ 06:26AM BLOOD cTropnT-0.18*
Brief Hospital Course:
The patient is a ___ with history of ADPKD on HD (MWF),
hypertensive cardiomyopathy (EF 35-40%), large pericardial
effusion and moderate-large ascites presents with an acute pain
crisis of her right flank/hip, most likely secondary to a cyst
rupture.
=============
ACUTE ISSUES:
=============
# Abdominal pain:
The patient was admitted for severe colicky right flank pain
since ___. The differential for her pain included renal cyst
rupture ISO PKD and hematuria. Also on ddx included
nephrolithiasis, pyelonephritis, SBO, appendicitis, and various
ovarian pathologies. On admission, she had a CT abd/pelvis which
ruled out ureteral stones. UA is negative for WBCs making
pyelonephritis unlikely. Non-renal/urinary source of pain was
also considered. Given CVAT and localization to RLQ/R lower
flank, ruptured ovarian cyst and ovarian torsion were
considered, however pelvic US was negative for this. Intestinal
source was also considered including SBO and appendicitis, as
well as tense ascites. The patient's pain improved significantly
without further intervention apart from pain medications, and
thus this was all likely secondary to a large cyst rupture and
resultant peritoneal irritation. He pain and exam improved, and
she was discharged with a two day course of oral Dilaudid 2mg PO
Q6h PRN severe pain.
# Large circumferential pericardial effusion:
First noted on ECHO in ___. She remained HD stable though
pulsus was noted to be between ___ mmHg. ADPKD poses
independent risk for pericardial effusion which is most likely.
DDx also includes uremia, undertreated thyroid disease, collagen
vascular disease, idiopathic or immune mediated; given the
chronicity. Her pulsus paradoxus was trended while she was
inpatient and remained from ___. She has scheduled follow up in
the heart failure clinic.
# Ascites
Recurrent ascites in setting of organomegaly/cystic burden
requiring therapeutic paracentesis, last performed ~2.5 months
prior to admission. She is s/p diagnostic tap in the ED. SAAG
has been < 1.1, suggestive of non-cardiac or hepatic etiology.
Most likely related to organomegaly/cystic burden. Therapeutic
para was considered, however the patient was transiently
hypotensive at dialysis and very sensitive to fluid shifts and
thus this was deferred. She should have a therapeutic
paracentesis as an outpatient after follow up.
# Hypoxia
The patient was admitted with an oxygen requirement of 2L. This
improved drastically with pain control and with volume removal
at hemodialysis. She was stable on room air at the time of
discharge.
CHRONIC/STABLE:
================
# Adult onset polycystic kidney disease: ESRD on HD HD MWF
# Heart failure with reduced EF (35-40%), non-ischemic
# NYHA Class I and ACC/AHA Stage C
Thought to be secondary to hypertension. Symptoms include mild
orthopnea and shortness of breath on exertion, though ascites
may
be contributing. Continued on home medications: ASA 81 mg,
atorvastatin 40 mg QHS,
carvedilol 25 mg BID on non-HD days (___), Isosorbide
mononitrate ER 60 mg DAILY. Heart failure follow up was
scheduled on discharge.
# Anemia: CBC is at goal. s/p EPO 8,000 units prior to HD.
# Gross Hematuria: Intermittent hematuria over the last ___ years
with recent
exacerbation x1 month s/p treatment for presumed UTI without
improvement. Most likely ISO ADPKD.
# Secondary hyperparathyroidism: Continued Zemplar
(paracalcitol) 4 mcg IV with HD
# Hypothyroidism: Continued home Levothyroxine 25 mcg daily
# Homelessness: Currently living at ___ in
___.
TRANSITIONAL ISSUES:
=====================
[] Discharge pain regimen: Dilaudid 2mg PO Q6 PRN pain for 2
days (8 pills total)
[] Consider repeating TTE at cardiology follow up to trend known
pericardial effusion
[] Please schedule therapeutic paracentesis with ___ as
outpatient: Deffered as inpatient given very sensitive to fluid
shifts
[] Discharged on regular HD schedule MWF
[] Discharge HGB 9.7
#CODE: Full
#CONTACT: ___, daughter - ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Simethicone 80 mg PO TID:PRN gas pain
2. Nephrocaps 1 CAP PO DAILY
3. sevelamer CARBONATE 800 mg PO TID W/MEALS
4. Aspirin 81 mg PO DAILY
5. Acetaminophen 1000 mg PO TID:PRN Pain - Mild
6. Atorvastatin 40 mg PO QPM
7. Carvedilol 25 mg PO BID
8. Vitamin D ___ UNIT PO 1X/MONTH
9. Isosorbide Mononitrate 60 mg PO DAILY
10. Levothyroxine Sodium 25 mcg PO DAILY
11. LORazepam 1 mg PO TID W/MEALS
12. nitroglycerin 0.4 mg sublingual Q5M:PRN chest pain
13. Omeprazole 40 mg PO DAILY
14. Temazepam 30 mg PO QHS:PRN insomnia, mm spasms
15. Lactulose 30 mL PO PRN constipation
16. Docusate Sodium Dose is Unknown PO PRN constipation
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe
Duration: 3 Days
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Every 6
hours Disp #*8 Tablet Refills:*0
2. Docusate Sodium 100 mg PO PRN constipation
3. Acetaminophen 1000 mg PO TID:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Carvedilol 25 mg PO BID
7. Isosorbide Mononitrate 60 mg PO DAILY
8. Lactulose 30 mL PO PRN constipation
9. Levothyroxine Sodium 25 mcg PO DAILY
10. LORazepam 1 mg PO TID W/MEALS
11. Nephrocaps 1 CAP PO DAILY
12. nitroglycerin 0.4 mg sublingual Q5M:PRN chest pain
13. Omeprazole 40 mg PO DAILY
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Simethicone 80 mg PO TID:PRN gas pain
16. Temazepam 30 mg PO QHS:PRN insomnia, mm spasms
17. Vitamin D ___ UNIT PO 1X/MONTH
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Autosomal dominant polycystic kidney disease
Secondary Diagnosis:
- Pericardial effusion
- Heart failure with reduced ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because:
- You were having one month of blood in your urine
- This stopped, however you developed severe abdominal pain
While you were in the hospital:
- You were treated with pain medications which improved your
symptoms
- You had some imaging studies which showed no change to your
cystic kidney disease
- You had imaging of your ovaries which showed no evidence of
disease there
- You had lab tests which did not show any evidence of infection
in the urine or in the kidney
- Ultimately, your pain improved with pain medications and this
was likely caused by a ruptured kidney cyst
When you leave:
- Please take all of your medications as prescribed
- Please attend all of your follow up appointments as arranged
for you
It was a pleasure to care for your during your hospitalization!
- Your ___ Care team
Followup Instructions:
___
|
10318991-DS-26 | 10,318,991 | 22,761,575 | DS | 26 | 2169-01-23 00:00:00 | 2169-01-24 13:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / Oxycodone / tramadol
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Diagnostic paracentesis (___)
Therapeutic paracentesis (___) - 5L fluid drained, repleted
with 37.5g albumin
History of Present Illness:
___ is ___ with history of ESRD ___ ADPKD on
HD (MWF), hypertensive cardiomyopathy (EF 35-40%), known
moderately-sized circumferential pericardial effusion w/o
tamponade, large volume ascites secondary to be ___ organomegaly
requiring consistent paras, and recent admission for flank pain
and hematuria thought secondary to cyst rupture (___)
presenting with 1 day of fever, chills, myalgias.
Patient reports that starting last night, she has had myalgia,
malaise, fatigue, and chills. This AM at HD, she says she had a
fever of 103.8F. She completed dialysis. She has had runny nose
for months. She says her abdomen size has gradually increased
but
without acute increase. Patient reports a mild headache but has
full range of motion of neck, and denies visual changes.
Patient admitted ___ for 1 month of heamturia and
subsequent right flank pain, suspected ___ large cyst rupture
and
peritoneal irritation. Also noted to have moderately-sized
circumferential pericardial effusion on TTE in ___, seen
again
on ___, without tamponade physiology, not sampled, as well as
ascites w/ SAAG <1, thought ___ cystic burden. She treated with
pain control and discharged with Dilaudid for 2 day course (2mg
Q6H PRN).
In the ED:
Initial vital signs were notable for:
103.1F, HR 85, BP 140/86, RR 18, 95% RA
Exam notable for:
TM wnl, OP clear
full ROM of neck
lungs ctab
abd distended w/ fluid wave, +ascites, no cva tenderness
no leg swelling
no rashes
Labs were notable for:
Lactate 1.3
K 4.5
BUN 20, Cr 6.0
WBC 3.0
H/H 10.0/33.2
plt 112
INR 1.3
Studies performed include:
CXR
1. Left basilar atelectasis.
2. No consolidation or evidence of pneumonia.
Patient was given:
1L LR, 1g vanc, Tylenol
Consults:
Renal HD
Vitals on transfer:
98.9F, 131 / 86, HR 92, RR 20, 98% Ra
Upon arrival to the floor, patient was endorsing myalgia,
malaise, fatigue, and mild headache at her temples. She endorses
mild posterior neck pain with neck flexion but has full range of
motion. Denies chest pain, dyspnea, abdominal pain, leg
swelling,
new rashes. Denies dysuria or increased urinary frequency. Last
stool yesterday and normal per pt. Denies new rash. AVF looks
normal per pt (currently partially covered in dressing).
Past Medical History:
- Autosomal Dominant Polycystic Kidney Disease on HD ___.
Cystic involvement of the liver and ovaries as well.
- HTN-induced dilated cardiomyopathy, EF ___, with cardiac
ascites
- Hypertension
- Migraine headaches
- Questionable history of cerebral aneurysm; MRI in ___ did not
see any cerebral aneurysms
- h/o UGIB requiring PRBC ___ EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to
NSAID use.
- Colelithiasis
- GERD
- Hyperparathyroidism ___ kidney disease
Social History:
___
Family History:
8 family members with ___ kidney disease in an autosomal
dominant pattern on paternal side. Two sisters and one brother
with ESRD ___ ___
Physical Exam:
ADMISSION EXAM:
VITALS: per above
GENERAL: Alert and interactive. In no acute distress. Fatigued.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Loud S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Lower left inspiratory crackles. No wheezes, rhonchi. No
increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Distended, non-tender to deep palpation in all four
quadrants. RLQ dressing over para site. +fluid wave
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. LUE AVF, +bruit, +thrill, partially covered w/
dressing but no erythema outside.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: ___ strength throughout. Normal sensation. AOx3.
DISCHARGE EXAM:
VITALS: 24 HR Data (last updated ___ @ 1238)
Temp: 98.8 (Tm 99.6), BP: 131/80 (94-145/61-88), HR: 89
(89-106), RR: 18, O2 sat: 96% (93-98), O2 delivery: Ra, Wt:
158.8
lb/72.03 kg
GENERAL: Lying comfortably in bed
HEENT: Mucous membranes moist.
CARDIAC: Regular rhythm, no murmurs, rubs, or
gallops.
LUNGS: CTAB. No w/r/r
ABDOMEN: Distended. Nontender. + fluid wave, normoactive bowel
sounds
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash.
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS:
___ 12:20PM RET AUT-0.4 ABS RET-0.02
___ 12:20PM ___ PTT-29.6 ___
___ 12:20PM PLT COUNT-112*
___ 12:20PM NEUTS-78.7* LYMPHS-10.9* MONOS-9.5 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-2.39 AbsLymp-0.33* AbsMono-0.29
AbsEos-0.01* AbsBaso-0.01
___ 12:20PM WBC-3.0* RBC-3.67* HGB-10.0* HCT-33.2* MCV-91
MCH-27.2 MCHC-30.1* RDW-17.1* RDWSD-57.2*
___ 12:20PM ALBUMIN-3.4* CALCIUM-9.0 PHOSPHATE-3.5
MAGNESIUM-1.8
___ 12:20PM LIPASE-58
___ 12:20PM ALT(SGPT)-6 AST(SGOT)-25 LD(LDH)-405* ALK
PHOS-80 TOT BILI-0.5
___ 12:20PM estGFR-Using this
___ 12:20PM GLUCOSE-83 UREA N-20 CREAT-6.0*# SODIUM-139
POTASSIUM-5.7* CHLORIDE-94* TOTAL CO2-29 ANION GAP-16
___ 01:00PM ASCITES TNC-537* RBC-426* POLYS-0 LYMPHS-20*
MONOS-16* MESOTHELI-4* MACROPHAG-60*
___ 01:00PM ASCITES TOT PROT-4.3 GLUCOSE-92
___ 01:04PM LACTATE-1.3 K+-4.5
___ 01:04PM ___
INTERVAL LABS:
___ 06:02AM BLOOD WBC-3.6* RBC-3.37* Hgb-9.3* Hct-30.8*
MCV-91 MCH-27.6 MCHC-30.2* RDW-17.2* RDWSD-58.0* Plt Ct-86*
___ 06:03AM BLOOD WBC-4.0 RBC-3.50* Hgb-9.6* Hct-32.2*
MCV-92 MCH-27.4 MCHC-29.8* RDW-17.2* RDWSD-58.5* Plt ___
___ 02:49PM BLOOD ___ PTT-29.9 ___
___ 06:02AM BLOOD Plt Ct-86*
___ 06:03AM BLOOD Plt ___
___ 02:49PM BLOOD ___ 06:02AM BLOOD Glucose-98 UreaN-39* Creat-9.4*# Na-134*
K-5.5* Cl-92* HCO3-29 AnGap-13
___ 06:03AM BLOOD Glucose-95 UreaN-28* Creat-7.3*# Na-133*
K-5.2 Cl-91* HCO3-27 AnGap-15
___ 06:02AM BLOOD Calcium-8.4 Phos-5.4* Mg-1.8
___ 06:03AM BLOOD Calcium-8.8 Phos-4.4 Mg-1.7
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-4.3 RBC-3.10* Hgb-8.5* Hct-28.2*
MCV-91 MCH-27.4 MCHC-30.1* RDW-17.7* RDWSD-59.2* Plt Ct-84*
___ 02:49PM BLOOD ___ PTT-29.9 ___
___ 06:20AM BLOOD Glucose-91 UreaN-32* Creat-7.5*# Na-137
K-4.7 Cl-93* HCO3-27 AnGap-17
___ 06:20AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8
IMAGING:
Chest Xray ___:
IMPRESSION:
1. Left basilar atelectasis.
2. No consolidation or evidence of pneumonia
CT Abdomen and Pelvis w/ contrast ___:
IMPRESSION:
1. Persistent moderate volume pericardial effusion.
2. Interval increase in large abdominopelvic ascites.
3. Findings consistent with known autosomal dominant polycystic
liver and
kidney disease.
4. Uterine fibroids.
5. Ascites containing right inguinal hernia.
6. Trace right pleural effusion.
7. Apparent circumferential thickening of the urinary bladder
may represent acute cystitis. Correlation with urinalysis
recommended.
___ guided paracentesis ___:
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 5 L of fluid were removed.
Brief Hospital Course:
Ms. ___ is a ___ with history of ESRD ___ ADPKD on HD
(MWF), hypertensive cardiomyopathy (EF 35-40%), known
moderately-sized circumferential pericardial effusion w/o
tamponade, and large volume ascites ___ organomegaly requiring
intermittent therapeutic paras approximately every other month,
who presented with worsening abdominal pain and acute fevers and
chills from HD. She was found to have Klebsiella bacteremia,
likely from a urinary source and was given two weeks of
antibiotic therapy.
=============
ACUTE ISSUES:
=============
# Sepsis secondary to klebsiella blood stream infection
Initially presented with 5 day history of abdominal pain,
nausea, emesis x4 and fevers at HD. Abdominal pain improved and
emesis resolved. She was found to have GNR bacteremia speciated
to Klebsiella on initial blood cultures with unclear source, but
presumed urinary given findings of bladder wall thickening on CT
abd/pelvis. There was no evidence of SBP on tap. Diagnostic
urine cultures showed mixed bacterial flora. CXR showed no
evidence of PNA. She was started on cefepime/flagyl on ___ and
subsequently narrowed to ciprofloxacin based on sensitivies. All
home anti-hypertensives were held in the setting of GNR sepsis.
[] Continue ciprofloxacin (HD dosing) until ___
#Thrombocytopenia
Patient noted to have decrease in PLT 112->80s (from ___
concerning for sepsis induced bone marrow suppression. Labs not
concerning for DIC.
[] Repeat CBC on ___
# Diarrhea
Patient with four loose bowel movements the day before discharge
concerning for antibiotic-related diarrhea vs. c. diff.
Self-resolved, so unlikely c. diff.
[] If diarrhea persists, consider c. diff testing
#Ascites
Patient with recurrent ascites in setting of organomegaly/cystic
burden requiring consistent therapeutic paracentesis, last
performed ~3 months prior to admission. She received diagnostic
para in ED, with no evidence of SBP. Patient received inpatient
therapeutic paracentesis with post-procedure albumin on ___,
which also was not diagnostic for SBP. She was continued on
simethicone and Ativan 0.5mg TID with meals for nausea.
[] Follow up peritoneal fluid cultures
#ESRD due to ADPKD on HD MWF
She received HD on ___. During her hospitalization she was
continued on a renal diet, nephrocaps 1 CAP daily, home
sevelamer 800mg PO TID, and paracalcitol 4mcg IV with HD. Per
above, home Isosorbide mononitrate 60mg and carvedilol 25mg PO
BID held in setting of GNR bactermia.
#HTN
Held home carvedilol 25mg PO BID and imdur 60mg PO QD in setting
of GNR sepsis as above, which were restarted on discharge.
===============
CHRONIC ISSUES:
===============
#Moderate-sized circumferential pericardial effusion
First noted on TTE in ___, seen again on TTE in ___, both
w/o evidence of tamponade. Patient was initially on telemetry
but this was discontinued due to stability.
[] Will need repeat echo after discharge
#Heart failure with reduced EF (35-40%), non-ischemic
#NYHA Class I and ACC/AHA Stage C
Thought to be secondary to hypertension. Patient had no chest
pain or dyspnea during hospitalization. EKG on ___ was notable
for TWI. Patient continued on home ASA 81 mg and atorvastatin 40
mg QHS. Home carvedilol and isosorbide mononitrate were held in
the setting of bacteremia.
#Anemia - CBC remained stable through her course. Continued EPO
8000 unit with HD
[] Recommend outpatient colon cancer screening
#Secondary hyperparathyroidism - Continued Zemplar
(paracalcitol) 4 mcg IV per HD
#Hypothyroidism - Continued home Levothyroxine 25 mcg daily
#GERD - Continued home Omeprazole 40mg
#Insomnia - Patient reported that home temazepam 30mg PO QHS not
helping. Was started on remelteon 8mg QHS PRN and trazadone 25mg
QHS PRN, which were stopped upon discharge.
#Homelessness: Currently living at ___ in
___.
TRANSITIONAL ISSUES
====================
[] Please get CBC on ___ for PLT check (last PLT = 84
on ___
[] Consider repeat echo and stress test in outpatient setting
[] Continue ciprofloxacin (HD dosing) until ___
[] Follow up peritoneal fluid cultures
[] Recommend outpatient colon cancer screening
[] If diarrhea persists, consider c. diff testing
#CODE: Full (confirmed)
#CONTACT: ___, daughter - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 25 mg PO BID
4. Docusate Sodium 100 mg PO PRN constipation
5. Isosorbide Mononitrate 60 mg PO DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. LORazepam 1 mg PO TID W/MEALS
8. Nephrocaps 1 CAP PO DAILY
9. Omeprazole 40 mg PO DAILY
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
11. Simethicone 80 mg PO TID:PRN gas pain
12. Lactulose 30 mL PO PRN constipation
13. nitroglycerin 0.4 mg sublingual Q5M:PRN chest pain
14. Vitamin D ___ UNIT PO 1X/MONTH
15. Calcitriol 2 mcg PO ___
16. Temazepam 30 mg PO QHS:PRN insomnia
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
Last day ___. Lactulose 30 mL PO DAILY:PRN constipation
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 2 mcg PO ___
6. Carvedilol 25 mg PO BID
7. Docusate Sodium 100 mg PO PRN constipation
8. Isosorbide Mononitrate 60 mg PO DAILY
9. Levothyroxine Sodium 25 mcg PO DAILY
10. LORazepam 1 mg PO TID W/MEALS
RX *lorazepam 1 mg 1 tablet by mouth three times a day Disp #*21
Tablet Refills:*0
11. Nephrocaps 1 CAP PO DAILY
12. nitroglycerin 0.4 mg sublingual Q5M:PRN chest pain
13. Omeprazole 40 mg PO DAILY
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Simethicone 80 mg PO TID:PRN gas pain
16. Temazepam 30 mg PO QHS:PRN insomnia
RX *temazepam 30 mg 1 capsule(s) by mouth at bedtime Disp #*5
Capsule Refills:*0
17. Vitamin D ___ UNIT PO 1X/MONTH
18.Outpatient Lab Work
Labs: CBC
___
ICD9 code 287.5
Please fax to ___, MD (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Sepsis secondary to Klebsiella blood stream infection
SECONDARY:
- HTN
- Pericardial effusion
- Heart failure with reduced EF
- Anemia
- Secondary Hyperparathyroidism
- Hypothyroidism
- GERD
- Insomnia
- ESRD on hemodialysis
- Ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
=================================
- You initially came to the hospital because of worsening
abdominal pain and fevers.
What happened during your hospitalization?
==========================================
- You had samples of your blood tested which showed an infection
called Klebsiella and your were started on antibiotics. This
likely spread from your urine.
- You initially received IV antibiotics for this infection, and
were switched to an oral antibiotic called Ciprofloxacin, which
you will take for 2 weeks total (last day ___
- A paracentesis was performed on ___ to reduce the fluid in
your abdomen and improve your nausea
What should you do when you leave the hospital?
- Continue to take all of your medications as prescribed
- Follow-up with your primary care physician within one week
- Please keep all of your other scheduled health care
appointments
- If you develop any nausea, vomiting, diarrhea, or abdominal
pain, please call your primary care doctor
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10318991-DS-27 | 10,318,991 | 26,166,292 | DS | 27 | 2169-05-29 00:00:00 | 2169-05-30 16:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / Oxycodone / tramadol
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ year old female with history of severe ADPKD with known
massive renal, hepatic and ovarian cysts first diagnosed in ___
on HD ___, h/o hematemesis ___ ___ lesion vs MW tears
___ EGD) requiring transfusion (___),
cardiomyopathy (EF 35-40% on ___ TTE), ascites requiring
frequent paracentesis, chronic R-sided abdominal pain and
hypothyroidism, presented to the ED for chest pain.
The patient reports she had a car accident in ___ and
began
having chest pain since, ongoing for the last ___ weeks. She
describes her pain as sharp, substernal, radiating to left arm
and to her neck. She reports that it is normally relieved with
nitro. She notes the pain is at rest and not worse with
exertion,
though she has been having dyspnea on exertion that she believes
is associated.
She experienced worsening chest pain last ___ during HD that
was not relieved with any treatment. Her HD session was
terminated after 30 min per patient. She was then sent to
___ where she had flash pulmonary edema and was placed on
nitro and BIPAP. She then received dialysis in the ICU at
___
with 3 liters UF with improvement in her respiratory status. She
underwent cardiac workup including stress test, however, patient
stated she did not tolerate the stress test due to hypertension
and tachycardia. She also notes that the results of the stress
were never reported to her. She left AMA from ___ due to
difficulty in getting HD.
She went to her outpatient HD unit on ___, completed
dialysis with 0.3L UF without difficulty. This morning she
again
woke up with chest pain, associated with dyspnea. She reports
she
took all her medications and presented to ED. Her chest pain
resolved prior to arrival.
She has chronic ascities, reported has been getting frequent
paracentesis for the past year, last para was in ___. She
reported that her abdominal has been getting progressively
distended, with epigastric and lower abdominal pain.
In the ED:
Patient was noted to be grossly volume overloaded on exam after
missing several HD sessions recently. Renal was consulted and
the
patient received HD in the ED. A diagnostic para was performed
and the patient was given CTX.
Initial vital signs were notable for:
T 99.3 HR 126 BP 161/100 RR 20
Exam notable for:
Gen: Well developed female, mild distress. Grossly volume
overloaded.
HEENT: NC/AT.
CV: RRR. Normal S1 and S2.
Pulm: bibasilar crackles, nonlabored respirations.
Abd: distended, positive fluid wave. mild abdominal pain.
Ext: lower extremity edema
Labs were notable for:
WBC 3.6, Hgb 10.7
BNP >70k
BUN 48, Cr 10.0. whole blood K 4.3
TropT 0.15
Studies performed include:
CXR:
Mild pulmonary edema. Patchy opacities in the lung bases,
greater on the right, which could reflect atelectasis, with
infection or aspiration not excluded.
Patient was given:
___ 16:48 IV DiphenhydrAMINE 25 mg
Dialysis done in ED
Consults:
Renal - Dialysis
Vitals on transfer:
T 97.5 HR 92 BP 142/81 RR 25 97% RA
Upon arrival to the floor, she complains of chills, lower
abdominal pain and nausea, however has no chest pain, dyspnea,
urinary symptoms diarrhea or constipation.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
- Autosomal Dominant Polycystic Kidney Disease on HD ___.
Cystic involvement of the liver and ovaries as well.
- HTN-induced dilated cardiomyopathy, EF ___, with cardiac
ascites
- Hypertension
- Migraine headaches
- Questionable history of cerebral aneurysm; MRI in ___ did not
see any cerebral aneurysms
- h/o UGIB requiring PRBC ___ EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to
NSAID use.
- Colelithiasis
- GERD
- Hyperparathyroidism ___ kidney disease
Social History:
___
Family History:
8 family members with ___ kidney disease in an autosomal
dominant pattern on paternal side. Two sisters and one brother
with ESRD ___ ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 2237)
Temp: 99.9 (Tm 99.9), BP: 153/86 (153-167/86-98), HR: 120
(116-120), RR: 16, O2 sat: 95%, O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
NECK: JVD to the angle of the jaw.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Bibasilar crackles, no respiratory distress,
BACK: No spinous process tenderness.
ABDOMEN: Normal bowels sounds, mildly distended, + fluid wave,
mildly tender in both lower quadrents, no rebound or guarding.
Non-tender to deep palpation in all four quadrants. No
organomegaly.
EXTREMITIES: 1+ edema to knees bilaterally
SKIN: Warm. Cap refill <2s.
NEUROLOGIC: ___ strength throughout. Normal sensation. Gait is
normal. AOx3.
DISCHARGE PHYSICAL EXAM:
VITALS: Per OMR
GENERAL: Alert and interactive.
HEENT: Pupils equal in size and reactive to light
CARDIAC: Regular rhythm, tachycardic. Audible S1 and S2. No
murmurs/rubs/gallops. Pulsing carotid
LUNGS: CTAB, no increased work of breathing
BACK: No spinous process tenderness.
ABDOMEN: Normal bowels sounds, minimally tender to deep
palpation. bowel sounds present.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:45PM BLOOD WBC-3.6* RBC-3.98 Hgb-10.7* Hct-36.8
MCV-93 MCH-26.9 MCHC-29.1* RDW-18.5* RDWSD-63.1* Plt ___
___ 01:45PM BLOOD Neuts-72.1* Lymphs-16.5* Monos-9.4
Eos-1.4 Baso-0.3 Im ___ AbsNeut-2.62 AbsLymp-0.60*
AbsMono-0.34 AbsEos-0.05 AbsBaso-0.01
___ 02:15PM BLOOD ___ PTT-30.6 ___
___ 06:25AM BLOOD Glucose-107* UreaN-29* Creat-7.1*# Na-141
K-4.0 Cl-96 HCO3-27 AnGap-18
___ 01:45PM BLOOD proBNP->70000*
___ 01:45PM BLOOD cTropnT-0.15*
___ 06:30PM BLOOD cTropnT-0.16*
___ 06:25AM BLOOD Calcium-9.2 Phos-4.4 Mg-1.7
___ 07:00AM BLOOD Vanco-14.4
___ 02:05PM BLOOD Lactate-1.2 K-4.3
INTERVAL LABS:
===============
___ 06:11AM BLOOD WBC-4.3 RBC-3.52* Hgb-9.4* Hct-33.0*
MCV-94 MCH-26.7 MCHC-28.5* RDW-19.2* RDWSD-67.1* Plt ___
___ 10:50AM BLOOD WBC-4.4 RBC-3.55* Hgb-9.4* Hct-32.3*
MCV-91 MCH-26.5 MCHC-29.1* RDW-19.4* RDWSD-64.9* Plt ___
___ 06:24AM BLOOD WBC-5.5 RBC-3.62* Hgb-9.6* Hct-34.0
MCV-94 MCH-26.5 MCHC-28.2* RDW-19.5* RDWSD-68.1* Plt ___
___ 07:00AM BLOOD ___ PTT-32.6 ___
___ 10:50AM BLOOD ___ PTT-29.4 ___
___ 06:23AM BLOOD Glucose-96 UreaN-50* Creat-10.3* Na-136
K-5.2 Cl-93* HCO3-23 AnGap-20*
___ 06:11AM BLOOD Glucose-93 UreaN-32* Creat-6.7*# Na-138
K-4.6 Cl-92* HCO3-29 AnGap-17
___ 10:50AM BLOOD Glucose-86 UreaN-46* Creat-8.6*# Na-137
K-4.4 Cl-91* HCO3-26 AnGap-20*
___ 06:24AM BLOOD Glucose-117* UreaN-28* Creat-5.8*# Na-139
K-3.9 Cl-92* HCO3-29 AnGap-18
___ 07:00AM BLOOD ALT-<5 AST-9 LD(LDH)-150 AlkPhos-87
TotBili-0.6
___ 01:45PM BLOOD cTropnT-0.15*
___ 06:30PM BLOOD cTropnT-0.16*
___ 04:51PM ASCITES ___ RBC-5266* Polys-75*
Lymphs-9* ___ Mesothe-1* Macroph-15*
___ 01:32PM ASCITES TNC-2884* ___ Polys-12*
Lymphs-61* Monos-3* Atyps-8* Mesothe-1* Macroph-15* Other-0
IMAGING:
========
___ CXR: Mild pulmonary edema. Patchy opacities in the lung
bases, greater on the
right, which could reflect atelectasis, with infection or
aspiration not
excluded.
___ CT AP: 1. Stable appearance of innumerable hepatic and
bilateral renal cysts in
keeping with polycystic kidney disease.
2. Interval increased small right and trace left pleural
effusion.
3. Stable moderate pericardial effusion.
4. Stable to increased large volume ascites.
5. Sigmoid diverticulosis with suboptimal evaluation for
diverticulitis
secondary to surrounding ascites.
___ Portable Abdomen:
No evidence for obstruction or free air. Ascites.
___ TTE:(images not available for review) of ___ ,
signs of impaired
ventricular filling without frank cardiac tamponade are now
present. IVC plethora now suggests increased right
atrial pressure.
___ CXR:
Bilateral linear opacities are consistent with areas of
atelectasis. There is
no pneumothorax. There is minimal amount of pleural effusion.
MICROBIOLOGY:
==============
___ 6:54 pm DIALYSIS FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 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.
___ 4:51 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 6:25 am BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:32 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
DISCHARGE LABS:
================
___ 07:00AM BLOOD WBC-6.5 RBC-3.65* Hgb-9.6* Hct-33.1*
MCV-91 MCH-26.3 MCHC-29.0* RDW-20.2* RDWSD-68.2* Plt ___
___ 06:10AM BLOOD Glucose-94 UreaN-38* Creat-6.7*# Na-140
K-4.9 Cl-98 HCO3-29 AnGap-13
___ 06:10AM BLOOD Calcium-9.1 Phos-4.6* Mg-2.1
Brief Hospital Course:
Patient Summary for Admission:
================================
___ year old female with history of severe ADPKD with known
massive renal, hepatic and ovarian cysts first diagnosed in ___
on HD ___, h/o hematemesis ___ ___ lesion vs MW tears
___ EGD) requiring transfusion (___),
cardiomyopathy (EF 35-40% on ___ TTE), ascites requiring
frequent paracentesis, chronic R-sided abdominal pain, found to
have peritonitis.
ACUTE ISSUES:
=============
#Acute Peritonitis, unspecific organism: Patient presented with
significant abodminal pain prompting CT AP with contrast. This
study demonstrated the appearance of known renal and liver cysts
with no evidence of bowel obstruction or free air. Diagnostic
tap ___ consistent with peritonitis with no growth in
cultures. ID was consulted and she was initially treated with an
empiric course of Vancomycin and Zosyn and transitioned to
Vancomcycin and Cefepime for a total course of ___. In
discussion with ID team, no prophylaxis was indicated.
# Acute on Chronic Abdominal Pain: Patient with chronic
abdominal pain which was worsened by the acute inflammation of
peritonitis. Additionally pain likely worsened by known ascites
and cysts. She initially required IV dialudid 0.5mg Q4H which
was transitioned to oral medical and weaned to ___ PO dilaudid
Q8H PRN by the time of discharge. To further help with her
abdominal pain, she underwent a therapeutic paracentesis on
___ with removal of 1.5L. She was discharged with a 3 day
course of PO dilaudid to aid in transition to outpatient
setting.
# Moderate-sized circumferential pericardial effusion First
noted on TTE in ___, seen again on TTE in ___, both w/o
e/o tamponade, repeat TTE ___ with tamponade, negative pulsus
during admission. Per Cardiology evaluation, no indication for
pericardial drain given hemodynamic stability.
#Sinus Tachycardia: Baseline tachycardia 100-115 and worsened by
acute illness. Her tachycardia stabilized in the low 100s prior
to discharge. EKG demonstrated sinus rhythm.
#Acute Heart failure with reduced EF (35-40%): TTE completed
during admission demonstrated again known reduced EF. Her volume
status was managed with HD. Carvediolol, isosorbide mononitrate
and lisinopril were initially held in setting of acute infection
and Carvedilol restarted prior to discharge. She also continued
home aspirin and atorvastatin.
# Malnutrition: Patient with poor PO intake this admission,
which was limited by nausea. Tube feeding was deferred given
patient's preference. Scheduled zofran was utilized with meals
and ativan for nausea. PO intake stable prior to discharge.
limited by pain and nausea
CHRONIC ISSUES:
===============
#ESRD on HD MWF
#Bone mineral density
Access via LUE radiocephalic AVF. Continued HD while inpatient.
# Secondary hyperparathyroidism: Continued Zemplar
(paracalcitol) 4 mcg IV per HD
# Hypothyroidism: Continued home Levothyroxine.
#GERD: Continued home omeprazole.
TRANSITIONAL ISSUES:
======================
Pending issues at discharge:
___ 16:02 PERITONEAL FLUID FLUID CULTURE; ANAEROBIC CULTURE
[ ] Isosorbide Mononitrate and Lisionopril were held on
discharge. Lisionpril should be restarted once patient's
pressures can tolerate medication as an outpatient likely at a
reduced dose.
[ ] Carvedilol was dose reduced to 12.5mg BID on non HD days
while inpatient
[ ] Patient prescribed 3 day course of PO dilaudid in
anticipation of resolving abdominal pain as well as bowel
regimen.
[ ] Recommend outpatient nutritional follow up, patient deferred
tube feeding while inpatient.
[ ] Continue outpatient paracentesis as needed outpatient,
consider obtaining portal vein gradient as outpatient to
determine if portal hypertension present.
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. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. sevelamer CARBONATE 800 mg PO TID W/MEALS
6. Vitamin D ___ UNIT PO 1X/MONTH
7. Omeprazole 20 mg PO DAILY
8. Carvedilol 25 mg PO BID
9. Isosorbide Mononitrate 60 mg PO DAILY
10. nitroglycerin 0.4 mg sublingual Q5M:PRN chest pain
11. Calcitriol 2 mcg PO ___
12. Lisinopril 20 mg PO DAILY
13. Temazepam 30 mg PO QHS:PRN insomnia
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate
Duration: 3 Days
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
6H as needed Disp #*30 Tablet Refills:*0
3. Ondansetron 4 mg PO TID
RX *ondansetron 4 mg 1 tablet(s) by mouth TID PRN Disp #*9
Tablet Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tablet by mouth BID PRN Disp #*60 Tablet
Refills:*0
5. CARVedilol 12.5 mg PO 4X/WEEK
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Calcitriol 2 mcg PO ___
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. nitroglycerin 0.4 mg sublingual Q5M:PRN chest pain
12. Omeprazole 20 mg PO DAILY
13. sevelamer CARBONATE 800 mg PO TID W/MEALS
14. Temazepam 30 mg PO QHS:PRN insomnia
15. Vitamin D ___ UNIT PO 1X/MONTH
16. HELD- Isosorbide Mononitrate 60 mg PO DAILY This medication
was held. Do not restart Isosorbide Mononitrate until instructed
to restart by your primary care provider
17. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until instructed to restart by your
primary care provider
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Spontaneous Bacterial Peritonitis
ADPKD
Pericardial Effusion
Acute on Chronic Abdominal Pain
Secondary Diagnosis:
=====================
Heart Failure with Reduced Ejection Fraction
ESRD on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing ___ as your site of care.
Why was I admitted to the hospital?
-You were admitted to the hospital because of abdominal pain.
What was done for me while I was in the hospital?
-You had a CT scan of your abdomen which did not show any acute
changes. It showed again the cysts in your liver and kidney.
-You had a sample from your abdominal fluid which showed signs
of infection.
-You received IV antibiotics to treat this infection.
-You had an ultrasound of your heart which showed some fluid
around your heart.
-Your pain was treated with IV pain medications and improved.
What should I do when I go home?
-Please continue drinking Nepro shakes at least 3x a day.
-You were given a prescription for abdominal pain medications.
If the pain worsens please call your doctor.
-___ should not take your home Imdur or Lisinopril until
instructed to restart by your primary care provider.
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best!
Followup Instructions:
___
|
10318991-DS-28 | 10,318,991 | 20,331,227 | DS | 28 | 2169-06-08 00:00:00 | 2169-06-08 18:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Morphine / Verapamil / Oxycodone / tramadol
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Paracentesis - ___
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ with h/o severe ADPKD with known renal, hepatic, and ovarian
cysts on HD ___ esophageal bleeding requiring transfusions
(___), cardiomyopathy (EF 35-40%), and
hypothyroidism presents to the emergency department with pain in
her lower abdomen. She states that since discharge on ___ she
was doing well, but then the pain started again this morning and
she felt it acutely with bumps in the road on her way to her
kidney transplant service appointment. She notes feeling
bloated,
distended, and felt lightheaded and SOB this morning. She notes
nausea and had one episode of non-bloody, non-bilious vomiting
yesterday. She denies any blood in the vomit, diarrhea, or
dysuria. She last got her dialysis on ___ as her ride service
was cancelled during her prior admission.
In the ED: She received dialysis and a diagnostic paracentesis
in
the ED that was not concerning for infection. She also received
Vanc/Zosyn (unclear as to why this given - ED referred to last
admission note as reason it was started though per discharge
summary finished a course of ABX for SBP during last admission).
Initial vital signs were notable for:
Pain 8 Temp 98.0 HR 94 BP 112/72 RR 17 Pox 97% RA
Exam notable for:
Uncomfortable, speaking in short sentences, mild respiratory
distress
RRR, no appreciable murmur
Diminished breath sounds, no appreciable crackles or wheezing
Abdomen distended, very tender to touch
Skin warm and dry, fistula in left wrist with palpable thrill
Labs were notable for:
___
-------------- < 88 AGap=20
___
8.9
7.6 >----< 369
30.5
N:76.8 L:12.5 M:9.3 E:0.3 Bas:0.4 ___: 0.7 Absneut: 5.86
Abslymp: 0.95 Absmono: 0.71 Abseos: 0.02 Absbaso: 0.03
___: 14.5 PTT: 30.7 INR: 1.3
Studies performed include:
- Chest (Pa & Lat) with comparison to exam dated ___
FINDINGS: There is interval increase in size of right pleural
effusion with increasing collapse in the right middle and lower
lobes. Previously noted left basal
atelectasis has significantly cleared. No significant left
effusion. Right
heart border is effaced in the setting of right pleural
effusion.
The heart
however does appear enlarged as on prior. Consider the
possibility of a
pericardial effusion.
IMPRESSION: Marked cardiomegaly, correlate for possible
pericardial effusion. Increasing right pleural effusion with
increasing right middle and lower lobe collapse.
- Peracentesis - 1+ (<1 per 1000X FIELD): /POLYMORPHONUCLEAR
LEUKOCYTES
NO MICROORGANISMS SEEN
Ascites Chemistry: Protein 4.5, Glucose 112, TotBili: 0.3
Ascites: WBC 1143, RBC 2947, Poly 9, Lymph 52, Mono 0,
Basos: 1, Plasma: 5, Mesothe: 3, Macroph: 30
- Blood culture (Pending)
Patient was given:
Dialysis done in ED
IV HYDROmorphone (Dilaudid) .5 mg
Acetaminophen 1000 mg
Insulin (Regular) for Hyperkalemia 10 units
Albuterol 0.083% Neb Soln 1 NEB
Dextrose 50% 25 gm
IV Piperacillin-Tazobactam
IV Vancomycin 1000 mg
IV DiphenhydrAMINE 25 mg
Consults:
Renal - Dialysis
Vitals on transfer: Temp 97.8 BP 168 / 92HR 99 RR 18 O2 Sat
96
RA
Upon arrival to the floor, she has lower abdominal pain but is
in
no acute distress. She is eating.
REVIEW OF SYSTEMS:
- constipation
- itchy skin
Complete ROS obtained and is otherwise negative.
Past Medical History:
- Autosomal Dominant Polycystic Kidney Disease on HD ___.
Cystic involvement of the liver and ovaries as well.
- HTN-induced dilated cardiomyopathy, EF ___, with cardiac
ascites
- Hypertension
- Migraine headaches
- Questionable history of cerebral aneurysm; MRI in ___ did not
see any cerebral aneurysms
- h/o UGIB requiring PRBC ___ EGD showed ___
erosion vs. MW tear + small ulcer at GE junction. Possibly
related to
NSAID use.
- Cholelithiasis
- GERD
- Hyperparathyroidism ___ kidney disease
Social History:
___
Family History:
8 family members with ___ kidney disease in an autosomal
dominant pattern on paternal side. Two sisters and one brother
with ESRD ___ ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp 97.8 BP 168 / 92HR 99 RR 18 O2 Sat 96 RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops but swooshing sound from fistula.
LUNGS: Decreased breath sounds in right lung to mid-lung
posteriorly. No wheezes, rhonchi or rales. No increased work of
breathing.
BACK: No spinous process tenderness.
ABDOMEN: Firm, distended abdomen tender to light palpation in
all
quadrants, but especially in lower abdomen/suprapubic area. +
rebounding.
EXTREMITIES: 2+ pitting edema in lower extremities to knee and
dependent areas of thigh. No clubbing or cyanosis. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: + Asterixis. AOx3. CN2-12 intact. Moving all
extremities with purpose. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
___ 1123 Temp: 97.8 PO BP: 119/75 HR: 95 RR: 20 O2 sat: 95%
O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops but swooshing sound from fistula.
LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing.
ABDOMEN: soft, distended abdomen tender to light palpation in
all
quadrants but decreased from previous days.
EXTREMITIES: Trace edema in lower extremities to knee and
dependent areas of thigh. No clubbing or cyanosis. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: A&Ox3. Moving all extremities with purpose. Normal
sensation.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:00PM BLOOD WBC-7.6 RBC-3.37* Hgb-8.9* Hct-30.5*
MCV-91 MCH-26.4 MCHC-29.2* RDW-20.1* RDWSD-67.7* Plt ___
___ 12:00PM BLOOD Neuts-76.8* Lymphs-12.5* Monos-9.3
Eos-0.3* Baso-0.4 Im ___ AbsNeut-5.86 AbsLymp-0.95*
AbsMono-0.71 AbsEos-0.02* AbsBaso-0.03
___ 12:00PM BLOOD Glucose-88 UreaN-70* Creat-11.5*# Na-138
K-6.8* Cl-95* HCO3-23 AnGap-20*
___ 12:00PM BLOOD ALT-6 AST-14 AlkPhos-139* TotBili-0.4
___ 12:00PM BLOOD Albumin-2.6* Calcium-8.7 Phos-7.1* Mg-2.0
___ 12:07PM BLOOD Lactate-0.7 K-6.0*
RELEVANT LABS:
==============
Ascitic Fluid: TNC 1143; 9% Polys; 52% lymphs
MICROBIOLOGY:
=============
___ 2:06 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Pending): No growth to date.
___ 2:06 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.
IMAGING:
========
Abdominal U/S ___:
1. Innumerable cysts seen in the liver and in the region of the
right kidney consistent with the patient's known polycystic
kidney disease. A cyst in segment 5 of the liver demonstrates
internal avascular debris likely related to prior hemorrhage.
No suspicious mass is visualized.
2. Cholelithiasis.
3. Note is made that this was a limited ultrasound exam due to
the patient's limited ability to tolerate the ultrasound. The
spleen and left kidney were not examined.
Brief Hospital Course:
___ with h/o severe ADPKD with known renal, hepatic, and ovarian
cysts on HD ___ esophageal bleeding requiring transfusions
___, cardiomyopathy (EF 31%), and hypothyroidism
presents with acute on chronic abdominal pain likely from
hemorrhage into a cyst, constipation, and two missed HD
treatments leading to abdominal distention from ascites. She
received HD and therapeutic paracentesis. Her bowel regimen was
optimized and her pain improved to baseline.
ACUTE ISSUES:
=============
# Acute on Chronic Abdominal Pain:
Patient with chronic abdominal pain that was ongoing during last
admission last week that worsened acutely while riding in car on
___. Pain likely a combination of capsular pain due to old
hemorrhage into a cyst, increased ascites due to missed dialysis
appointments, and worsened by constipation. She did have recent
SBO, but ascitic fluid was not consistent with SBP on
presentation this time. She had a therapeutic para with 1.3L of
ascites removed with minimal effect on pain. Pain was controlled
with dilaudid ___ PO q6h:prn which was weaned to ATC tylenol.
Nausea improved with zofran and she was tolerating PO by time of
discharge. For constipation her bowel regimen was expanded to
reduce straining. Her pain improved and was back to her
baseline.
# Oliguria:
The patient typically urinates ___ times per day, however during
two days of admission she did not urinate. She reports this has
happened during prior admissions. Bedside bladder scan was
impaired by cysts and straight catheterization relieved only
20cc. Likely a progression of her ESRD. She is already on
hemodialysis. Her nephrologist was updated.
# ESRD on HD MWF:
# Bone mineral density:
# Hyperkalemia:
At the time of admission on ___, last HD was on ___ and
potassium was 6.8. She underwent hemodialysis on ___ and
resumed her MWF schedule. She has access via LUE radiocephalic
AVF. Hyperkalemia improved with HD. She has had difficulty
scheduling her cab rides to outpatient HD and she received
information about how to confirm her standing cab order when
discharged.
# Inadequate PO intake: Patient reports nausea and vomiting on
admission. Weight on ___ down 3.69 kg from ___. Nausea now
improved, able to tolerate PO.
# Moderate-sized circumferential pericardial effusion
First noted on TTE in ___, seen again on TTE in ___, both
w/o e/o tamponade, repeat TTE ___ with some tamponade
physiology, however, no clinical signs of this. Pulsus on ___
negative (systolic change 5 mm Hg). TTE's should be trended in
follow-up.
CHRONIC ISSUES:
===============
# Chronic Heart failure with reduced EF (31%): O2 saturation
normal on RA.
- Continued home ASA 81 mg
- Continued home atorvastatin 40 mg QHS
- Continued home carvedilol at reduced dose 12.5mg BID on non HD
days
- Continued HD to assist volume removal
# Secondary hyperparathyroidism:
- Zemplar w/ HD per nephrology
# Hypothyroidism
- Continued home Levothyroxine 25 mcg daily
#GERD
- Continued home omeprazole 40mg
TRANSITIONAL ISSUES:
====================
[ ] Continue to monitor abdominal pain. Patient discharged off
of narcotics. Given her ___, she may continue to have
abdominal pain. Can consider referring to chronic pain clinic if
this continues to be an issue.
[ ] Isosorbide Mononitrate and Lisionopril were held on
discharge during prior admission. Lisinopril should be restarted
once patient's pressures can tolerate medication as an
outpatient likely at a reduced dose.
[ ] Given her HFrEF, patient's carvedilol should be uptitrated
as tolerated, or switched to metoprolol if titration limited by
low BPs.
[ ] Follow-up with Dr. ___ for the patient's heart
failure.
[ ] The patient's pericardial effusion should be monitored as
above.
[ ] Recommend outpatient nutritional follow up.
[ ] Continue outpatient paracentesis as needed.
[ ] CXR on presentation notable for increased right pleural
effusion, presumable ___ missed HD sessions. Would repeat CXR
after patient has had several HD sessions and consider referral
for thoracentesis if this persists.
# CODE STATUS: Full
# CONTACT:
- Name of ___ care proxy: ___
- Relationship: Daughter
- Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Omeprazole 20 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO BID
9. nitroglycerin 0.4 mg sublingual Q5M:PRN chest pain
10. Vitamin D ___ UNIT PO 1X/MONTH
11. Temazepam 30 mg PO QHS:PRN insomnia
12. CARVedilol 12.5 mg PO 4X/WEEK (___)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
4. Senna 17.2 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. CARVedilol 12.5 mg PO 4X/WEEK (___)
8. Docusate Sodium 100 mg PO BID
9. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN Pain - Moderate
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. nitroglycerin 0.4 mg sublingual Q5M:PRN chest pain
13. Omeprazole 20 mg PO DAILY
14. sevelamer CARBONATE 800 mg PO TID W/MEALS
15. Temazepam 30 mg PO QHS:PRN insomnia
16. Vitamin D ___ UNIT PO 1X/MONTH
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
# Acute on Chronic Abdominal Pain secondary to polycystic kidney
disease
# Oliguria
# ESRD on HD MWF
# Bone mineral density
# Hyperkalemia
# Inadequate PO intake
# Moderate-sized circumferential pericardial effusion
SECONDARY DIAGNOSIS
=====================
# Sinus Tachycardia
# Chronic Heart failure with reduced EF (31%)
# Secondary hyperparathyroidism
# Hypothyroidism
# 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 privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital after missing a dialysis appointment
and had developed severe pain in your belly
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We removed ascites (fluid) from your belly which slightly
improved your pain. This fluid did not appear infected.
- We believe your pain was most likely from bleeding in one of
your cysts
- You received medicine for your pain and medicine to help with
your bowels.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10319342-DS-11 | 10,319,342 | 24,260,449 | DS | 11 | 2126-04-24 00:00:00 | 2126-04-25 10:20:00 |
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 distention, confusion
Major Surgical or Invasive Procedure:
Paracentesis (___)
EGD (___)
History of Present Illness:
Ms. ___ is a ___ with Childs C alcoholic cirrhosis (MELD 15)
c/b hepatic encephalopathy, ascites who presents with 3 weeks of
worsening abdominal distention and lower extremity edema and
several days of confusion.
The patient sees Dr. ___ as an outpatient. Per patient's
sister in ___ notes, the patient has been getting more confused
over the last several days. The patient reports increased
abdominal distention and lower extremity swelling over the past
3 weeks. She indicates that she has been told that she has been
more confused over the past week but has not noticed many
changes in her mental status. When asked if she takes lactulose,
she believes she does but she indicates that her sister
administers her meds for her.
She denies any fevers, hematemesis, BRBPR, black tarry stools.
Past Medical History:
- EtOH cirrhosis (dx age ___
- Psoriasis (not on medication)
- Hypothyroidism
- Depression/anxiety
- Osteoporosis
- Insomnia
- Cholelithiasis (evidence on u/s)
Social History:
___
Family History:
Heavy alcohol abuse on her side of the family
- Father died when she was ___, etiology unknown
- Mother died at age ___ from ?COPD/emphysema
- Brother died for unknown reasons but related to etoh
- Sister has a cardiac history (valve replacement) and etoh
abuse
- Sister ___ is a nurse in the ___ at ___ - unclear ETOH
history
- Son has type I diabetes mellitus
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98, BP 170/72, HR 65, RR 16, O2 sat 96% RA
GENERAL: NAD, cooperative, calm
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: very distended, no fluid wave appreciated, mildly
tender in all four quadrants, no rebound/guarding
EXTREMITIES: no cyanosis, 1+ pitting edema to knees bilatearlly
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, responding appropriately to questions, sensation
intact in bilateral upper and lower extremities, moving all 4
extremities with purpose, negative asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 01:47PM BLOOD WBC-5.4 RBC-3.73* Hgb-11.7 Hct-35.7
MCV-96 MCH-31.4 MCHC-32.8 RDW-15.7* RDWSD-55.0* Plt ___
___ 01:47PM BLOOD Neuts-78.7* Lymphs-12.0* Monos-6.4
Eos-1.7 Baso-0.6 Im ___ AbsNeut-4.22 AbsLymp-0.64*
AbsMono-0.34 AbsEos-0.09 AbsBaso-0.03
___ 01:47PM BLOOD Glucose-82 UreaN-12 Creat-1.1 Na-139
K-3.7 Cl-100 HCO3-26 AnGap-13
___ 01:47PM BLOOD ALT-17 AST-47* AlkPhos-142* TotBili-1.9*
___ 01:47PM BLOOD Albumin-2.6* Calcium-8.3* Phos-2.5*
Mg-1.6
___ 06:59AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
STUDIES:
___ LIVER US: Cirrhotic liver with splenomegaly and large
volume ascites. The main portal vein is patent.
___ CHEST XRAY: Lung volumes are low. The lungs are clear
without focal consolidation. Cardiomediastinal and hilar
contours are normal. No evidence of pulmonary vascular
congestion. No pneumothorax or pleural effusion.
DISCHARGE LABS:
___ 05:23AM BLOOD WBC-5.2 RBC-3.08* Hgb-9.7* Hct-29.4*
MCV-96 MCH-31.5 MCHC-33.0 RDW-15.9* RDWSD-54.4* Plt Ct-76*
___ 05:23AM BLOOD Glucose-96 UreaN-12 Creat-1.0 Na-139
K-4.2 Cl-102 HCO3-27 AnGap-10
___ 05:23AM BLOOD ALT-14 AST-36 AlkPhos-98 TotBili-1.2
___ 05:23AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.9 Mg-2.3
___ 05:11AM BLOOD CK-MB-<1 cTropnT-<0.01
Brief Hospital Course:
TRANSITIONAL ISSUES:
==================
[ ] Discharged on lasix 40 mg and spirinolactone 100 mg daily
[ ] Please check chem-10 at follow-up appointment and titrate
diuretics as needed based off volume exam and labs
[ ] EGD showed grade I varices but given Child C cirrhosis,
would likely benefit from beta blocker for primary ppx
[ ] Would avoid sedating medications given history of HE
Ms. ___ is a ___ with Child C10 MELD 15 alcoholic cirrhosis
c/b hepatic encephalopathy and ascites who presents with
confusion, abdominal distention, and lower extremity edema
concerning for decompensated cirrhosis.
ACUTE ISSUES:
=============
#Decompensated ETOH Cirrhosis. Child C10, MELD 15 on admission.
Decompensated by ascites and hepatic encephalopathy on
adimssion. Unclear etiology of decompensation. Patient's sister
confirms that patient takes medications as prescribed. Possibly
due to underdosing of diuretics and lack of followup with liver
service in recent months. Patient has not drank alcohol in ___
years, as confirmed by patient's sister. For hepatic
encephalopathy, patient was treated with lactulose 30 mL q2H and
rifaximin 550 mg BID. Blood, peritoneal, urine cx showed no
growth. RUQUS negative for PVT. Patient had large volume ascites
and underwent paracentesis with 5L removed. Diuretics were also
uptitrated to Lasix 40 mg/Spironolactone 100 mg daily. Patient
underwent screening EGD which showed 2 cords of grade I varices,
PHG, and GAVE s/p APC. No history of SBP and was no concern for
SBP here.
#Hepatic encephalopathy
Per patient's sister, the patient was confused for several weeks
often forgetting details. No neuro deficits on exam, deemed less
likely to be secondary to central process. No significant
electrolyte abnormalities. Altered mental status ultimately
attributed to hepatic encephalopathy. Treated with lactulose and
rifaxamin and mental status improved by discharge.
#Thrombocytopenia
Likely ___ cirrhosis.
CHRONIC ISSUES:
===============
#Anxiety/Depression:
Continued fluoxetine 40 mg daily.
#Peripheral neuropathy.
Likely due to hx of ETOH use. Reduced Gabapentin to 100 mg QHS
given encephalopathy on presentation,
#Hypothyroidism:
Continued levothyroxine 137mcg daily.
#Iron deficiency:
Held ferrous gluconate initially until infection was ruled out.
Restarted on discharge.
#Nausea
Given sedating effects of Compazine, nausea meds were
transitioned to Zofran PRN. Patient states that she is nauseated
every morning and that this has been a long-standing issue for
which she takes Compazine. She was nauseated after the EGD with
argon plasma coagulation for GAVE, however, the nausea improved
at the time of admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. rifAXIMin 550 mg PO BID
2. Alendronate Sodium 35 mg PO 1X/WEEK (___)
3. FLUoxetine 40 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Gabapentin 300 mg PO QHS
6. Gabapentin 100 mg PO QAM
7. HydrOXYzine 25 mg PO BID:PRN itching
8. Levothyroxine Sodium 137 mcg PO DAILY
9. Magnesium Oxide 400 mg PO BID
10. Nadolol 20 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Potassium Chloride 20 mEq PO EVERY OTHER DAY
13. Promethazine 25 mg PO BID:PRN nausea
14. Spironolactone 50 mg PO DAILY
15. Thiamine 100 mg PO DAILY
16. TraZODone 50 mg PO QHS:PRN insomnia
17. Ferrous GLUCONATE 324 mg PO DAILY
18. Lactulose 30 mL PO QID
19. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Ondansetron 4 mg PO Q12H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*15 Tablet Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
3. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*2
4. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*2
5. Alendronate Sodium 35 mg PO 1X/WEEK (___)
6. Ferrous GLUCONATE 324 mg PO DAILY
7. FLUoxetine 40 mg PO DAILY
8. Lactulose 30 mL PO QID
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Magnesium Oxide 400 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. Potassium Chloride 20 mEq PO EVERY OTHER DAY
Hold for K >
14. rifAXIMin 550 mg PO BID
15. Thiamine 100 mg PO DAILY
16. TraZODone 50 mg PO QHS:PRN insomnia
17. HELD- HydrOXYzine 25 mg PO BID:PRN itching This medication
was held. Do not restart HydrOXYzine until you talk to your PCP
18. HELD- Nadolol 20 mg PO DAILY This medication was held. Do
not restart Nadolol until you talk to your liver doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
ASCITES
HEPATIC ENCEPHALOPATHY
CIRRHOSIS ___ ETOH
GAVE
SECONDARY DIAGNOSES
===================
DEPRESSION
HYPOTHYROIDISM
PERIPHERAL NEUROPATHY
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 abdominal and leg swelling
and confusion over the course of ___ weeks.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were treated with medications to help remove the fluid.
- You had a paracentesis to drain the fluid in your belly.
- You underwent an endoscopy to determine if there were bleeding
vessels in your esophagus
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your liver doctor if your weight changes by
more than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10319651-DS-11 | 10,319,651 | 23,185,185 | DS | 11 | 2119-03-14 00:00:00 | 2119-03-14 10:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Catapres-TTS-1 / Lopid / Tricor / doxycycline
Attending: ___.
Chief Complaint:
Cough, dyspnea, regurgitation
Major Surgical or Invasive Procedure:
right pleurex catheter placement
PEG tube placement attempt
History of Present Illness:
___ ___ man presenting with worsening cough, SOB
and sensation of regurgitation over last few days, though
duration longer. Son at bedside translating ___ and states
pt minimizes symptoms. Hasn't been vomiting but whatever he eats
"comes up." Duration of dysphagia has been few weeks,
corresponds to time he started a new "medication to help him
sleep," not sure if Zolpidem or lorazepam. Made an appt to see
PCP on ___ ___ but symptoms worsened and he ultimately asked
son to bring him to ED today. Denies CP, abd pain, or any pain.
No change in chronic ___ edema. 15lb weight loss in one month per
family.
.
In the ED: VS afeb 150s/40s ___ 92-95% RA. CXR showed bibasilar
pneumonia, L>R, and he was treated with levofloxacin and flagyl.
Also given magnesium for serum Mg 1.5. Currently denies SOB or
pain but was coughing during exam. ROS otherwise
noncontributory.
.
Upon arrival to the medical floor, he reported abdominal pain
and inability to void. He was straight catheterized and 800cc
were drained.
Past Medical History:
Diabetes mellitus type II (last HbA1c 7.2% on ___
CAD s/p CABG, s/p PCI ___
sick sinus syndrome s/p PPM ___ with generator change ___
paroxysmal atrial fibrillation
Hypertension
Hyperlipidemia
glaucoma
s/p cholecystectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
--------------
VITALS: afeb 165/68 68 96% 2L
GEN: NAD, well-appearing
EYES: conjunctiva clear anicteric
ENT: dry mucous membranes
NECK: supple
CV: RRR s1s2 II/VI SEM
PULM: bibasilar rales, L>R, +cough during exam with diminished
BS
GI: normal BS, ND, soft, nontender
EXT: warm, 2+ BLE edema
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands
PSYCH: appropriate, pleasant
ACCESS: PIV
FOLEY: none
DISCHARGE EXAM
--------------
Vitals:
Gen: NAD, sleepy
Pulm: R pleurex cath in place, diffuse crackles and decr breath
sounds in left lower base
Abd: soft, NTND, normal bowel sounds
Ext: no edema
Neuro: at times awake and able to converse via ___
interpreter (attention waxes and wanes)
Pertinent Results:
ADMISSION LABS
--------------
___ 12:55PM WBC-12.9* HGB-11.7*# HCT-35.9* MCV-83# PLT
COUNT-216
___ 12:55PM NEUTS-62.2 ___ MONOS-6.9 EOS-1.0
BASOS-1.1
___ 12:55PM GLUCOSE-115* UREA N-35* CREAT-1.0 SODIUM-138
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15
___ 12:55PM ALT(SGPT)-13 AST(SGOT)-23 ALK PHOS-77 TOT
BILI-0.4
___ 12:55PM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-3.0
MAGNESIUM-1.5*
___ 12:55PM LIPASE-15
DISCHARGE LABS
--------------
___ 11:45PM BLOOD WBC-20.4* RBC-4.76 Hgb-13.3* Hct-41.4
MCV-87 MCH-28.0 MCHC-32.1 RDW-17.1* Plt ___
___ 11:45PM BLOOD Glucose-93 UreaN-49* Creat-1.1 Na-148*
K-3.7 Cl-110* HCO3-26 AnGap-16
___ 11:45PM BLOOD ALT-7 AST-18 LD(LDH)-356* CK(CPK)-34*
AlkPhos-120 Amylase-15 TotBili-0.5
IMAGING
-------
TTE ___:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Diastolic function could not be assessed. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
moderately thickened. There is no aortic valve stenosis. Mild to
moderate (___) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. [Due to acoustic shadowing, the severity of
tricuspid regurgitation may be significantly UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Thickened aortic leaflets with at least mild-to-moderate
eccentric aortic regurgitation. Moderate elevation of pulmonary
artery systolic pressure.
Compared with the prior study (images reviewed) of ___, the
severity of aortic regurgitation and pulmonary hypertension have
increased. The other findings are simiilar.
.
CT chest without contrast:
IMPRESSION:
1. Left upper lobe pneumonia. Nodular opacity in the right
upper lobe may also be infectious, but can be reevaluated after
resolution of symptoms.
2. 10.9 cm subcapsular hepatic fluid collection concerning for
abscess. In the absence of recent surgery procedure, hematoma
and biloma are unlikely. This lesion would be amenable to
percutaneous drainage.
3. Multiple sclerotic lesions throughout the thoracic spine,
one of which is discrete in the T10 vertebral body, are
worrisome for metastatic disease, possibly prostate.
.
Video swallow ___:
Significant holdup of contrast at approximately the level of the
hilum with a dilated esophagus seen and subsequent regurgitation
of all the administered contrast. This patient would not
benefit from nor would he be able to tolerate to tolerate a
complete esophagram study. It's probably that there is a
invasive process in this area which constricts the esophagus,
but the recent CT was done without contrast and therefore that
evaluation is limited. A CT with contrast could be considered to
further evaluate.
.
RUQ ultrasound ___:
Successful drainage of perihepatic fluid collection with no
residual
collection demonstrated. The pigtail catheter has been removed.
.
___ chest/abd/pelvic CT:
IMPRESSION:
1. Filling defect in the proximal right internal jugular vein
which could
relate to early arterial phase scanning, however cannot rule out
thrombus. If
clinical concern ultrasound is recommended. No evidence of large
pulmonary
embolism, however evaluation of subsegmental pulmonary arteries
is limited.
2. Enhancing ill-defined mass/ adenopathy encasing and
narrowing the left
mainstem bronchus. Complete obstruction of the left lower lobe
bronchus and
associated left lower lobe collapse.
3. Persistent left upper lobe post obstructive pneurmonia and
bibasilar
atelectasis. Right lower lobe bronchopneumonia.
4. Interval decrease of known subcapsular fluid collection.
5. Focal hypodensity in the upper pole of the right kidney
without definite
mass effect for which ultrasound is recommend.
.
___ head CT:
No acute intracranial process. No areas of brain edema or
hemorrhage. Please
note MRI is more sensitive in the evaluation for metastatic
lesions.
.
___ pleural fluid cytology:
Diagnosis
POSITIVE FOR MALIGNANT CELLS.
Metastatic adenocarcinoma; (see note.)
Note: The tumor cells show positive staining for cytokeratin 7,
___
and TTF-1. Some tumor cells show staining for B72.3. The tumor
cells
are nonreactive for calretinin and WT-1. These findings support
the
diagnosis and are consistent with lung origin. Clinical
correlation is
needed.
Brief Hospital Course:
___ year old ___ man with diabetes and coronary
artery disease presenting with two months of dysphagia and
worsening cough and dyspnea found to have metastatic
adenocarcinoma of the lung. Patient made CMO on ___ after
family meeting.
#metastatic adenocarcinoma of the lung: Patient was found to
have a lung mass encasing the left mainstem bronchus, with LLL
collapse, and a right sided malignant effusion, consistent with
metastatic adenocarcinoma of the lung. There is also mass effect
on the mid thoracic esophagus. The tumor cells show positive
staining for cytokeratin 7, ___ and TTF-1. Some tumor cells
show staining for B72.3. The tumor cells are nonreactive for
calretinin and WT-1. This was consistent with lung origin. The
stage was at least IIIB. This finding explained both his
dysphagia and dyspnea over the past few months. He was treated
empirically with various broad spectrum antibiotics for possible
pneumonia and for a subcapsular liver lobe fluid collection.
Heme onc and rad onc were consulted, and he was not a candidate
for chemotherapy or radiation therapy. He ultimately did have a
right pleurex catheter placed for symptomatic management of the
right-sided pleural effusion. A PEG placement was unsuccessfuly
attempted on ___. Surrounding this time, his mental status
subactuely declined, demonstrating confusion and
unresponsiveness at times. A pan CT scan was not revealing for
any new pathology or sources of infection. The patient was made
CMO after a family meeting on ___ given his poor
prognosis. TPN was stopped, as was the empiric course of zosyn.
Prior to discharge, he did have periods of lucidity and was able
to communicate via a ___ interpreter. He seemed comfortable.
He will be transitioned to ___ with ___ services for symptom
management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NIFEdipine 90 mg PO DAILY
2. GlipiZIDE XL 10 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Simvastatin 20 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Atenolol 100 mg PO DAILY
8. Metoclopramide 5 mg PO QIDACHS
9. Hyoscyamine 0.125 mg PO QID
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Lorazepam 0.5 mg PO Frequency is Unknown
12. Zolpidem Tartrate 10 mg PO HS
13. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
14. Pioglitazone 45 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortnes of breath
2. Nitroglycerin SL 0.4 mg SL PRN chest pain
3. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q1H:PRN
pain, shortness of breath
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg SL Q1H
Disp #*2 Bottle Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic lung carcinoma
Prostate cancer
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with weakness and inability to eat. You were
found to have metastatic cancer of the lung. You had a pleurex
catheter placed to drain fluid from the right side of your lung
in order to make your breathing more comfortable. The goal on
discharge is to focus on making you as comfortable as possible.
Followup Instructions:
___
|
10319873-DS-17 | 10,319,873 | 29,565,639 | DS | 17 | 2160-03-08 00:00:00 | 2160-03-15 21:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
IV Dye, Iodine Containing / Celexa / citalopram
Attending: ___.
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI:
Mrs. ___ is a ___ y.o. right handed woman with a history of
HTN, Diabetes, HLD, intraop right frontal stroke during aneurysm
clipping in ___, history of BPPV in ___, presents to the ED
with a 4 day history of vertigo.
She first noticed the symptoms on ___ morning upon waking up.
When she stood up, she felt the room was spinning around her.
The
symptoms were severe for the first few minutes then improved
over
the course of 30 minutes. She continued to experience similar
symptoms when she would stand up of have a sudden change in
position, but never at rest. She also reported some unsteadiness
upon walking. She reported blurry vision during the episodes,
but
no diplopia or residual blurry vision otherwise.
She had episodes of nausea but no vomiting. There is no recent
history of trauma.
Her symptoms continued to worsen over the following few days,
with more severe and frequent episodes.
Of note, she had a similar presentation in ___ and was admitted
to ___ where evaluation included an MRI which showed no acute
changes, she was diagnosed with BPPV and received Meclizine. She
does not remember this medication and whether it helped at that
time.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies new
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:
HTN, Diabetes, HLD, intraop right frontal stroke during aneurysm
clipping in ___, history of BPPV in ___
Social History:
___
Family History:
Positive for aneurysms.
Physical Exam:
Physical Exam on admission:
Vitals: T: 97.9 P: 92 R: 16 BP: 132/72 SaO2: 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. 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. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII:minimal NL flattening on the left.
VIII: Hearing intact to finger-rub bilaterally. ___ and ___
tests normal.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
___ Hall Pike Maneuver positive bilaterally with reproduction of
symptoms and fatigable nystagmus.
-Motor: Normal bulk, tone throughout.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Left:
Delt 4+/5, ___ 4+/5, Tri 4+/5, Grip 4+/5, Spread ___, IP 4+/5,
Quad ___, Ham ___, TA ___, ___ ___, Gastroc ___
Right:
Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad
___, Ham ___, TA ___, ___ ___, Gastroc ___
Left Pronator drift:
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense
Reflexes:
DTRs
Right: ___ 2 Tri 2 ___ 2 Patellar 2 Achilles 2 Toes
downgoing
Left: ___ 3 Tri 3 ___ 3 Patellar 3 Achilles 2 Toes mute
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally (slow on the left but
appropriate to degree of weakness). No overshooting on mirror
test.
-Gait: Unable to assess. Patient experienced severe vertigo and
nausea upon standing up, and felt unsafe to walk.
Physical exam on discharge:
VSS
NAD, comfortable
alert & fully oriented, conversing appropriately, ambulating
easily
No nystagmus or other focal neurological deficits evident
Pertinent Results:
___ 07:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 06:50PM GLUCOSE-196* UREA N-10 CREAT-0.8 SODIUM-135
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-16
___ 06:50PM estGFR-Using this
___ 06:50PM WBC-6.4 RBC-5.34 HGB-15.3 HCT-45.4 MCV-85
MCH-28.7 MCHC-33.8 RDW-13.0
___ 06:50PM NEUTS-57 BANDS-1 ___ MONOS-8 EOS-1
BASOS-0 ATYPS-1* ___ MYELOS-0
___ 06:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 06:50PM PLT SMR-NORMAL PLT COUNT-214
CT head ___:
FINDINGS: Metallic artifact from an aneurysm clip is seen in
the right
sylvian fissure with adjacent encephalomalacia from history of
infarction.
There is no acute intracranial hemorrhage, extra-axial
collection, or mass
effect. The ventricles and sulci remain normal in size and
configuration.
Gray matter/white matter elsewhere is preserved. The mastoid
air cells are
clear bilaterally. The visualized portions of the paranasal
sinuses are
clear. There are post-surgical changes of pterional craniotomy.
IMPRESSION:
1. No acute intracranial process.
2. Aneurysm clips, with adjacent encephalomalacia consistent
with given
history.
Brief Hospital Course:
Ms. ___ presented with episodic vertigo. She did not have any
diplopia, dysarthria,dysphagia, or sensorimotor changes. She has
a mild left hemiparesis with some ataxia from her old stroke.
She was found to have a ___ maneuever positive when
going to the left, producing fatigable left-beating nystagmus
without an upward or torsional component. There was also
evidence for an old left hemiparesis. She had a CT of her head
that showed no bleed or other acute changes.
She was diagnosed with left horizontal canal benign paroxysmal
positional vertigo. We taught her the barbecue spit maneuver,
which is the equivalent of the Epley maneuver that is
appropriate for this rarer variant of BPPV. We also gave
meclizine for additional vestibular suppression.
Ms. ___ improved considerably over her admission. On the day
of discharge, she had no vertigo, even when turning over in bed
or changing positions. On examination, the ___
maneuevers and barbecue spit maneuvers were negative in both
directions. Signs of her mild left hemiparesis persisted.
Ms. ___ fasting lipid panel was checked during this
admission (TChol 167 ___ 661 HDL 55 LDL 99). As the LDL was above
goal for someone with a previous stroke, her pravastatin was
increased 40->60 mg daily. She is to follow up with her PCP
regarding this and her vertigo. She was also given a
prescription for meclizine, and a referral to OT for vestibular
therapy.
Medications on Admission:
metformin 500mg BID
pravastatin 40mg daily
metoprolol 25 mg BID
aspirin 81 mg daily
Multivitamins
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Meclizine 12.5 mg PO TID vertigo
RX *meclizine 12.5 mg 1 tablet(s) by mouth up to three times
daily Disp #*42 Tablet Refills:*0
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Metoprolol Tartrate 25 mg PO BID
5. Pravastatin 60 mg PO DAILY
RX *pravastatin 20 mg 3 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
6. Outpatient Occupational Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
BPPV (Left horizontal canal benign paroxysmal positional
vertigo)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because of dizziness. We diagnosed your
dizziness as a problem with your inner ear, called BPPV (benign
paroxysmal positional vertigo) of the horizontal canal. You also
had a CT of your head during this admission that showed no bleed
or other acute changes. We taught you a series of maneuvers of
maneuvers that should help with your vertigo. We also gave you a
medication that should help with this problem called meclizine.
You can continue taking this medication as long as you still
have symptoms.
We also found that when we checked your "bad cholesterol", it
was a little too hight. We recommend that you take a higher dose
of your pravastatin (Pravachol) from now on. You can discuss
this with your primary care doctor.
Followup Instructions:
___
|
10319938-DS-11 | 10,319,938 | 20,515,469 | DS | 11 | 2187-06-07 00:00:00 | 2187-06-07 23:23:00 |
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:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 11:15PM BLOOD WBC-4.1 RBC-2.01* Hgb-6.4* Hct-20.9*
MCV-104* MCH-31.8 MCHC-30.6* RDW-16.5* RDWSD-62.5* Plt ___
___ 11:15PM BLOOD Neuts-63 Bands-2 ___ Monos-6 Eos-1
Baso-4* AbsNeut-2.67 AbsLymp-0.98* AbsMono-0.25 AbsEos-0.04
AbsBaso-0.16*
___ 01:38AM BLOOD ___ PTT-22.3* ___
___ 08:00AM BLOOD Ret Aut-4.7* Abs Ret-0.13*
___ 11:15PM BLOOD Glucose-128* UreaN-31* Creat-1.8* Na-138
K-4.4 Cl-103 HCO3-23 AnGap-___ 11:15PM BLOOD ALT-15 AST-18 AlkPhos-29* TotBili-0.8
___ 11:15PM BLOOD Lipase-31
___ 11:15PM BLOOD cTropnT-<0.01
___ 05:20AM BLOOD cTropnT-<0.01
___ 11:15PM BLOOD Albumin-4.3 Calcium-9.5 Phos-3.7 Mg-1.8
___ 08:00AM BLOOD calTIBC-237* VitB12-969* Folate-12
Hapto-<10* Ferritn-1084* TRF-182*
___ 08:00AM BLOOD tacroFK-8.9
___ 01:50AM BLOOD ___ pO2-21* pCO2-48* pH-7.36
calTCO2-28 Base XS-0
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-4.2 RBC-2.87* Hgb-9.0* Hct-28.8*
MCV-100* MCH-31.4 MCHC-31.3* RDW-18.4* RDWSD-67.6* Plt ___
___ 08:00AM BLOOD Glucose-109* UreaN-29* Creat-1.9* Na-141
K-5.2 Cl-104 HCO3-21* AnGap-16
___ 08:00AM BLOOD ALT-16 AST-30 LD(LDH)-507* AlkPhos-29*
TotBili-1.0
___ 08:00AM BLOOD Albumin-4.4 Calcium-9.6 Phos-5.0* Mg-1.8
Iron-103
IMAGING:
Renal ultrasound (___)
No hydronephrosis or renal calculi.
RUQUS with doppler:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the
liver is smooth. There is no focal liver mass.
There is no ascites, right pleural effusion, or sub- or
___ fluid
collections/hematomas.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 mm
SPLEEN: Normal echogenicity.
Spleen length: 9.8 cm
DOPPLER:
The main hepatic arterial waveform is within normal limits, with
prompt
systolic upstrokes and continuous antegrade diastolic flow. Peak
systolic
velocity in the main hepatic artery is 68 cm per second.
Appropriate arterial
waveforms are seen in the right hepatic artery and the left
hepatic artery
with resistive indices of 0.68, and 0.83, respectively.
The main portal vein and the right and left portal veins are
patent with
hepatopetal flow and normal waveform.
Appropriate flow is seen in the hepatic veins and the IVC.
IMPRESSION:
Patent hepatic vasculature with appropriate waveforms.
CXR (___)
No acute cardiopulmonary abnormality.
Brief Hospital Course:
BRIEF SUMMARY:
==============
___ year-old man with a history of acute liver failure secondary
to hepatitis B now s/p deceased donor liver transplant on
___, closed ___ w/ portal vein revision, course c/b
ileus with recent admission in ___ with acute cellular
rejection as seen on liver biopsy now on prednison taper
presenting with dyspnea and weakness in the setting of acute on
chronic anemia.
TRANSITIONAL ISSUES:
====================
[] Please schedule patient for a colonoscopy and EGD as an
outpatient (none documented in our system) to further
investigate chronic anemia requiring periodic transfusions.
[] Patient was switched from dapsone to atovaquone in the
setting of his chronic anemia.
[] Please continue to follow patient's renal function and make
adjustments to medications as appropriate. Recent baseline Cr
1.8-2.0.
[] Please continue prednisone taper as follows:
prednisone 7.5mg daily ___
prednisone 5mg daily ___
prednisone 2.5mg daily ___
MEDICATION CHANGES:
New: Atovaquone
Stopped: Dapsone, Valganciclovir
Changed: Tacrolimus 6mg BID -> 5.5mg BID
ACUTE ISSUES:
=============
#Anemia
#Weakness
Patient has had intermittent anemia over the past several months
with intermittent transfusion requirement during his prior
hospitalizations. This was believed to be low in setting of
active infection and bone marrow suppression rather than overt
bleeding at that time. Review of medical records show no sign of
prior EGD or colonoscopy, though patient denies melena or other
GI bleeding. Elevated MCV suggestive of nutritional component,
though with increased RDW possibly conflating with acute
reticulocyte response. B12 and folate was normal. He received 2
units of pRBCs with appropriate response. Hgb on discharge was
9.0.
#Acute on Chronic Kidney Disease
Recent baseline Cr 1.8-2.0 (during last admission 1.4-1.7).
Renal ultrasound with no evidence of hydronephrosis or
obstruction. ___ be related to tacrolimus and so his dose was
decreased from 6mg BID -> 5.5mg BID.
#Acute Cellular Rejection
#DDLT
#Immunosuppression
Patient s/p DDLT as described in HPI I/s/o acute liver failure
___ acute hepatitis B with re-presentation in ___ for
acute rejection. He was given steroids at that time with
transition of tacrolimus target to ___ and mycophenolate 720
BID. His transaminase and Tbili remained within normal limits
and no changes will be made to his immunosuppressive regimen.
- Continued home Mycophenolate Sodium ___ 720 mg PO BID
- Continued prednisone taper of 2.5mg/week (received 7.5mg daily
___, to start 5mg daily ___ x1 week with 2.5mg decrease
per week)
- Will continue prophylaxis while on steroids
- Valgancyte x 6 weeks last day ___
- Holding Dapsone given drop in Hgb - switched to atovaquone
daily
- Continue PPI
- Received tacrolimus 5.5mg BID - goal tacro level ___
#Steroid induced hyperglycemia:
-Continued home lantus without change with ISS
CHRONIC ISSUES:
===============
#Latent TB
Patient continued on home isoniazid ___ daily and pyridoxine
50mg daily.
#Hepatitis B:
- Continued entecavir - deceased dose to 0.5 mg given Cr rise
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
2. Dapsone 100 mg PO DAILY
3. Isoniazid ___ mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Polyethylene Glycol 17 g PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. Tacrolimus 6 mg PO Q12H
8. Mycophenolate Sodium ___ 720 mg PO BID
9. PredniSONE 20 mg PO DAILY
10. ValGANCIclovir 450 mg PO DAILY
11. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN hyperkalemia
12. Entecavir 1 mg PO DAILY
13. Hepatitis B Immun Globulin (HepaGam B) 0.5 mL IM EVERY 4
WEEKS (MO)
14. Glargine 7 Units Bedtime
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 1500 mg by mouth once a day
Refills:*0
2. Glargine 7 Units Bedtime
3. PredniSONE 7.5 mg PO DAILY Duration: 3 Doses
4. PredniSONE 5 mg PO DAILY
5. Tacrolimus 5.5 mg PO Q12H
6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
7. Entecavir 1 mg PO DAILY
8. Hepatitis B Immun Globulin (HepaGam B) 0.5 mL IM EVERY 4
WEEKS (MO)
9. Isoniazid ___ mg PO DAILY
10. Mycophenolate Sodium ___ 720 mg PO BID
11. Pantoprazole 40 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY
13. Pyridoxine 50 mg PO DAILY
14. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN
hyperkalemia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute on chronic anemia
SECONDARY DIAGNOSIS:
S/p Liver transplant recipient complicated by recent acute
cellular rejection
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 feeling weak and were found to have a low blood count
WHAT HAPPENED TO ME IN THE HOSPITAL?
-You received 2 units of blood which made you feel better. You
had no evidence of active bleeding and so we felt that you could
leave the hospital and have a colonoscopy and endoscopy done as
an outpatient to investigate for any sources of bleeding.
-We stopped your dapsone since this can contribute to low blood
counts - we started you instead on atovaquone.
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:
___
|
10320037-DS-13 | 10,320,037 | 24,076,109 | DS | 13 | 2124-10-10 00:00:00 | 2124-10-10 16:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Right eye pain and swelling
Major Surgical or Invasive Procedure:
___ Right lateral Canthotomy x 2
___ Cerebral Angiogram
History of Present Illness:
___ presents to the ED from ophthalmology clinic with right eye
pain, proptosis, and elevated intraocular pressure. Pt reports
to
have right eye redness and itchiness for approximately two
weeks,
for which she was prescribed a topical steroid for her
ophthalmologist. Last evening, she developed intense pain and
with decreased vision. Today she was evaluated by ophthalmology,
who noted her IOC to be 40 in the setting of chemosis and
limited
mobility. She was transfered to ___ for further workup.
Upon arrival to the ED she underwent CT head which revealed a
dilated right opthalmic vein consistent with a right
carotid-cavernous sinus fistula. Ophthalmologic evaluation
revealed an IOC of 51, for which a lateral canthotomy was
performed. Post-procedure canthotomy IOC was 33, and her pain
improved significantly.
Past Medical History:
-GERD
-Hypertension
-Hypercholesterolemia
-Osteoarthritis s/p bilateral TKR
Social History:
___
Family History:
nc
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: R globe swollen, tight with conjunctival hemorrhage, s/p
lateral canthotomy. Pupils 3->2 bilaterally. R eye with
decreased
EOM. Post-canthotomy acuity ___.
Lungs: Breathing comfortably.
Cardiac: RRR.
Abd: Soft, NT.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Communication via interpreter.
Orientation: Oriented to person, place, and date.
Language: Speech fluent.
Motor: ___ strength bilateral upper and lower extremities.
Sensation: Intact to light touch
Upon discharge:
Awake, alert, MAE full, R CN VI palsy
Pertinent Results:
___ CTA head : Early filling of a dilated right opthalmic vein
consistent with a right carotid-cavernous sinus fistula.
___ Chest Xray: Tip of endotracheal tube terminates
approximately 2 cm above the carina and could be withdrawn a few
centimeters for standard positioning. Nasogastric tube
terminates within the stomach. Heart size is normal. Aorta is
tortuous. Multifocal linear areas of atelectasis are present in
the right suprahilar region and both lower lobes. No visible
pneumothorax.
___ CT head: The right superior ophthalmic vein is enlarged,
similar to prior. There is no evidence of hemorrhage, edema,
mass effect, or large territorial infarction. The ventricles and
sulci are normal in size and configuration for age. The basal
cisterns appear patent and there is preservation of gray-white
matter differentiation. Dense bilateral cavernous carotid
artery calcifications are similar to prior. Calcification of
the distal right vertebral artery is unchanged. The orbital
soft tissues are unremarkable. No fracture is identified. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear.
Brief Hospital Course:
Ms. ___ was admitted to the Neurosurgery service with a Right
Carotid-Cavernous fistula and high Right eye intraocular
pressures. Ophthalmology was closely involved in her care. SHe
was started on Diamox, Combigan drops, Latanoprost drops for
treatment of high intraocular pressures. She underwent a
cerebral angiogram on ___ that was ultimately a failed attempt
at embolization of the fistula depsite the involvement of
vascular surgery for access through the right facial vein.
Post-procedure evaluation of IOP revealed elevated pressures
again on the right and another bedside canthotomy was performed
with good result.
On ___ Ms. ___ had two episodes of bradycardia over the night
with
concern of increased IOP causing oculocardiac reflex. Her IOP
measured 14 in the right eye and 6 in the left eye. She has
minimal proptosis on the right eye. Her subconj heme/chemosis
has improved as well. Her orbit is improved to retropulsion on
the right side. Her pupil reactivity has improved although
still sluggish. The patient was extubated and doing well.
On ___, IOP ___. Patient was transferred to the floor. Did
not have any more issues with bradycardia.
On ___, The patient was neurogically intact. Underwent visulal
field testing on ___. Intraocular pressures were 29.
On ___, the patient was assessed by ___ and cleared for home
with ___.
Medications on Admission:
Prazosin 2mg HS
Amlodipine 10mg daily
Atorvastatin 10mg daily
Prednisone ophthalmic drops
Sulfacetamide-prednisolone ophthalmic drops
Bacitracin ophthalmic ointment
Triamcinolone acetonide topical ointment
Emolient topical cream
Omeprazole 20mg daily
Valsartan 160mg daily
Gabapentin 300mg daily
Furosemide 20mg daily
Fluocinonide topical ointment
Calcium + Vitamin D
Aspirin 81mg daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Atorvastatin 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q8H
RX *brimonidine 0.15 % 1 drop in the right eye every 8 hours
Disp #*1 Bottle Refills:*0
5. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE TID
RX *erythromycin 5 mg/gram (0.5 %) 1 drop in the right eye three
times a day Disp #*1 Tube Refills:*0
6. Gabapentin 300 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
RX *latanoprost 0.005 % 1 drop OD at bedtime Disp #*1 Bottle
Refills:*0
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 capsule,delayed ___ by
mouth once a day Disp #*30 Capsule Refills:*0
9. Senna 2 TAB PO HS
10. Timolol Maleate 0.5% 1 DROP RIGHT EYE Q 8H
RX *timolol maleate 0.5 % 1 drop OD Every 8 hours Disp #*1
Bottle Refills:*0
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Carotid-Cavernous Fistula
Elevated intraocular pressures
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:
Angiogram
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
When you go home, you may walk and go up and down stairs.
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
After 1 week, you may resume sexual activity.
After 1 week, gradually increase your activities and distance
walked as you can tolerate.
No driving until you are no longer taking pain medications
What to report to office:
Changes in vision
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call ___ for transfer to closest
Emergency Room!
Followup Instructions:
___
|
10320090-DS-18 | 10,320,090 | 28,883,516 | DS | 18 | 2176-12-26 00:00:00 | 2176-12-26 16:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pink grapefruit / Ultram
Attending: ___.
Chief Complaint:
AICD firing
Major Surgical or Invasive Procedure:
+ LEFT HEART AND RIGHT HEART CATHERIZATION - ___:
Cardiac Output Results
Phase Fick Fick
C.O. C.I.
L/min LPM/m2
Baseline 6.93 2.80
Using an assumed oxygen consumption
Hemodynamic Measurements (mmHg)
Baseline
Site ___ ___ End Mean A Wave V Wave HR
RA 2 5 3 83
RV 36 3 81
PCW 10 15 15 70
PA 28 10 17 81
LV 93 16 80
AO 83 52 66 80
Resistance Results
Phase PVR SVR PVR SVR
dsc-5 dsc-5 ___ ___
Baseline 81 738 1.01 9.23
Coronary angiography: right dominant
LMCA: The LMCA had mild distal tapering to 20%.
LAD: The LAD gave off a very high diagonal branch
(functionally a ramus intermedius). The mid LAD had mild
plaquing.
LCX: The LCX was of large caliber and patent, supplying an
atrial branch, a small OM1, long OM2 and OM3/LPL.
RCA: The RCA could not be engaged despite attempts with
multiple catheters due to kinking, inability to prolapse
catheters high, and inability to reach the RCA. Non-selective
injections suggested patency of the proximal-mid vessel. The
distal vessel was not visualized well on non-invasive
injections.
History of Present Illness:
___ y/o M PMH significant for nonischemic dilated cardiomyopathy
s/p BiV-ICD c/b LV thrombus, atrial fibrillation who comes into
the ED because his ICD fired. Has had multiple AICD firings in
past, uisually a-fib RVR, but also had episode of VT. On ___
around 8pm patient got up out of bed quickly, felt heart racing
with lightheadedness, no CP or SOB, felt AICD fire. Then had
adrenaline rush and felt better with heart palpitations and
lightheadedness resolved. He initially presented to ___ and case discussed with Dr. ___ with plan to discharge
home. However, patient dropped BP in 80-90s range, normal 100s
and reported never in the ___. Discussed again, this time with
Dr. ___ felt best to do ED to ED transfer to monitor him
overnight and have cath in the morning to better assess heart
pressures. Has had mild malaise for 2 days, but no other
significant symptoms. Xfer from ___. Has cath scheduled for
___ ___. Last similar event 9 months ago.
In the ED initial vitals were: 98.2 84 116/84 18 98% RA.
- Labs were significant for WBC 12.5 (at baseline), H/H
10.1/29.3 (baseline ___, BNP ___, Cr 1.6.
- Patient received nothing in the ED.
Vitals prior to transfer were: 98.4 74 96/49 13 99% RA.
On the floor, patient is chest pain free. He denies
palpitations, lightheadness at rest, SOB, orthopnea and PND.
Past Medical History:
1. Non-infarct related cardiomyopathy.
2. Status post Biotronik Biventricular ICD (EchoCRT narrow QRS
___
3. Biventricular cardiomyopathy with EF of 20%.
4. History of LV thrombus status post 12 months of Warfarin
which was stopped ___.
5. Obesity.
6. Status post ICD shock in the ___ while playing
basketball, likely for atrial flutter that conducted 1:1.
7. ICD shock on ___ for a ventricular tachycardia that
degenerated quickly into ventricular fibrillation, this was
refractory to one ICD shock, and finally broke after the second
ICD shock. Brief LOC without injury. Patient no longer driving.
ICD shock in ___ for AF with RVR (240-280 bpm) vs
atrial flutter with 1:1 conduction.
8. Psoriasis
9. Knee pain
10. PNA ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Vitals: 98.0 95-102/50-54 ___ 20 95RA
WEIGHT: 138.9kg
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, ICD in place
with well-healed scar
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, psoriatic pink scaly plaques on
extremities
Pertinent Results:
ADMISSION LABS:
___ 02:05AM BLOOD WBC-12.5* RBC-3.24* Hgb-10.1* Hct-29.3*
MCV-91 MCH-31.3 MCHC-34.6 RDW-14.8 Plt ___
___ 02:05AM BLOOD Neuts-81.6* Lymphs-11.3* Monos-5.8
Eos-1.0 Baso-0.3
___ 02:05AM BLOOD ___ PTT-31.8 ___
___ 02:05AM BLOOD Glucose-97 UreaN-36* Creat-1.6* Na-139
K-5.1 Cl-102 HCO3-26 AnGap-16
___ 08:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.3
___ 02:05AM BLOOD ___ 02:05AM BLOOD calTIBC-272 Ferritn-252 TRF-209
___ 02:05AM BLOOD Iron-47
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-10.9 RBC-3.07* Hgb-9.5* Hct-28.4*
MCV-93 MCH-31.0 MCHC-33.5 RDW-15.2 Plt ___
___ 08:00AM BLOOD Glucose-102* UreaN-19 Creat-1.2 Na-138
K-4.5 Cl-103 HCO3-27 AnGap-13
+ ___ TEE: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The left atrial appendage is
small; the ___ emptying velocity is depressed (<0.2m/s). No
atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is dilated. Overall left ventricular systolic
function is severely depressed (LVEF <20%). [Intrinsic function
is more depressed given the severity of mitral regurgitation.]
Right ventricular chamber size is normal with depressed free
wall contractility. The aortic arch is not well seen. There is
no atheroma in the descending aorta to 40 cm from the incisors.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal but fail to fully
coapt. Severe (4+) mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: No echocardiographic evidence of thrombus or
spontaneous echo contrast in either atria or atrial appendages.
Dilated left ventricular cavity with biventricular severe global
hypokinesis. Severe mitral regurgitation.
+ EKG: A-sensed, V-paced at rate of 80, normal intervals, normal
axis, no ST or T wave changes.
+ ICD Interrogation: ___
Reason for interrogation: ICD shock
Generator Brand: Biotron___
Model Name: ___
Model Number: 540 HF-T
Presenting rhythm: Sinus with BiV Pacing
Intrinsic Rhythm: Sinus with intact AV conduction
Programmed Mode: DDD 60/130
RA lead
Model Brand/Number:
Intrinsic amplitude: 1.8 mV
Pacing impedance: 336 ohms
Pacing threshold: 0.6 V @ 0.4 ms
% Pacing: 2%
RV lead
Model Brand/Number:
Intrinsic amplitude: 21.6 mV
Pacing impedance: 499 ohms
Pacing threshold: 0.4 V @ 0.5 ms
% Pacing: 87%
LV lead
Model Brand/Number:
Intrinsic amplitude: 21.9 mV
Pacing impedance: 513 ohms
Pacing threshold: 1.2 V @ 0.4 ms
% Pacing: 98%
Diagnostic information: arrhythmias, morphologies, rates, Rx:
1 episode of VF/Fast VT at 220 ms terminated with a single shock
No additional arrhythmias since last interrogation ___
Programming changes (details): None
Summary (normal / abnormal device function):
Normally functioning BiV ICD
1 appropriate shock for VT/VF
+ CXR - ___:
Moderate cardiomegaly has been stable compared to exams dating
back to ___. No consolidations concerning for pneumonia are
identified. Mild
left basilar atelectasis.
+ LHC/RHC - ___:
Cardiac Output Results
Phase Fick Fick
C.O. C.I.
L/min LPM/m2
Baseline 6.93 2.80
Using an assumed oxygen consumption
Hemodynamic Measurements (mmHg)
Baseline
Site ___ ___ End Mean A Wave V Wave HR
RA 2 5 3 83
RV 36 3 81
PCW 10 15 15 70
PA 28 10 17 81
LV 93 16 80
AO 83 52 66 80
Resistance Results
Phase PVR SVR PVR SVR
dsc-5 dsc-5 ___ ___
Baseline 81 738 1.01 9.23
Coronary angiography: right dominant
LMCA: The LMCA had mild distal tapering to 20%.
LAD: The LAD gave off a very high diagonal branch
(functionally a ramus intermedius). The mid LAD had mild
plaquing.
LCX: The LCX was of large caliber and patent, supplying an
atrial branch, a small OM1, long OM2 and OM3/LPL.
RCA: The RCA could not be engaged despite attempts with
multiple catheters due to kinking, inability to prolapse
catheters high, and inability to reach the RCA. Non-selective
injections suggested patency of the proximal-mid vessel. The
distal vessel was not visualized well on non-invasive
injections.
Brief Hospital Course:
___ y/o M PMH significant for nonischemic dilated cardiomyopathy
s/p BiV-ICD c/b LV thrombus, atrial fibrillation who comes into
the ED because his ICD fired.
# Non-ischemic Dilated Cardiomyopathy: Severe idiopathy
cardiomyopathy in ___ s/p BiV-ICD who remains in ___
Functional Class III. Unable to uptitrate meds further due to
mild symptomatic orthostasis. Referred for cardiac
transplantation, however currently not a candidate due to morbid
obesity. However, continued pre-transplantation work-up with a
right and left heart catheterization during hospitalization,
which showed normal coronary arteries, cardiac index of 2.8 and
low right heart filling pressures. Continued Pradaxa and
Aspirin. Continue lisinopril, spironolactone with strict hold
parameters. Continued metropol tartrate 25mg PO q6h while
hospitalized, but transitioned to home metop XL 125mg daily.
- Held torsemide given low filling pressures on RHC during
hospitalization. Discharged on torsemide 20mg to start ___
(Home dose is 40mg).
- followup with Dr. ___ in heart failure clinic within 2 weeks
# VF/Fast VT at 220bps s/p ICD Firing: Patient reports had one
episode of ICD firing in the setting of palpitations and
lightheadedness. He then felt better and the palpitations
resolved. This may represent an episode of afib with RVR vs.
atrial tachycardia. He was recently seen in device clinic in
___ where his ICD was functioning appropriately with one
episode of atrial tachycardia. EP interrogated the ICD which
showed an appropriate shock for Vtach that resolved with shock.
- Per EP, holding off on anti-arrythmic (amiodarone) given that
he is a heart transplant candidate and amiodarone may cause lung
and liver abnormalities that may harm candidacy.
- followup with Dr. ___
# Leukocytosis: White count elevated to 12.5 without bandemia.
On review of ___ and ___ labs it appears that this is
chronic. No signs or symptoms of infection. Blood cultures were
without growth at time of discharge.
# CKD: Cr 1.6 on admission. On review of ___ and ___
records it appears his Cr has been 1.5-1.7 since ___
whereas previously it was normal (0.8-1.0). Likely pre-renal
etiology given low filling pressures seen on Right Heart Cath.
# Anemia: Drop in hemoglobin to 10 from as baseline ___. No
signs of active bleeding. Hct stable during hospitalization.
Iron studies within normal limits.
# Code: Full Code
# Emergency Contact: ___ (friend/HCP) ___
___ Medications:
1. Aspirin 81 mg PO DAILY
2. Spironolactone 12.5 mg PO DAILY
3. Dabigatran Etexilate 150 mg PO BID
4. Digoxin 0.25 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO QHS
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
8. Metoprolol Succinate XL 125 mg PO DAILY
9. Torsemide 20 mg PO DAILY
RX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: dilated cardiomyopathy with chronic compensated
systolic heart failure.
SECONDARY: Ventricular tachycardia, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of your during hospital stay. You
were admitted for monitoring following an episode of
lightheadedness and palpitations preceding an ICD shock. We
interrogated your pacemaker/ICD and saw that you had an episode
of ventricular tachycardia and were appropriately and
successfully shocked out of this rhythm.
As you had an already scheduled procedure as part of your
evaluation for heart transplantation, we decided to go ahead
with your procedure. You has a left and right sided
catherization of your heart, which showed no visible coronary
artery disease, but did show that you were slightly volume
depleted. We held your home diuretic and monitored your blood
pressures which were stable during the hospitalization. We think
you should take a lower dose of your home torsemide (20mg daily)
until you are told otherwise by the heart failure clinic. You
should continue to weigh yourself every morning, call Dr.
___, if your weight goes up more than 3 lbs.
We have contacted Dr. ___ regarding setting up an
appointment with his clinic within the next two weeks. If you
do not hear from them by ___ afternoon, please call them at
___ to schedule an appointment within 2 weeks.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10320090-DS-19 | 10,320,090 | 26,642,099 | DS | 19 | 2177-06-26 00:00:00 | 2177-06-28 11:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pink grapefruit / Ultram
Attending: ___.
Chief Complaint:
Chest pain, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male with PMHx of severe idiopathic dilated
cardiomyopathy (dx ___, s/p Biotronik BiV-ICD, c/b LV
thrombus), systolic CHF (LVEF <20% ___, currently ___
Functional Class III), atrial fibrillation (on dabigatran), and
severe mitral regurgitation.
He initially presented to ___ on the evening of ___ with
nonradiating substernal chest tightness/discomfort, left-sided
chest pain, and dyspnea. At ___ EKG was reportedly unchanged
from prior and initial troponinI was 0.03. He was transferred to
___ ED for further evaluation given that his outpatient
cardiology team is based here.
In the ED intial vitals were: 98.1 64 120/66 16 96% on room air.
Labs were notable for a WBC of 9.2, Hbg/Hct of 12.2/34.8, plt
308. Chemistries were unremarkable, except for BUN/Cr of ___.
Initial troponin here was <0.01.
He was observed overnight in the ED without any events, and the
decision was made to admit for further evaluation. Vitals on
transfer: 67 109/56 19 100% RA.
Upon arrival to the floor, pt reports his symptoms have not
recurred since last evening and he currently feels comfortable.
ROS: Per HPI, otherwise negative
Past Medical History:
1. Non-infarct related cardiomyopathy.
2. Status post Biotronik Biventricular ICD (EchoCRT narrow QRS
___
3. Biventricular cardiomyopathy with EF of 20%.
4. History of LV thrombus status post 12 months of Warfarin
which was stopped ___.
5. Obesity.
6. Status post ICD shock in the ___ while playing
basketball, likely for atrial flutter that conducted 1:1.
7. ICD shock on ___ for a ventricular tachycardia that
degenerated quickly into ventricular fibrillation, this was
refractory to one ICD shock, and finally broke after the second
ICD shock. Brief LOC without injury. Patient no longer driving.
ICD shock in ___ for AF with RVR (240-280 bpm) vs
atrial flutter with 1:1 conduction.
8. Psoriasis
9. Knee pain
10. PNA ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
==============
97.6 114/68 72 18 97%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP not elevated.
CARDIAC: heart sounds distant. RRR.
LUNGS: diffuse wheezing and rhonchi bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE EXAM
==============
97.6 124/78 62 18 97%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP not elevated.
CARDIAC: heart sounds distant. RRR.
LUNGS: CTAB, no wheeze/rhonchi
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS
==============
___ 02:45AM BLOOD WBC-9.2 RBC-4.23*# Hgb-12.2*# Hct-34.8*
MCV-82# MCH-28.8 MCHC-34.9 RDW-15.7* Plt ___
___ 02:45AM BLOOD Neuts-67.3 ___ Monos-5.9 Eos-2.8
Baso-0.4
___ 02:45AM BLOOD Glucose-99 UreaN-28* Creat-1.3* Na-137
K-4.4 Cl-103 HCO3-25 AnGap-13
___ 12:45PM BLOOD cTropnT-<0.01 proBNP-718*
___ 02:45AM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2
DISCHARGE LABS
==============
___ 06:55AM BLOOD WBC-8.8 RBC-3.93* Hgb-11.4* Hct-32.8*
MCV-84 MCH-29.0 MCHC-34.7 RDW-15.8* Plt ___
___ 06:55AM BLOOD Glucose-94 UreaN-21* Creat-1.2 Na-136
K-4.7 Cl-100 HCO3-27 AnGap-14
STUDIES
=======
___ CXR
In comparison to study of ___, there is again
substantial
enlargement of the cardiac silhouette consistent with
cardiomyopathy. Pacer device remains in place and there is no
evidence of vascular congestion, pleural effusion, or acute
focal pneumonia.
Brief Hospital Course:
___ y/o male with PMHx of chronic systolic heart failure(ECHO
___ with LVEF <20%), severe mitral regurgitation, history of
VT (s/p ICD, is 100% BiV-paced), and atrial fibrillation who
presented with 1 day duration of chest discomfort/pain and
shortness of breath. Pt reported having URI symptoms for the
past two days. He has a hx of childhood asthma that he reports
can be triggered with colds. He had an EKG without new changes,
negative cardiac enzymes, and was observed overnight on
telemetry without any events. CXR showed no acute abnormalities.
He did not have any recurrence of chest pain and he experienced
a brief episode of dyspnea that improved with albuterol
treatment. Pt showed no indication of volume overload and did
not require any diuresis. He was comfortable on room air,
asymptomatic, and at his baseline activity level on day of
discharge.
TRANSITIONAL ISSUES:
====================
- Please evaluate pt for recurrence of chest pain or dyspnea on
___ visit.
- Please resume all other outpatient care as scheduled.
# CODE: Full code
# CONTACT: ___, friend, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Dabigatran Etexilate 150 mg PO BID
3. Amiodarone 300 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Succinate XL 125 mg PO DAILY
6. Spironolactone 12.5 mg PO DAILY
7. Torsemide 20 mg PO DAILY
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
9. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
10. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Amiodarone 300 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Dabigatran Etexilate 150 mg PO BID
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Succinate XL 125 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
7. Spironolactone 12.5 mg PO DAILY
8. Torsemide 20 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Upper Viral Respiratory Tract Infection
Secondary Diagnosis:
- Systolic Heart Failure
- Dilated Cardiomyopathy
- Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
hospitalized for chest pain and shortness of breath. You were
found to have cold symptoms and had wheezing in your lungs,
indicating that you may have experienced an asthma attack. You
were carefully evaluated with telemetry, EKG, and laboratory
studies and there was no indication that your chest pain was due
to a heart attack. You had shortness of breath in the hospital
that improved with albuterol treatments. You did not experience
chest pain again. You should use your albuterol inhaler if you
have any shortness of breath or wheezing. You have been
discharged in stable condition to follow up with your primary
care physician.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Best wishes and good luck.
- Your ___ Team
Followup Instructions:
___
|
10320090-DS-22 | 10,320,090 | 28,783,904 | DS | 22 | 2178-05-13 00:00:00 | 2178-05-13 22:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pink grapefruit / Ultram
Attending: ___.
Chief Complaint:
Leg swelling, weight gain
Major Surgical or Invasive Procedure:
Right heart catheterization ___ and ___
History of Present Illness:
Mr. ___ is ___ with a history of idiopathic cardiomyopathy
and systolic CHF with LVEF 20% in ___ s/p biV ICD placement
in ___, AF with RVR s/p DCCV in ___ (on Coumadin), and
recent hospitalization from ___ to ___ for acute kidney
injury thought to be ___ overdiuresis from torsemide.
Patient reports ___ days of weakness and bilateral lower
extremity swelling since hospital discharge. He thinks he has
gained 18 lbs since discharge. He had one episode of
nausea/vomiting/diarrhea the night prior to admission. He denies
chest pain or worsening PND. He feels overall, that he is
becoming more volume overloaded, feeling more swollen in the
lower extremities.
Patient presented to ___ where he was found to be volume
overloaded. Labs notable for Cr 2.4, troponin <0.01, proBNP 875
(improved from 900s ___. EKG showed ventricular paced at
68, normal axis, paced QRS, no significant STE/Sgarbossa's
negative, similar to ___. He was transferred to ___ for
further management.
In the ED initial vitals were: T 96.9, HR 68, BP 100/63, RR 12,
SaO2 100% RA.
EKG: Paced @ 64, LAD, neg Sgarbossa, stable from ___
___ notable for: WBC 11.3, H/H 9.8/30.2, plts 333, K
5.0, BUN/Cr 52/2.7, BNP 1018, troponin <0.01, INR 1.2. CXR
showed severe cardiomegaly and possible mild congestion.
Cardiology was consulted and recommended admission to ___
service. Patient was not given PO Acetaminophen 1000 mg and PO
OxycoDONE (Immediate Release) 5 mg.
Vitals on transfer: 98.1 71 121/47 15 98% RA. Ambulatory O2 sat
in ED was 98% on RA.
On the floor, the patient reports compliance with all of his
medications. He notes that his main symptoms are that his legs
are significantly more swollen than usual. He has his baseline
orthopnea and does not think it has worsened. His respiratory
status with exertion is about stable as well. He does not recall
his ICD having fired.
ROS: On review of systems, denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative. Cardiac review of systems is notable
for absence of chest pain, dyspnea on exertion, paroxysmal
nocturnal dyspnea, palpitations, syncope or presyncope.
Past Medical History:
1. Non-infarct related cardiomyopathy.
2. Status post Biotronik Biventricular ICD (EchoCRT narrow QRS
___
3. Biventricular cardiomyopathy with EF of 20%.
4. History of LV thrombus status post 12 months of Warfarin
which was stopped ___.
5. Obesity.
6. Status post ICD shock in the ___ while playing
basketball, likely for atrial flutter that conducted 1:1.
7. ICD shock on ___ for a ventricular tachycardia that
degenerated quickly into ventricular fibrillation, this was
refractory to one ICD shock, and finally broke after the second
ICD shock. Brief LOC without injury. Patient no longer driving.
ICD shock in ___ for AF with RVR (240-280 bpm) vs
atrial flutter with 1:1 conduction.
8. Psoriasis
9. Knee pain
10. PNA ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VS: T=97.7 BP=120/53 HR=72 RR=18 O2 sat=94% on RA; Wt: 163 kg
standing
GENERAL: WDWN Caucasian male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, very obese neck habitus.
CARDIAC: RRR, normal S1, S2. ___ holosystolic murmur loudest at
the apex
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: warm, well perfused; ___ symmetric pitting ___
edema up to knees
SKIN: scattered erythematous rash with silver scaling in lower
extremities and upper extremities
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM
======================
VS: 97.8 ___ 18 100% RA
Weight: 154.0 <- 155.3 <- 156.5 <- 155.9 <- 153.9 <- 154.9 kg
<- 154.6 <- 156.2 kg <- 158 kg
I/O: 1200/3625 (net neg 2425 ccs); since MN ___
GENERAL: Obese Caucasian male in NAD. Oriented x3. Mood, affect
appropriate. Sitting on edge of bed.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa.
NECK: Supple, very obese neck habitus.
CARDIAC: RRR, normal S1, S2. ___ systolic murmur heard best at
RUSB and LUSB. JVP couldn't be appreciated d/t neck habitus
LUNGS: Resp unlabored, no accessory muscle use. No crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: warm, well perfused; No ___ edema
SKIN: scattered erythematous rash with silver scaling in lower
extremities and upper extremities
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS
==============
___ 12:01PM BLOOD Plt ___
___ 01:33PM BLOOD ___ PTT-31.5 ___
___ 12:01PM BLOOD WBC-11.3* RBC-3.33* Hgb-9.8* Hct-30.2*
MCV-91 MCH-29.4 MCHC-32.5 RDW-15.4 RDWSD-50.6* Plt ___
___ 12:01PM BLOOD Neuts-72.9* Lymphs-14.1* Monos-9.1
Eos-2.4 Baso-0.5 Im ___ AbsNeut-8.24* AbsLymp-1.59
AbsMono-1.03* AbsEos-0.27 AbsBaso-0.06
___ 12:01PM BLOOD Glucose-104* UreaN-52* Creat-2.7*# Na-135
K-5.0 Cl-94* HCO3-29 AnGap-17
___ 12:01PM BLOOD ALT-40 AST-28 AlkPhos-68 TotBili-0.3
___ 12:01PM BLOOD cTropnT-<0.01
___ 12:01PM BLOOD proBNP-1018*
___ 12:01PM BLOOD Albumin-4.2
___ 12:01PM BLOOD HoldBLu-HOLD
___ 12:01PM BLOOD LtGrnHD-HOLD
___ 12:01PM BLOOD GreenHd-HOLD
DISCHARGE AND PERTINENT LABS
==========================
___ 07:00AM BLOOD WBC-6.3 RBC-3.40* Hgb-9.8* Hct-30.3*
MCV-89 MCH-28.8 MCHC-32.3 RDW-14.6 RDWSD-47.0* Plt ___
___ 07:00AM BLOOD ___ PTT-33.6 ___
___ 07:00AM BLOOD Glucose-94 UreaN-24* Creat-1.3* Na-135
K-5.1 Cl-100 HCO3-29 AnGap-11
___ 05:30AM BLOOD ALT-65* AST-23 LD(LDH)-264* AlkPhos-52
TotBili-0.3
___ 07:14PM BLOOD proBNP-1010*
___ 07:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.5
IMAGING
=======
___ CXR PA&L
FINDINGS:
Severe cardiomegaly is unchanged. No focal consolidation is
seen concerning
for pneumonia. No convincing evidence for edema. Mild
congestion difficult
to exclude. There is no pleural effusion or pneumothorax. AICD
leads again
noted extending to the region the right atrium, right ventricle
and coronary
sinus. No acute bony abnormality. No free air below the right
hemidiaphragm.
___ Right Heart Cath : RA 21, RV 83/25, PA 81/39 mean 58, PCWP
36, CO 6.3, CI 2.4
___ Right Heart Cath: RA 10, RV 44/12, PA ___ mean 32, PCWP
___, CO 6.2, CI 2.5
IMPRESSION:
Severe cardiomegaly and possible mild congestion.
MICROBIOLOGY
============
None
Brief Hospital Course:
Mr. ___ is ___ with a history of idiopathic cardiomyopathy
and systolic CHF with LVEF 20% in ___ s/p biV ICD placement
in ___, AF with RVR s/p DCCV in ___ (on Coumadin), admitted
for management of acute on chronic sCHF exacerbation.
#Acute on chronic SCHF Exacerbation: JVP elevated to the neck,
peripheral edema. Slightly volume up but weight near baseline on
admission. He underwent a right heart cath on ___ that
demonstrated elevated pressures consistent with severe fluid
overload. He was started on a Lasix gtt at 5 mg/hr. He was
transitioned to 40 mg PO torsemide but then had increased
creatinine concerning for overdiuresis. Diuretics were held for
24 hours but then he was found to have increased LFTs and
creatinine continued to be elevated, so it was felt that patient
may need additional diuresis. He was given 40 mg IV Lasix then
80mg IV lasix once to twice a day to maintain negative 1 to 2
liters per day urine output. Patient underwent a repeat heart
cath on ___ as fluid status was difficult to determine
clinically which showed improved pressures. The patient was also
started on 10 mg Lisinopril BID and 12.5mg Spironolactone daily
for optimal heart failure management. He was discharged on 60mg
Torsemide daily for diuresis.
# ___ on CKD: Cr up to 2.7 but downtrended with diuresis. As
above, patient's creatinine rose which was concerning for
overdiuresis but then with LFTs elevated and concern for
congestive hepatopathy, patient was felt to require some more
diuretics which improved creatine. Cr at discharge was 1.3. He
is to have a repeat chem10 checked on ___ and was given a
script. Results will be faxed to ___ clinic.
# Atrial Fibrillation s/p BiV ICD: CHADS 2. We discussed the
risks of bridging vs. no bridging with the patient and he
preferred to be started on heparin to absolutely minimize the
risk of stroke. As a result, we started him on hep gtt while
continuing Coumadin. He was discharged on 7.5 mg coumadin with
INR 1.6. He was given a script to check INR on ___ and to
have results faxed to the ___ clinic. He was started on aspirin
81mg that he is to take until his INR is therapeutic. He doesn't
need aspirin from a CHF standpoint as his cardiomyopathy is not
ischemic.
#Transaminitis: Patient had LFT elevation most likely from
congestive hepatopathy from CHF exacerbation. Was improving with
diuresis and returned to near baseline at discharge. Should be
followed up as outpatient for stability of resolution.
# Psoriasis: We continued his home halobetasol Propionate 0.05 %
topical BID:PRN.
TRANSITIONAL ISSUES:
====================
-New PO diuretic regimen: Torsemide 60 mg PO daily.
-monitor volume status closely and adjust diuretic if needed
-anti coagulation Coumadin at 7.5mg. INR was 1.6 on day of
discharge, INR should be checked on ___. Patient
should continue taking ASA 81 mg daily until INR is therapeutic.
-chem10 panel should also be checked on ___
-check liver panel at PCP follow up appointment to make sure
creatinine and LFTs are stable
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
2. Spironolactone 12.5 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
6. Amiodarone 300 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Halobetasol Propionate 0.05 % topical BID:PRN
9. Metoprolol Succinate XL 125 mg PO DAILY
10. Warfarin 5 mg PO DAILY16
11. Torsemide 20 mg PO EVERY OTHER DAY
12. Torsemide 40 mg PO EVERY OTHER DAY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
2. Amiodarone 300 mg PO DAILY
3. Halobetasol Propionate 0.05 % topical BID:PRN
4. Metoprolol Succinate XL 125 mg PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
6. Vitamin D ___ UNIT PO DAILY
7. Spironolactone 12.5 mg PO DAILY
8. Torsemide 60 mg PO DAILY
RX *torsemide [Demadex] 20 mg 3 tablet(s) by mouth Daily Disp
#*90 Tablet Refills:*0
9. Warfarin 7.5 mg PO DAILY16
RX *warfarin 7.5 mg 1 tablet(s) by mouth Daily, or as directed
Disp #*30 Tablet Refills:*0
10. Lisinopril 10 mg PO BID
RX *lisinopril 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
11. Outpatient Lab Work
ICD-10: I48.1
Please draw INR as well as chemistry-10 panel on ___ and fax
results to: ___ (Attn: ___ NP)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- congestive heart failure with reduced ejection fraction
- subtherapeutic INR
- acute kidney injury
- transaminits
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for volume overload. A right heart
catheterization showed high filling pressures in your heart
prompting the team to remove more fluid through IV diuresis.
Your oral diuretic medication regimen was changed to torsemide
80 mg daily. You were also briefly on a heparin drip while your
Coumadin dose was adjusted to get your INR to target. Your INR
was a little below target on day of discharge, so you should
have your INR checked on ___. You should also take a baby
aspirin (81 mg) until your INR is therapeutic, and then you
should stop the aspirin. You should be seen by the cardiology
team within ___ days.
Wishing you well,
Your ___ Cardiology Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10320090-DS-25 | 10,320,090 | 24,348,675 | DS | 25 | 2179-01-31 00:00:00 | 2179-02-05 23:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pink grapefruit / Ultram
Attending: ___.
Chief Complaint:
Renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M with HFrEF ___ NICM (EF 15%) s/p BiV
ICD, Atrial fibrillation on coumadin, history of VFib and CKD
(baseline 1.1) who was recently hospitalized for ___ on CKD with
hyperkalemia, pneumatosis with concern for necrotizing colitis
from C.diff s/p ex-lap who is now readmitted with recurrent ___.
Mr. ___ was recently admitted from ___. He
initially presented with hyperkalemia ___. This was thought to
be ___ to overdiuresis and improved with diuresis. However he
also developed abdominal pain and given ongoing abdominal pain
worsened with movement, CT with oral contrast was obtained that
showed pneumoperitoneum. Patient was taken urgently to the OR
for an exploratory laparotomy, which demonstrated viable colon
with inflammation of the omentum, without evidence of
perforation. The wound was closed without bowel resection.
Follow up testing was positive for C. Diff. Patient was treated
with vancomycin 500mg PO q6h, along with metronidazole 500mg q8h
IV with improvement in his status. Patient was switched over to
oral metronidazole and his dose of vancomycin reduced to 125mg
q6h and was treated for a total of 14 days.
During his hospitalization, his diuretics were held initially,
spironolactone was held, and lisinopril was held. After
patient's kidney function recovered he was restarted on
lisinopril, spironolactone, and his home dose of torsemide,
which was 40mg BID. Patient continued with net negative urine
output and developed ___ in setting of overdiuresis, so his
diuretics were held. He was ultimately discharged on torsemide
10mg on ___ with plans to follow up in ___ days with the Heart
Failure Team for dose titration. Patient's kidney function
dramatically improved by the end of hospital stay with Cr of
1.3.
However two days following discharge he had followup labs
checked which showed potassium of 5.1 creatinine of 2.9. In the
ED, initial VS were 0 98.7 84 94/55 18 99% RA. Exam notable for
well appearing gentleman, with non-tender abdomen. EKG showed no
peaked T waves. Labs showed BUN 35/Cr 2.6 which improved to
33/2.3 with 1LNS. Surgery was consulted but did not provide
recommendations in the ED. Decision was made to admit to
medicine for further management. Vitals prior to transfer were
asleep 98.4 75 104/52 16 100% RA On arrival to the floor,
patient reports chest pain or shortness of breath. No fevers or
chills. No palpitations. Does have some mild abdominal pain
which is been present since his surgery and is unchanged.
Past Medical History:
PAST MEDICAL HISTORY:
- idiopathic dilated cardiomyopathy (LVEF 20%) s/p BiV ICD
(___)
- ICD shocks in ___ for atrial flutter, ___ for VFib (shock
x2), ___ for AFib w/ RVR
- mitral regurgitation (3+)
- paroxysmal atrial fibrillation
- pulmonary hypertension
- morbid obesity
- history of LV thrombus (s/p 12 months of warfarin in ___
- psoriasis
- chronic knee pain
- pneumonia (___)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: T 97.3 HR 91 BP 115/60 RR 18 SpO2 100% RA
Weight on admission ___: 140.1 kg
Weight on discharge ___: 141.2 kg
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, dry. neck supple, JVP not
elevated, no LAD Lungs: Lungs clear bilaterally. No wheezes or
rhonchi.
CV: RRR, S1, S2. ___ systolic murmur heard, no radiation.
Abdomen: Large midline incision from umbilicus to bottom of
sternum. Incision C/D/I with staples in place. BS+.
Ext: Warm, well perfused, 2+ pulses, no clubbing, mild edema.
Skin: Without rashes or lesions
Neuro: CN II-XII grossly intact.
DISCHARGE EXAM:
VS: T 98.2 HR ___ BP 91-105/51-61 RR ___ SpO2 97-100% RA
Wt: 140.1 kg > 140.0 > NR > 137.5
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, dry. Neck supple, JVP not
elevated
Lungs: CTAB
CV: RRR, systolic murmur present
Abdomen: Large midline incision from umbilicus to bottom of
sternum. Incision C/D/I with staples in place. BS+
Ext: Warm, well perfused, 2+ pulses, no clubbing, no edema noted
Skin: Without rashes or lesions
Neuro: AAOx3, no focal neuro deficits
Pertinent Results:
ADMISSION LABS:
___ 12:40AM BLOOD WBC-9.2 RBC-2.59* Hgb-7.4* Hct-24.2*
MCV-93 MCH-28.6 MCHC-30.6* RDW-15.0 RDWSD-51.4* Plt ___
___ 12:40AM BLOOD Neuts-77.4* Lymphs-12.0* Monos-8.2
Eos-1.1 Baso-0.3 Im ___ AbsNeut-7.10*# AbsLymp-1.10*
AbsMono-0.75 AbsEos-0.10 AbsBaso-0.03
___ 12:40AM BLOOD ___ PTT-38.0* ___
___ 12:40AM BLOOD Plt ___
___ 10:22PM BLOOD Glucose-101* UreaN-35* Creat-2.6*# Na-134
K-5.2* Cl-99 HCO3-24 AnGap-16
___ 12:40AM BLOOD Glucose-97 UreaN-33* Creat-2.3* Na-136
K-5.1 Cl-102 HCO3-22 AnGap-17
___ 09:00AM BLOOD ALT-15 AST-16 LD(LDH)-306* AlkPhos-51
Amylase-121* TotBili-0.2
___ 10:22PM BLOOD Calcium-8.6 Phos-4.1 Mg-2.3
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-8.1 RBC-2.88* Hgb-8.5* Hct-26.7*
MCV-93 MCH-29.5 MCHC-31.8* RDW-14.6 RDWSD-49.4* Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-36.8* ___
___ 06:20AM BLOOD Glucose-101* UreaN-12 Creat-1.2 Na-138
K-4.7 Cl-101 HCO3-28 AnGap-14
___ 06:20AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.2
IMAGING:
RENAL U/S ___:
FINDINGS:
The right kidney measures 11.9 cm. The left kidney measures 11.6
cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal
cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
Renal Doppler: Intrarenal arteries show normal waveforms with
sharp systolic
peaks and continuous antegrade diastolic flow. The resistive
indices of the
right intra renal arteries range from 0.67- 0.76. The
resistive indices on
the left range from 0.70- 0.80. Bilaterally, the main renal
arteries are
patent with normal waveforms. The peak systolic velocity on the
right is 111
centimeters/second. The peak systolic velocity on the left is
77.1
centimeters/second. Main renal veins are patent bilaterally with
normal
waveforms.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
Normal renal ultrasound without evidence of hydronephrosis,
stones or masses.
No evidence of renal artery stenosis. Mildly elevated
intrarenal resistive
indices can be seen in the setting of hypertension or renal
insufficiency.
Brief Hospital Course:
___ M with HFrEF ___ NICM (EF 15%) s/p BiV ICD, Atrial
fibrillation on coumadin, history of VFib and CKD (baseline 1.1)
who was recently hospitalized from ___ for ___ on
CKD with hyperkalemia, pneumatosis with concern for necrotizing
colitis from C.diff s/p ex-lap who is now readmitted with
recurrent ___. There was no clear trigger for this kidney injury
though it was thought to be due to dehydration in the setting of
the patient's strict adherence to fluid restriction. Patient
denied diarrhea. Improved with IVF and remained normal with only
PO intake. Renal U/S was normal w/ no evidence of obstruction or
renal artery stenosis. He will be discharged on lisinopril 5 mg
PO daily with close follow up with heart failure/PCP to decide
on adding a diuretic. He will also have labs drawn within the
first few days of discharge to monitor kidney function. His
Coumadin was also increased from 6 to 7 mg PO daily w/ a
discharge INR of 2.2.
# Acute on chronic renal failure ___ pre-renal azotemia: Pt
presented on ___ with Cr of 14 thought multifactorial from
increase in lisinopril and poor PO intake. Admission FeUrea 24%,
c/f prerenal etiology. Patient denied diarrhea. Improved with
IVF and holding steady with PO intake. Renal U/S normal w/ no
evidence of obstruction or renal artery stenosis. Will discharge
today with close follow up for Cr. Encouraged him to liberalize
fluid restriction to 3L if he felt like he was exerting himself
and becoming dehydrated while at home.
-Encouraged PO intake
-Continue Lisinopril 5 mg PO daily
-Pt to take diary of fluid intake to be brought to next Heart
Failure appointment
-Close follow up with PCP and heart failure
# HFrEF ___ NICM (EF 15%) s/p BIV ICD: Patient had cardiac
course previously complicated by ICD shocks, VF s/p shock in
___, LV thrombus now on anticoagulation. Patient initially had
medications held in the setting of hypotension, heart failure
consulted s/p laparotomy. Patient does not appear grossly volume
overloaded, thus not decompensated. Held diuretic at time of
discharge but with close heart failure follow up.
-Proload: Held home Torsemide in the setting ___
-Afterload: Continued Lisinopril 5 mg PO daily
-Inotrope: None
-Neurohormonal: Held home Spironolactone
-Continued home Metoprolol Succinate 50 mg PO QDaily
# Atrial Fibrillation: Patient was s/p BIV ICD and paced, with
prior interrogation on ___ without arrhythmia. Patient was
restarted on warfarin for anticoagulation with INR goal ___.
-Continued home rate control: Metoprolol Succinate 50 mg PO
QDaily
-Continued home Amiodarone 300 mg PO
-Coumadin 7 mg PO daily, INR goal ___
-Rate: Metop succ 50mg daily
CHRONIC ISSUES:
# Anemia: Was likely in the setting of post-op, as well as
chronic disease. Patient had been maintaining cardiac perfusion,
with transfusion threshold of > 7, now s/p 2 units with
appropriate increases. No evidence of active bleeding and H/H
remained stable throughout admission.
# Psoriasis:
- ContinueD home Clobetasol
TRANSITIONAL ISSUES:
DISCHARGE WEIGHT: 137.5 kg
DISCHARGE DIURETICS: None
DISCHARGE AFTERLOAD: Lisinopril 5 mg PO/NG DAILY
- Close follow up with Heart Failure at ___ and PCP, ___.
___
- ___ follow up Cr to be checked as outpatient within ___
days
- Please follow up INR for potential changes to Coumadin dosage.
Discharge INR 2.2 (goal ___.
- Discharged on lisinopril 5 mg. No diuretic at time of
discharge. Consider changing heart failure regimen based on
kidney function
- Pt asked to document fluid intake as an outpatient and bring
this to his heart failure appointment for review
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 300 mg PO DAILY
2. Halobetasol Propionate 0.05 % topical BID:PRN
3. Lisinopril 30 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
6. Spironolactone 12.5 mg PO DAILY
7. Warfarin 6 mg PO DAILY16
8. Vitamin D ___ UNIT PO DAILY
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
10. Lidocaine 5% Patch 2 PTCH TD QAM
11. Pantoprazole 40 mg PO Q12H
12. Torsemide 10 mg PO ONCE
Discharge Medications:
1. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Warfarin 7 mg PO DAILY16
RX *warfarin 6 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
RX *warfarin 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea, wheezing
4. Amiodarone 300 mg PO DAILY
5. Halobetasol Propionate 0.05 % topical BID:PRN
6. Lidocaine 5% Patch 2 PTCH TD QAM
7. Metoprolol Succinate XL 50 mg PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
9. Pantoprazole 40 mg PO Q12H
10. Vitamin D ___ UNIT PO DAILY
11.Outpatient Lab Work
Please check a chem 7 and INR for this patient within ___ days
of discharge for follow up of his ___, N17.9, and a-fib
anticoagulation monitoring, I48.1.
Fax the results to ___. ___ with ___ Heart
Failure Team at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Acute kidney injury on chronic kidney disease stage 2
Secondary Diagnoses:
Systolic heart failure
Atrial fibrillation
Normocytic anemia
Psoriasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you. You were hospitalized due
to problems with your kidney function. We believe your kidneys
suffered some temporary damage because you were dehydrated. You
were given fluids, and your kidney function improved quite
quickly. The function then remained stable while you were off IV
fluids and taking in all of your fluid requirements through your
diet.
When you leave the hospital, it is important for you to take
your medications as directed. You should also continue on a
fluid restriction of 2L most days but can take in as much as 3L
on days that you exert yourself quite a bit. It is also
important for you to take a careful diary of your fluid intake
that will be reviewed at your appointment with the heart failure
specialists. Weigh yourself every morning, call MD if weight
goes up more than 3 lbs. You will follow up with your PCP, ___.
___ the heart failure team at ___.
All the best,
Your ___ Care Team
Followup Instructions:
___
|
10320222-DS-14 | 10,320,222 | 24,710,902 | DS | 14 | 2116-03-30 00:00:00 | 2116-03-30 13:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / codeine
Attending: ___.
Chief Complaint:
Hyperglycemia, Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ with PMH of IDDM and Alzhiemer's Disease
presenting with hyperglycemia and dizziness. Per ED ___, the
patient's daughter reports that pt lives with her other daughter
who went out of town yesterday. A caretaker was supposed to come
to administer medications and insulin, but did not show up until
4pm. Pts glucose was >600, she took 24 units of lantus but had
persistent hyperglycemia. Her diabetes regimen also includes
metformin 1000 mg daily, and she recently discontinued victoza
for financial reasons.
Past Medical History:
DM2, poorly controlled, uncomplicated
s/p thyroidectomy with hypothyroid
s/p CCY
Appendectomy
Dementia
s/p cataract surgery
Depression
Social History:
___
Family History:
Sister with breast cancer, diabetes, depression. Father with
depression.
Physical Exam:
Physical Exam on admission:
Vitals- 97.6 151/74 68 100% RA FSBG 196
General: alert, oriented, pleasant, NAD
HEENT: NC/AT, EOMI, sclera anicteric
Neck: supple
CV: RRR, no murmurs, rubs, or gallops
Lungs: CTAB, no wheezes, rales, or rhonchi
Abdomen: soft, NT, ND, bowel sounds present
GU: deferred
Ext: warm and well perfused, no ___ edema
Neuro: CN III-XII intact, MAE
Skin: no rash or lesions
Physical Exam on discharge:
Vitals- 97.2 123/53 91 20 99% RA BG- 183 on renal
General: alert, oriented only to person, not
situation/time/place, pleasant, NAD
HEENT: NC/AT, EOMI, sclera anicteric
Neck: supple
CV: RRR, no murmurs, rubs, or gallops
Lungs: CTAB, no wheezes, rales, or rhonchi
Abdomen: soft, NT, ND, bowel sounds present
GU: no foley
Ext: warm and well perfused, no ___ edema
Neuro: CN III-XII intact, MAE
Skin: no rash or lesions
Pertinent Results:
Labs on admission:
___ 09:45PM BLOOD WBC-6.5 RBC-4.37 Hgb-12.6 Hct-36.0 MCV-82
MCH-28.8 MCHC-35.0 RDW-14.6 RDWSD-42.6 Plt ___
___ 09:45PM BLOOD Glucose-516* UreaN-12 Creat-0.8 Na-131*
K-5.3* Cl-94* HCO3-27 AnGap-15
Imaging Reports
CT Head
FINDINGS:
There is no evidence of acute hemorrhage, pathologic extra-axial
collection,
edema, mass effect, or loss of gray/ white matter
differentiation. Prominent
ventricles and sulci are again seen, indicating age-related
involutional
change. Periventricular white matter hypodensities are
consistent with
chronic small vessel ischemic disease. A small chronic
infarction is again
seen in the left corona radiata.
No osseous abnormalities seen. A right posterior ethmoid air
cell is
opacified. There is minimal mucosal thickening in the superior
right
maxillary sinus. Visualized portions of other paranasal sinuses
and mastoid
air cells are clear.
IMPRESSION:
No evidence for acute intracranial abnormalities.
CXR
FINDINGS:
Heart size is normal. Aortic knob is calcified. Mediastinal
and hilar
contours are normal. Lungs are clear. Pulmonary vasculature is
normal. No
pleural effusion or pneumothorax is present. Moderate anterior
compression
deformity of a mid thoracic vertebral body is of indeterminate
age.
IMPRESSION:
No acute cardiopulmonary abnormality.
Pertinent Labs on D/C
___ 06:20AM BLOOD WBC-4.9 RBC-4.32 Hgb-12.2 Hct-35.9 MCV-83
MCH-28.2 MCHC-34.0 RDW-14.0 RDWSD-42.0 Plt ___
___ 06:20AM BLOOD Glucose-193* UreaN-15 Creat-0.6 Na-140
K-3.6 Cl-102 ___
Brief Hospital Course:
Ms. ___ is an ___ F with a history of DM on insulin and
Alzheimer's Disease/dementia presenting with hyperglycemia in
the setting of missing her insulin regimen and altered mental
status.
# Hyperglycemia
Patient is normally cared for by her daughter, who went on
vacation and ___ nurse was to take over medication
administration for Mrs ___. The ___ nurse showed up later in
the day and the pt missed her normal insulin regimen. She was
given 24 units of lantus at home, and 10 units of regular
insulin in the ED. FSBG have been <200. She received only long
acting insulin while at home which likely accounts for her
persistent hyperglycemia. Her daughter confirmed her regimen of
22U of lantus with breakfast and we continued to monitor FSBG
QID covered with sliding scale insulin.
# AMS
There were reports of confusion while in the ED. However, when
the patient was transferred to the floor she was alert,
oriented, mentating and answering all questions appropriately.
CT Head negative for acute intracranial process. Most likely her
confusion was in the setting of hyperglycemia, change in
location, in the setting of dementia and alzheimer's disease.
Very low concern for DKA given no abd pain and normal anion gap.
On hospital day 2 she was confused about where she was, but
appropriate. C/w her known AD.
# Hypothyroidism
The pt's TSH was checked and was within normal limits, her home
levothyroxine was continued.
TRANSITIONAL ISSUES
# please monitor FSBG
# pt recently discontinued victoza due to insurance coverage
issues. Pls assist with insurance coverage or consider different
choice of medication as appropriate.
# Code Status: Full Code
# Contact Person: Daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO DAILY
2. Memantine 10 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Donepezil 10 mg PO QHS
5. Atorvastatin 10 mg PO QPM
6. Glargine 22 Units Breakfast
7. Senior Probiotic (lactobacillus combination no.4) 15 billion
cell oral DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Donepezil 10 mg PO QHS
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Memantine 10 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO DAILY
6. Senior Probiotic (lactobacillus combination no.4) 15 billion
cell oral DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Glargine 22 Units Breakfast
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Hyperglycemia
SECONDARY DIAGNOSIS
1. Diabetes Mellitus
2. Alzheimer's Disease
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Ms. ___:
It was our pleasure caring for you at ___
___. You were admitted because your blood sugars were
high, and there was concern you may be confused. Your blood
sugars were elevated because your insulin was given later than
usual, and your confusion soon resolved.
Please be sure that your insulin is given at the appropriate
time.
Thank you for choosing ___. We wish you the very best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10320289-DS-19 | 10,320,289 | 27,936,912 | DS | 19 | 2161-06-25 00:00:00 | 2161-06-25 23:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of COPD, CHF, renal infarction on
hemodialysis, chronic aortic thrombosis status post recent
stenting with one-day history of shortness of breath. Around 4
a.m. the patient began to have a strange feeling in his chest
(patient unable to explain, not pain or pressure) and felt
acutely SOB and tachypneic, prompting him to call ___. He was
seen at ___ where he was started on
nitroglycerin and BiPAP with improvement of his symptoms. He
also received ceftriaxone and azithromycin for a COPD
exacerbation. His BNP was 3800. Troponin was 0.066.
EKG in the ED showed LBBB, not meeting Sgarbossa criteria. A
bedside echo showed pericardial effusion, right ventricular EF
adequate without tamponade as well as B lines to the mid lung.
He reports 3 days of subjective fevers, diaphoresis, chills,sore
throat, nausea/vomiting and has recently started having
diarrhea. He received a full dose of HD yesterday.
He currently denies CP, SOB, palpitations, nausea, pedal edema,
lightheadedness.
Past Medical History:
-Chronic abdominal pain of unknown etiology
-Hyperlipidemia
-Non-ischemic cardiomyopathy: dx ___? at ___ with no CAD
-Chronic kidney disease
-Tobacco use
-Hepatitis C infection
Social History:
___
Family History:
No family history of cardiomyopathy or thrombophilia.
Physical Exam:
ADMISSION EXAM:
====================
VS: 136/71 74 20 100% 2L
___: Cachectic and tired-appearing male in NAD
HEENT: NCAT. Sclera anicteric. Conjunctiva noninjected.
NECK: Supple with JVP not elevated
CARDIAC: RRR, no m/r/g
LUNGS: Decreased breath sounds, few wheezes, no crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
DISCHARGE EXAM:
=====================
VS: 98.6 108-138/58-66 55-61 18 98% RA
I/O: 1030/0
Wt: 48.6 kg
___: Cachectic-appearing male, comfortable appearing
HEENT: NCAT. Sclera anicteric. Conjunctiva noninjected.
NECK: Supple with JVP not elevated
CARDIAC: RRR, no m/r/g
LUNGS: Decreased breath sounds, no w/r/r
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
Pertinent Results:
ADMISSION LABS:
===================
___ 08:11AM BLOOD WBC-13.5*# RBC-2.60* Hgb-7.8* Hct-25.5*
MCV-98 MCH-30.0 MCHC-30.6* RDW-16.9* RDWSD-60.6* Plt ___
___ 08:11AM BLOOD Neuts-83.4* Lymphs-7.0* Monos-7.4 Eos-1.0
Baso-0.4 Im ___ AbsNeut-11.27* AbsLymp-0.94* AbsMono-1.00*
AbsEos-0.13 AbsBaso-0.06
___ 08:11AM BLOOD ___ PTT-26.5 ___
___ 08:11AM BLOOD Glucose-114* UreaN-18 Creat-4.3* Na-135
K-4.9 Cl-96 HCO3-27 AnGap-17
___ 08:11AM BLOOD proBNP-GREATER TH
___ 01:07PM BLOOD Calcium-7.9* Phos-2.4* Mg-1.8
___ 10:45PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
PERTINENT LABS:
===================
___ 05:45AM BLOOD ALT-11 AST-20 CK(CPK)-32* AlkPhos-141*
TotBili-0.3
___ 05:45AM BLOOD CK-MB-2 cTropnT-0.10*
___ 07:14AM BLOOD Lactate-1.2
DISCHARGE LABS:
===================
___ 06:12AM BLOOD WBC-7.3 RBC-2.65* Hgb-7.9* Hct-25.8*
MCV-97 MCH-29.8 MCHC-30.6* RDW-16.1* RDWSD-56.7* Plt ___
___ 03:53AM BLOOD ___ PTT-42.2* ___
___ 06:12AM BLOOD Glucose-109* UreaN-38* Creat-7.7*# Na-134
K-4.6 Cl-97 HCO3-28 AnGap-14
___ 06:12AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.2
MICROBIOLOGY:
===================
___ Blood cultures x2: NGTD
IMAGING:
===================
___ Chest X ray: Unchanged small bilateral pleural effusions
with worsening bibasilar airspace opacities, potentially
atelectasis. Infection, however, cannot be excluded.
___ CTA chest:
1. No evidence of pulmonary embolism or thoracic aortic
abnormality.
2. Stable small pericardial effusion
3. Bilateral lower lobe and right middle lobe consolidations
likely reflecting infection or aspiration.
4. Stable bilateral nonhemorrhagic pleural effusions.
5. Unchanged thrombus within the descending aorta at the level
of the
diaphragmatic hiatus status post placement of a retrograde stent
which appears to opacified a centrally.
___ TTE:
Overall left ventricular systolic function is severely depressed
(LVEF = 20 %) secondary to marked intraventricular dyssynchrony
with a left bundle branch block activation sequence. The patient
meets modified CARE-HF criteria for ventricular dyssynchrony,
and may benefit from resynchronization therapy. Right
ventricular chamber size and free wall motion are normal. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___
the findings are similar. Marked left ventricular dyssynchrony
is again present.
___ Chest X ray:
New consolidation left lower lobe, pneumonia until proved
otherwise.
Pulmonary edema has been a recurrent finding since ___.
It developed between ___ and ___,
subsequently stable. Severe hyperinflation attributed to COPD.
PLEURAL EFFUSIONS ARE SMALL, NOT NECESSARILY CHANGED. MILD TO
MODERATE CARDIOMEGALY IS LONG-STANDING. DUAL CHANNEL RIGHT
CENTRAL VENOUS CATHETER ENDS IN THE LOW SVC
Brief Hospital Course:
___ is a ___ with a history of COPD, CHF, renal
infarction on hemodialysis, and chronic aortic thrombosis status
post recent stenting who presented with worsening dyspnea.
# Dyspnea: Mr. ___ had CTA negative for PE but findings were
concerning for pneumonia so he was treated for HCAP given his
status as a HD patient. He received vanc/cefepime x1 then was
transitioned to levofloxacin. A CHF exacerbation was thought to
be less likely as he had no evidence of volume overload on
clinical exam of imaging. He had an acute episode of
desaturation to the ___ with an ABG showing hypoxia without CO2
retention, arguing against COPD as the predominant mechanism of
his dyspnea. His breathing improved on antibiotics and he was
weaned off NC.
# H/o thrombosis: He has a history of aortic thrombosis but had
a subtherapeutic INR on admission, so the decision was made to
bridge him with heparin. Of note, he was reported to have a
history of HIT but had a documented negative serotonin release
assay, so after discussion with pharmacy, heparin was started.
However, his INR remained low and he wished to leave the
hospital without bridging. The risks of leaving with a
subtherapeutic INR, including organ injury, limb loss, stroke,
and death were explained to him and he expressed understanding.
He chose to leave the hospital against medical advice.
# CHF: Mr. ___ has a history of systolic heart failure with
an EF 20% on TTE from ___. The etiology of his heart failure
is unknown. He had no clinical evidence of decompensation during
this admission. Fluid status was maintained via HD. He was
continued on carvedilol and aspirin.
# COPD: He has a history of COPD so due to his dyspnea was put
on standing duonebs q6h.
# Renal failure: Secondary to renal infarct. On HD ___.
Continued on sevelamer and nephrocaps.
# HCV: Patient HCV positive. Followed by liver with plan to
potentially initiate treatment ___.
Transitional issues:
- patient discharged AMA with subtherapeutic INR (INR 1.2 on day
of discharge); he should follow closely to raise his INR to
therapeutic range (his warfarin is managed at his ___
clinic)
- discharged on 3 mg warfarin; INR 1.2 on ___
- patient discharged on carvedilol 25 mg BID, lisinopril 5 mg;
his Imdur 10 mg TID is being held due to concern for low BP
- patient interested in smoking cessation - wellbutrin has
worked well for him in the past and could be considered but is
renally cleared; he was discharged with nicotine patches
- patient returning ___ for fistula placement
- CODE: full code, confirmed
- CONTACT: ___ (daughter, HCP): ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Isosorbide Dinitrate 10 mg PO TID
5. Nephrocaps 1 CAP PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. Warfarin 0.5 mg PO DAILY16
9. Omeprazole 20 mg PO BID
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Docusate Sodium 100 mg PO BID
12. Acetaminophen 650 mg PO Q8H:PRN pain
13. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Citalopram 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Nephrocaps 1 CAP PO DAILY
7. Omeprazole 20 mg PO BID
8. sevelamer CARBONATE 1600 mg PO TID W/MEALS
9. Warfarin 3 mg PO ONCE Duration: 1 Dose
RX *warfarin 1 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
12. Calcitriol 0.25 mcg PO EVERY OTHER DAY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth Every other day
Disp #*15 Capsule Refills:*0
13. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
14. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
15. Nicotine Patch 14 mg TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour Apply one patch per 24
hour period to clean, dry, intact skin daily Disp #*21 Patch
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Pneumonia
chronic diastolic heart failure
Arterial thrombosis
Chronic obstructive pulmonary disease
Secondary diagnosis:
Hypertension
Coronary artery disease
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 ___
because you were having difficulty breathing. You likely had a
pneumonia causing your symptoms. You were given antibiotics and
your breathing improved.
You also are known to have blood clots in the major artery in
your body, called the aorta. For this reason, you have been on a
medication, called warfarin, that thins the blood to prevent
future clots. Blood tests showed that your levels of warfarin
were not high enough to prevent blood clots from forming. For
this reason, we recommended that you stay in the hospital to
receive an IV blood thinner called heparin until your warfarin
levels were high enough to prevent clots from forming. You chose
to leave the hospital against medical advice. We explained that
by leaving, you are at risk of clots forming which can cause
organ damage, loss of limbs, stroke, or death. You expressed
understanding of this as well as of the fact that it is our
recommendation that you stay in the hospital to continue
receiving treatment. However, you wished to leave despite the
risks and against our recommendations.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ team
Followup Instructions:
___
|
10320861-DS-13 | 10,320,861 | 20,458,450 | DS | 13 | 2121-03-03 00:00:00 | 2121-03-04 22:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aldactone / senna
Attending: ___.
Chief Complaint:
L1 Fracture with severe back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ M with history of hypercoagulable state
chronically on anticoagulation, currently on liver transplant
list for portal vein thrombosis and non-cirrhotic pulmonary
hypertension c/b ascites and esophageal varices who presented to
the ED with back pain/L1 compression fracture after a boating
accident. Patient was on vacation last week when he sufferred a
boating accident in which the boat dropped at least four feet in
the water. He landed hard on his seat and immediately started
noticing back pain for which he self medicated by increasing
Oxycontin to TID from BID. He has been able to walk, however, is
having significant pain with any change in position and was
feeling some numbness and tingling in his right leg and foot.
Patient presented to ___ clinic for back pain and an MRI
was prescribed, MRI on ___ showed an L1 burst wedge
compression fracture with no retropulsion or spinal cord
impingement. Outpatient urgent neurosurgery appointment was
attempted but unable so patient sent to ED for evaluation and
treatment.
In the ED, initial VS were: 8 98.2 62 ___ 100% RA.
Neurologic exam with ___ strength bilateral ___ with normal
sensation to soft touch and 2 point discrimination. Patellar and
Achilles reflexes 2+ bilaterally. Babinski not tolerated. Gait
normal with negative Romberg. Spine was consulted who felt: "No
sensorimotor defecit, isolated L1 burst fracture. Please obtain
weight-bearing AP and lateral spine x-rays, admit to medicine,
fit for TLSO brace x10 weeks and follow up with neurosurgery as
outpatient. Discussed with Dr. ___
VS prior to transfer were: 97.9 po, 57, 96/60, 16, 99% RA
On arrival to the floor, patient is comfortable, in only
tolerable back pain without focal neurologic deficits.
Past Medical History:
1. L-sided CVA ___
2. hypercoagulable d/o (unclear etiology)
3. lung/liver granulomas
4. DVTs/PEs
5. Portal & meseneteric vein thrombus
6. Portal hypertension, listed for liver transplant
7. s/p TIPS ___
8. s/p LL lobectomy for granulomas ___
9. s/p jaw surgery
___. s/p exploratory Laparotomy (___) ___ for
intra-abdominal hemorrhage after paracentesis.
Social History:
___
Family History:
sister DVT and stroke in ___
Physical Exam:
ADMISSION:
VITALS: W93.3kg 97.8 105/66 57 18 99%RA
GENERAL: Well appearing, pleasant ___ M who appears comfortable
in NAD.
HEENT: PERRL, EOMI, NCAT
NECK: no carotid bruits, no JVD
LUNGS: CTAB, moving air well and symmetrically
HEART: RRR, S1 S2 clear and good quality, no MRG
ABDOMEN: midline surgical scar is well healed. Abdomen
non-distended, soft, tender to palpation over right side but
chronic per patient, NABS, no HSM. Tympanic to percussion
without appreciable ascites on exam.
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, ___ strenght bilateral ___, full sensation
bilateral ___, 2+ reflexes bilateral ___
D/C:
VITALS: 97.5(afebrile since admission), 108/57(90-105/50-60),
___ 18 99%RA
GENERAL: Well appearing, pleasant ___ caucasian M who appears
comfortable in NAD.
HEENT: MMM, PERRL, EOMI,
NECK: supple, no JVD
LUNGS: CTAB, moving air well and symmetrically
HEART: RRR, S1 S2 clear and good quality, no MRG
ABDOMEN: midline surgical scar is well healed. Abdomen
non-distended, soft, tender to palpation over right side but
chronic per patient, NABS, no HSM. Tympanic to percussion
without appreciable ascites on exam.
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, ___ strenght bilateral ___, full sensation
bilateral ___, 2+ reflexes bilateral ___
Pertinent Results:
ADMISSION:
___ 10:10PM BLOOD WBC-2.8* RBC-4.33* Hgb-13.1* Hct-37.9*
MCV-88 MCH-30.3 MCHC-34.6 RDW-13.6 Plt Ct-64*
___ 10:10PM BLOOD ___ PTT-43.0* ___
___ 10:10PM BLOOD Glucose-88 UreaN-17 Creat-1.0 Na-139
K-3.0* Cl-96 HCO3-35* AnGap-11
D/C:
___ 05:40AM BLOOD WBC-2.1* RBC-4.07* Hgb-12.3* Hct-35.1*
MCV-86 MCH-30.1 MCHC-34.9 RDW-13.6 Plt Ct-56*
___ 05:40AM BLOOD Plt Ct-56*
___ 05:40AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-138
K-3.0* Cl-98 HCO3-33* AnGap-10
STUDIES:
L SPINE XR
IMPRESSION:
1. Anterior wedge compression fracture at L1 with loss of ~40%
vertebral body
height anteriorly. Direct comparison to MRI is limited by
differences between
the 2 modalities.
2. Remaining lspine vertebral bodies preserved in height.
L SPINE MRI
IMPRESSION: Acute-to-subacute wedge compression deformity of L1
without
retropulsion or abnormalities in cord signal.
Brief Hospital Course:
___ yo M presents to the ED with L1 burst compression fracture
diagnosed by outpatient MRI. Has PMH of non-cirrhotic portal
hypertension ___ portal vein thrombosis complicated by
esophageal varices and ascites, hypercoagulable chronically
anticoagulated.
# T1 Fracute: T1 compression fracture likely from recent boating
accident (~3 weeks prior to arrival). Seen by neurosurgery and
orthopoedics in the ED who recommended admission to medicine for
pain control and TLSO brace. Patient without focal neurologic
deficits on admission and with normal gait limited by pain. MRI
also reassuring without acute cord compression or compromise.
On day two of the admission the patient had a weight bearing
LSpine that did not show concerning signs. Neurosurgery
recommended a TLSO brace and an outpatient follow up. The TLSO
brace was fitted and the patient was given instruction on use by
___. The patient's pain was controlled with oxycodone and
morphine. The patient has a follow-up appt planned with
Neurosurgery in 6 weeks. On day of discharge the patient could
ambulate with the TLSO brace. On day of discharge the patient
tolerated a full diet, moving bowels and urinating with
problems, was afebrile, and had well controlled pain.
# Chronic Portal Hypertension: Chronic, stable. No ascites, ___
or weight gain to suggest diuretic refractory ascites.
Non-cirrhotic portal hypertension active on liver transplant
list, s/p TIPS, likely related to portal vein thrombosis ___
chronic hypercoagulable state. Portal hypertension also
complicated by ascites which is well controlled with diuretics
and also history of grade III varices without history of
variceal bleed currently on nadolol. The patient's home
medications were continued.
# Hypercoagulable state: Chronic, anticoagulated complicated by
Noncirrhotic portal hypertension ___ portal venous thrombosis,
also with SMV, splenic vein thrombosis and CVA in ___. The
patient's home warfarin regiment was continued as below:
- Warfarin 7.5 mg PO 3X/WEEK (___)
- Warfarin 7 mg PO 4X/WEEK (___)
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amiloride HCl 10 mg PO DAILY
Hold for SBP<100
2. Furosemide 160 mg PO DAILY
Hold for SBP<100
3. Metolazone 2.5 mg PO 2X/WEEK (___)
Hold for SBP<100
4. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
Hold for sedation or RR<12
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K >5
7. Warfarin 7.5 mg PO 3X/WEEK (___)
8. Warfarin 7 mg PO 4X/WEEK (___)
9. Docusate Sodium 100 mg PO BID
10. Nadolol 20 mg PO DAILY
Hold for SBP<100 or HR<60
Discharge Medications:
1. Amiloride HCl 10 mg PO DAILY
Hold for SBP<90
2. Docusate Sodium 100 mg PO BID
3. Furosemide 160 mg PO DAILY
Hold for SBP<100
4. Metolazone 2.5 mg PO 2X/WEEK (___)
Hold for SBP<100
5. Nadolol 20 mg PO DAILY
Hold for SBP<100 or HR<60
6. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
Hold for sedation or RR<12
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Warfarin 7.5 mg PO 3X/WEEK (___)
9. Warfarin 7 mg PO 4X/WEEK (___)
10. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
11. Acetaminophen 325-650 mg PO Q6H:PRN Pain or fever
Not to exceed 3 grams per day
RX *acetaminophen 500 mg 1 tablet(s) by mouth every six hours
Disp #*60 Tablet Refills:*0
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
hold for sedation, RR<12
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L1 Vertebral fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you at the ___
___. You were admitted for an L1 fracture
confirmed by MRI. In the hospital you were examined by
Neurosurgery and Orthopoedic surgery. They recommended a
Thoraco-Lumbar Sacral Orthosis (TLSO) Brace. The brace was
placed and fitted. Physical therapy discussed with you the
appropriate use of the brace after discharge. Nursurgery would
like you to follow up in 6 weeks. Prior to the appointment with
neurosurgery, you will need to do a CT scan. All follow up
appointments including CT scan have been made for you, please
find time/location below.
Please continue your home medication as before.
No changes were made to your medications.
Followup Instructions:
___
|
10320861-DS-17 | 10,320,861 | 20,256,730 | DS | 17 | 2126-06-21 00:00:00 | 2126-06-23 21:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aldactone / senna / CytoGam
Attending: ___.
Chief Complaint:
fatigue, nausea
Major Surgical or Invasive Procedure:
EGD (___)
History of Present Illness:
___ year old male with PMHx PVT on lovenox s/p liver, pancreas,
small bowel transplant ___ in ___ on tacro/cellcept who is
presenting with lethargy and nausea progressively worsening over
the past two weeks. He states that he is compliant with
transplant medications. He endorses intermittent dry heaves, but
denies vomiting and has been able to tolerate his medications.
He
denies fevers, chills, chest pain, cough, SOB, abdominal pain,
v/d. He has had decreased PO intake over the past few weeks and
nothing to eat or drink today.
Recently has not been taking prednisone 5mg due to issues with
getting it refilled. Additionally his ID doctor at ___
discontinued his valcyte ppx in ___, as he has had
negative
CMV for the past 6 months.
At baseline, alternates nighttime tube feeds and IV fluids
everyday. Also tries to eat 1 meal a day. Complaining of fatigue
& nausea for past 2 weeks. At some nights he has been unable to
finish his tube feeds.
In the ED, initial VS were: 97.6 62 129/77 18 98% RA
Exam notable for:
RRR. CTAB. NTND abd, healed surgical scar, g tube site without
erythema or drainage. No c/c/e. Sleepy but arousable. Appears
very uncomfortable.
Labs showed:
10.8>9.3/31.8<344
136 99 18 AGap=14
------------<86
5.7 23 2.3
LFTs, INR wnl
Lactate 1.3
Whole blood K: 5.1
Imaging showed:
RUQ U/S:
1. Patent hepatic vasculature with appropriate waveforms.
2. Dilated common hepatic duct, measuring 1.2 cm, and
intrahepatic biliary
dilatation.
3. Left pleural effusion
CT head: No acute intracranial process.
CXR: Decrease in size of left pleural effusion. No focal
consolidation worrisome for pneumonia.
Patient received: 1L NS, dilaudid 4mg PO, tacro 2mg, loperamide
2mg
Hepatology was consulted: "Infectious workup, RUQUS, admit to
ET"
Transfer VS were: AF 64 135/89 18 100% RA
On arrival to the floor, patient reports feeling a little
nauseous, but no vomiting. He denies any fevers, chills, SOB,
chest pain, cough, sore throat, rhinorrhea, sick contacts,
abdominal pain, odynophagia, dysuria. Diarrhea at his baseline,
not worse than usual.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
-L-sided CVA ___
-hypercoagulable d/o (unclear etiology. Extensive workup has
been unrevealing)
-lung/liver granulomas
-DVTs/PEs - ___
-Portal & meseneteric vein thrombus
-s/p TIPS ___, revision ___
-s/p LL lobectomy for granulomas ___
-s/p exploratory Laparotomy (___) ___ for
intra-abdominal hemorrhage after paracentesis.
-s/p splenectomy
-Nodular regenerative hyperplasia
-Osteoporosis
-S/p liver/small intestine/pancreas transplant in ___ at
___
-___
-Left pleural effusion, s/p thoracentesis ___
-CMV infection, viral loads negative since ___
-Serratia infection - peritoneal fluid w/ Serratia Marcescens
on ___, carbapenem intermediate/resistant. Hematoma
___ w/ S. marcescens, cipro resistant.
-Hx MAC bacteremia s/p 9 months imipenem, tigecycline, amikacin
-Amikacin induced hearing loss
Social History:
___
Family History:
-Sister has hypercoagulable state (antiphospholipid syndrome)-
had stroke at age ___- also history of miscarriages
-Sister vaginal cancer
-Mother had TIA and has APS
-Maternal uncles- MI's in ___
-Father: ___, MI, prothrombin deficiency
-No family history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: AF 120/76 60 16 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: no LAD, R-sided tunneled line c/d/I
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Surgical scars well healed. Soft, nontender,
nondistended. J tube c/d/i
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
GENERAL: pleasant middle-aged man, lying down in bed, appears
comfortable and in no acute distress
HEENT: AT/NC, EOMI, anicteric sclera, slightly pale conjunctiva,
MMM. Bilateral hearing aids in place
NECK: R-sided tunneled line c/d/i
HEART: RRR, normal S1/S2, no murmurs, gallops, thrills, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Surgical scars well healed. Soft, nontender,
nondistended. J tube c/d/i. Normal bowel sounds.
EXTREMITIES: warm and well-perfused, no cyanosis, clubbing, or
lower extremity edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: no excoriations or lesions, no rashes
Pertinent Results:
ADMISSION LABS
___ 03:35PM BLOOD WBC-10.8* RBC-3.73* Hgb-9.6* Hct-31.8*
MCV-85 MCH-25.7* MCHC-30.2* RDW-15.5 RDWSD-48.5* Plt ___
___ 03:35PM BLOOD Neuts-43.8 ___ Monos-15.8*
Eos-3.4 Baso-0.6 Im ___ AbsNeut-4.72 AbsLymp-3.89*
AbsMono-1.71* AbsEos-0.37 AbsBaso-0.07
___ 04:01PM BLOOD ___ PTT-31.8 ___
___ 03:35PM BLOOD Glucose-86 UreaN-18 Creat-2.3* Na-136
K-5.7* Cl-99 HCO3-23 AnGap-14
___ 03:35PM BLOOD ALT-17 AST-31 AlkPhos-111 TotBili-0.3
___ 03:35PM BLOOD Lipase-18
___ 03:35PM BLOOD Albumin-3.5 Calcium-9.4 Phos-4.1 Mg-1.8
___ 03:35PM BLOOD tacroFK-8.3
___ 03:53PM BLOOD Lactate-1.3 K-5.1
PERTINENT LABS
___ 02:21AM BLOOD WBC-11.0* RBC-3.35* Hgb-8.6* Hct-28.8*
MCV-86 MCH-25.7* MCHC-29.9* RDW-15.5 RDWSD-48.9* Plt ___
___ 02:59PM BLOOD Glucose-101* UreaN-17 Creat-1.9* Na-134*
K-5.4* Cl-100 HCO3-23 AnGap-11
___ 02:21AM BLOOD Glucose-128* UreaN-15 Creat-1.8* Na-140
K-4.7 Cl-105 HCO3-24 AnGap-11
___ 02:38AM BLOOD Glucose-112* UreaN-12 Creat-1.6* Na-140
K-4.6 Cl-107 HCO3-25 AnGap-8*
___ 06:30AM BLOOD TotProt-6.7 Calcium-8.7 Phos-4.0 Mg-1.5*
Iron-41* Cholest-115
___ 06:30AM BLOOD calTIBC-345 VitB12-351 Ferritn-27*
TRF-265
___ 06:30AM BLOOD Triglyc-59 HDL-43 CHOL/HD-2.7 LDLcalc-60
___ 06:30AM BLOOD TSH-0.06*
___ 06:30AM BLOOD Free T4-1.6
___ 06:30AM BLOOD Cortsol-3.3 25VitD-31
DISCHARGE LABS
___ 02:25AM BLOOD WBC-12.2* RBC-3.23* Hgb-8.4* Hct-27.8*
MCV-86 MCH-26.0 MCHC-30.2* RDW-15.9* RDWSD-50.1* Plt ___
___ 03:35AM BLOOD ___ PTT-115.0* ___
___ 02:25AM BLOOD Glucose-91 UreaN-11 Creat-1.6* Na-142
K-4.7 Cl-108 HCO3-24 AnGap-10
___ 02:25AM BLOOD ALT-11 AST-20 AlkPhos-90 TotBili-0.2
___ 02:25AM BLOOD Albumin-3.2* Calcium-8.9 Phos-3.6 Mg-2.1
IMAGING/STUDIES
CXR (___)- Decrease in size of left pleural effusion. No
focal consolidation worrisome for pneumonia.
NCHCT (___)- No acute intracranial process.
RUQUS (___)- 1. Patent hepatic vasculature with appropriate
waveforms.
2. Dilated common hepatic duct, measuring 1.2 cm, without
intrahepatic
biliary dilatation.
3. Left pleural effusion.
Brief Hospital Course:
Mr. ___ is a ___ year-old man with a history of
hypercoagulable disorder with chronic thrombosis of portal
vein/SMV/splenic vein resulting in portal
hypertension/cirrhosis, PE/DVT/splenectomy now s/p
liver/pancreas/small intestine transplant ___ at ___, who
presented with fatigue and nausea in the setting of not having
prednisone.
ACUTE ISSUES
# Malnutrition
# Fatigue
# Nausea: Unclear etiology. Patient was noted to have not been
taking prednisone for 3 weeks prior to admission in setting of
prescription issue. LFTs were stable so less likely acute liver
rejection. AM cortisol on the low end of normal, so possible
that patient has underlying adrenal insufficiency in setting of
stopping prednisone x 3 weeks. Patient was restarted on
prednisone with subsequent improvement of symptoms. Patient was
also noted to be iron deficient, which may contribute to
fatigue. CMV less likely given lack of diarrhea, though had been
recently taken off of prophylaxis. Also possible that patient
had underlying viral illness, though had no localizing symptoms.
EGD was done on ___ to rule out small bowel rejection and
showed gastritis and ___ cords of grade 1 varices. RUQ U/S
unrevealing. B12 normal. Low vitamin D. TSH 0.06, however FT4
normal. Patient received pred 10mg x 2 days, then pred 5mg daily
(home dose). Also received IV ferric gluconate x 2. Patient felt
significantly improved on day of discharge, with more energy and
less fatigue.
___ on CKD: ___ likely prerenal secondary to poor PO intake.
CKD most likely related to amikacin toxicity and multiple
insults from hypovolemia and vasoconstriction from tacrolimus.
Now improved to near baseline after IV fluids.
CHRONIC ISSUES
#Liver, pancreas, small intestine transplant ___: Secondary to
chronic PVT resulting in portal hypertension/cirrhosis.
Maintained on tacro+MMF+prednisone.
#PVT: Hx of hypercoaguable disorder (workup done at ___, see
last d/c summary) on Lovenox. Plan as outpatient to consider
transitioning to oral agent. Was maintained on heparin gtt as
inpatient as a result of ___. Discharged on home Lovenox.
TRANSITIONAL ISSUES
[] can consider switching back to Coumadin as per hematology and
hepatology outpatient discussions
[] restarted on increased frequency tube feeds by nutrition -
daily.
[] ensure that patient has enough immunosuppressants, as patient
ran out of prednisone in the setting of prescription issue -
counseled extensively
[] home immunosuppression regimen: pred 5mg daily, tacro 2mg
Q8H, MMF 250mg BID
[] discharge Cr: 1.6
[] Consider continuation of scheduled IV iron transfusions as an
outpatient for iron deficiency anemia
[] follow up EGD pathology
[] follow up H.pylori
[] CMV VL - uninterpretable - will need to be resent again
[] f/u FINAL SPEP/UPEP
[] Continue home Lovenox 60mg daily (for DVT ppx)
[] Tacro goal ___. Was 4.2 on discharge, however had been at
goal for several days, so no changes were made. Please recheck
within ___ weeks
[] Omeprazole increased to 40mg BID x 6 weeks for gastritis.
Should wean down to daily after this.
#CODE: FULL CODE (confirmed)
#CONTACT: ___, sister ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Fentanyl Patch 125 mcg/h TD Q72H
3. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
4. Magnesium Oxide 400 mg PO BID
5. Metoprolol Tartrate 25 mg PO BID
6. Mirtazapine 15 mg PO QHS
7. Mycophenolate Mofetil 250 mg PO BID
8. Omeprazole 40 mg PO DAILY
9. LOPERamide 4 mg PO QID:PRN constipation
10. PredniSONE 5 mg PO DAILY
11. Tacrolimus 2 mg PO Q8H
12. Ondansetron 4 mg PO DAILY:PRN nausea
13. Enoxaparin Sodium 60 mg SC QHS
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Vitamin D ___ UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Enoxaparin Sodium 60 mg SC QHS
5. Fentanyl Patch 125 mcg/h TD Q72H
6. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
7. LOPERamide 4 mg PO QID:PRN constipation
8. Magnesium Oxide 400 mg PO BID
9. Metoprolol Tartrate 25 mg PO BID
10. Mirtazapine 15 mg PO QHS
11. Mycophenolate Mofetil 250 mg PO BID
12. Ondansetron 4 mg PO DAILY:PRN nausea
13. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
14. Tacrolimus 2 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Adrenal insufficiency
Iron deficiency anemia
Malnutrition
Acute kidney injury
Secondary:
Hypercoagulable disorder
s/p liver, pancreas, and small bowel transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were feeling tired and nauseous
- Your labs showed that your kidneys were not working as well as
they usually do
What was done while I was in the hospital?
- You were given fluids, which improved your kidney function
back to your baseline
- You were restarted on prednisone, as you did not have any back
at home
- You had an endoscopy that showed inflammation in your stomach,
and also small varices.
What should I do when I get home from the hospital?
- Please take all of your medications as prescribed, especially
your immunosuppressants to prevent rejection of your transplant
- Make sure to follow your new tube feed instructions from the
nutritionists
- Be sure to go to your follow-up appointments with your primary
care doctor and your liver doctor
- If you have fevers, chills, worsening nausea, vomiting, or
generally feel unwell, please call your doctor or go to the
emergency room
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10320861-DS-19 | 10,320,861 | 20,291,227 | DS | 19 | 2127-01-07 00:00:00 | 2127-01-09 12:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aldactone / senna / CytoGam
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
This is a ___ year-old man with complicated PMH including
hypercoagulable state of unknown etiology with chronic
thrombosis of portal vein/SMV/splenic vein resulting in portal
hypertension (currently on Lovenox) and cirrhosis now s/p
liver/pancreas/small intestine transplant ___ at ___, on
tacrolimus, mycophenolate, prednisone), as well as
PE/DVT/splenectomy, congenital cystic adenomatoid malformation
s/p LLL in ___, and CKD stage III who presents with fevers,
chills, and altered mental status.
According to the patient's daughter, who is his primary
caretaker, the patient was in his usual state of health prior to
yesterday evening. She describes that, at baseline, he is
independent in ADLs, able to take his own medications and set up
his own tube feedings, walking, alert. She notes chronic
abdominal pain for which the patient is on a fentanyl patch as
well as PO dilaudid. He breathes "a little fast" at baseline
which she notes has been the case since he underwent LLL
resection in ___.
Yesterday evening, the patient's daughter returned home at 1 AM
and found the patient curled up in the fetal position in bed.
She noted that his breathing was faster than it is usually and
he was talking slower than normal. The patient has baseline
difficulty hearing. The patient endorsed chills at that time but
his daughter felt that he was very warm to touch. The patient
was otherwise alert and fully oriented. He had no headache,
abnormal movements (other than baseline tremulousness),
urinary/bowel incontinence, diplopia, trouble seeing, chest
pain, or palpitations.
Past Medical History:
- L-sided CVA ___
- Hypercoagulable d/o (unclear etiology. Extensive workup has
been unrevealing)
- Lung/liver granulomas
- DVTs/PEs - ___
- Portal & meseneteric vein thrombus
- S/p TIPS ___, revision ___
- S/p LL lobectomy for granulomas ___
- S/p exploratory Laparotomy (___) ___ for
intra-abdominal hemorrhage after paracentesis.
- S/p splenectomy
- Nodular regenerative hyperplasia
- Osteoporosis
- S/p liver/small intestine/pancreas transplant in ___ at
___
- MGUS
- Left pleural effusion, s/p thoracentesis ___
- CMV infection, viral loads negative since ___
- Serratia infection - peritoneal fluid w/ Serratia Marcescens
on ___, carbapenem intermediate/resistant. Hematoma
___ w/ S. marcescens, cipro resistant.
- Hx MAC bacteremia s/p 9 months imipenem, tigecycline, amikacin
Social History:
___
Family History:
- Sister has hypercoagulable state (antiphospholipid syndrome):
had stroke at age ___, also history of miscarriages
- Sister vaginal cancer
- Mother had TIA and has APS
- Maternal uncles, MI's in ___
- Father: sarcoidosis, MI, prothrombin deficiency
- No family history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS:98.9, BP 127 / 79, HR 60, RR 18, O2 98 Ra
GENERAL: Sitting up in bed, bent forward and holding his abdomen
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs. Right chest
hickman catheter present
LUNGS: CTAB, no wheezes,
ABDOMEN: soft, flat, abdominal surgical scar present, J-tube is
located in ___ abdomen, moderate tenderness to palpation
diffusely
EXTREMITIES: no cyanosis, clubbing, or edema. no lower extremity
rashes
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, speaks softly, moves all extremities with purpose,
sensation intact to light touch
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0724 Temp: 98.3 PO BP: 137/79 HR: 63 RR: 18 O2 sat:
100% O2 delivery: RA
GENERAL: Well-appearing, laying in bed, in NAD
HEENT: AT/NC, EOMI, MMM
HEART: RRR, normal S1/S2, no m/r/g. Right chest hickman catheter
present
LUNGS: CTAB, no wheezes/rhonci/rales
ABDOMEN: Non-distended, well-healed surgical incision, active
bowel sounds, J-tube in ___ abdomen without erythema or
drainage, soft, TTP in LUQ
EXTREMITIES: No c/c/e
NEURO: Alert/oriented, moving all extremities with purpose, no
asterixis
Pertinent Results:
ADMISSION LABS:
===============
___ 03:40PM IRON-19*
___ 03:40PM calTIBC-491* VIT B12-318 FOLATE->20
FERRITIN-9.6* TRF-378*
___ 03:40PM TSH-2.2
___ 03:40PM CMV VL-NOT DETECT
___ 10:12AM URINE HOURS-RANDOM
___ 10:12AM URINE UHOLD-HOLD
___ 10:12AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:12AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 05:26AM ___ PO2-30* PCO2-53* PH-7.40 TOTAL
CO2-34* BASE XS-5
___ 05:26AM LACTATE-0.9
___ 05:23AM GLUCOSE-87 UREA N-29* CREAT-1.9* SODIUM-137
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-12
___ 05:23AM estGFR-Using this
___ 05:23AM ALT(SGPT)-15 AST(SGOT)-23 LD(LDH)-180 ALK
PHOS-56 TOT BILI-0.2
___ 05:23AM LIPASE-16
___ 05:23AM ALBUMIN-3.9 CALCIUM-9.4 PHOSPHATE-3.5
MAGNESIUM-1.9
___ 05:23AM WBC-13.5* RBC-3.59* HGB-7.9* HCT-27.1*
MCV-76* MCH-22.0* MCHC-29.2* RDW-17.2* RDWSD-46.5*
___ 05:23AM NEUTS-47.1 ___ MONOS-10.3 EOS-2.4
BASOS-0.4 IM ___ AbsNeut-6.35* AbsLymp-5.32* AbsMono-1.38*
AbsEos-0.32 AbsBaso-0.05
___ 05:23AM HYPOCHROM-2+* ANISOCYT-NORMAL POIKILOCY-1+*
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL ACANTHOCY-1+*
___ 05:23AM PLT SMR-NORMAL PLT COUNT-432*
___ 05:23AM ___ PTT-34.3 ___
DISHARGE LABS:
=============
___ 04:55AM BLOOD WBC-9.6 RBC-3.69* Hgb-8.1* Hct-28.2*
MCV-76* MCH-22.0* MCHC-28.7* RDW-17.7* RDWSD-48.8* Plt ___
___ 04:55AM BLOOD Plt ___
___ 04:55AM BLOOD ___ PTT-30.3 ___
___ 04:55AM BLOOD Glucose-101* UreaN-13 Creat-1.9* Na-141
K-3.7 Cl-107 HCO3-24 AnGap-11
___ 04:55AM BLOOD ALT-12 AST-19 AlkPhos-46 TotBili-0.2
___ 04:55AM BLOOD Albumin-3.6 Calcium-8.7 Phos-4.0 Mg-1.7
MICROBIOLOGY:
==============
__________________________________________________________
___ 2:09 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
CANCELLED. PATIENT HAS BEEN HOSPITALIZED FOR >3 DAYS.
PATIENT CREDITED.
__________________________________________________________
___ 2:09 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
VIRAL CULTURE (Pending):
__________________________________________________________
___ 3:45 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
VIRAL CULTURE (Preliminary): RESULTS PENDING.
__________________________________________________________
___ 3:45 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
CANCELLED. PATIENT HAS BEEN HOSPITALIZED FOR >3 DAYS.
PATIENT CREDITED.
__________________________________________________________
___ 10:11 pm Rapid Respiratory Viral Screen & Culture
NASOPHARYNGEAL SWAB.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inadequate specimen for respiratory viral culture.
PLEASE SUBMIT ANOTHER SPECIMEN.
Respiratory Viral Antigen Screen (Final ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___ AT 14:52
ON
___.
__________________________________________________________
___ 6:35 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-___.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
__________________________________________________________
___ 5:25 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inadequate specimen for respiratory viral culture.
PLEASE SUBMIT ANOTHER SPECIMEN.
Respiratory Viral Antigen Screen (Final ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___.
__________________________________________________________
___ 12:00 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
__________________________________________________________
___ 12:12 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
__________________________________________________________
___ 6:02 pm BLOOD CULTURE Source: Line-hickman.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:12 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 5:15 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 5:21 am BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
========
___ CXR:
1. Pulmonary vascular congestion without frank pulmonary edema.
2. Left lung base opacification likely represents combination of
atelectasis
and small pleural effusion.
___ CT abdomen/pelvis:
1. Within limitations of this unenhanced scan, the right upper
quadrant liver
and pancreatic transplants are unremarkable.
2. No bowel obstruction.
3. Stable appearance of the lower mediastinal and upper
primarily left
retroperitoneal and left anterior upper quadrant soft tissue
mass when
compared to ___ CT.
___ CT head:
No evidence for acute intracranial abnormalities.
___ EGD:
- Severe portal hypertensive gastropathy
- Ulcer in G-J anastomosis
- Inflammatory polyps 3-4mm noted in stomach
- Varices in middle third esophagus
- Normal muscoa in jejunum; duodenum could not be evaluated
___ Renal US:
Unremarkable
Brief Hospital Course:
Brief Hospital Course:
Mr. ___ is a ___ year old male with a PMH of
hypercoagulability of unknown etiology with chronic thrombosis
of portal vein/SMV/splenic vein resulting in portal
hypertension/cirrhosis now s/p liver/pancreas/small intestine
transplant ___ at ___, and PE/DVT/splenectomy who
initially presented to the ___ with altered mental status,
severe left upper quadrant abdominal pain, and leukocytosis
concerning for infection. His course has been complicated by
chronic malabsorption/malnutrition requiring tube feeds and ___.
ACTIVE ISSUES:
=============
# LUQ Abdominal pain
# Fever
# Leukocytosis
Presented with acute worsening of his chronic LUQ abdominal pain
as well as fever, chills, and nausea. Initial labs were
significant for a leukocytosis of 13.5, concerning for infection
given immunosuppressed state vs. small bowel rejection. CT
abdomen/pelvis non-con unremarkable. Patient underwent EGD which
showed G-J ulceration which may have been contributing to pain.
Alternatively, viral gastroenteritis considered. Started on
broad spectrum antibiotics and broad infectious work-up sent,
ultimately all negative. Hickman line and J-tube evaluated, no
evidence of infection. Patient had no further fevers and
resolution of leukocytosis; antibiotics ultimately discontinued
___.
# Gastric-Jejunal Ulcer
EGD on ___ notable for severe gastritis with mucosal
inflammation and contact bleeding as well as a single
non-bleeding 5mm ulcer in the G-J anastomosis. Development of
new ulceration was concerning given home regimen of PO PPI BID.
Started on IV PPI BID given concern for poor absorption of PO
PPI. Also started on ranitidine and Carafate with improvement in
abdominal pain back to baseline. Plan to complete 6 week course
of IV PPI daily at home, then transition back to PO PPI.
Additionally, plan to complete 6 week course of H2 ___ and
Carafate ongoing.
# Acute on chronic microcytic anemia
Patient presented with a hemoglobin of 7.9 on ___, which
subsequently dropped to 6.9 on ___. Of note, he received
several liters of fluids on admission so hemodilution likely
contributed. He showed no evidence of active bleeding and denied
both hematemesis and melena. Iron studies showed very low iron,
and a transferrin saturation of 3.9% most consistent with an
iron-deficiency anemia. This was thought to be due to poor
absorption of iron in his gut. He received 1 unit of pRBC with
appropriate increase in his hemoglobin/hematocrit. IV iron was
deferred while he was in patient due to concerns of an active
infection, but should be considered when stable in the
outpatient setting.
# ___ on post-transplant CKD
Patient presented with a Cr of 1.9 (baseline 1.5-1.9) which
uptrended to 2.1. Etiology felt to be pre-renal and improved
with fluid resuscitation. Creatinine on discharge was 1.9.
# S/p liver/pancreas/small intestine transplant
Patient received this transplant at ___ in ___, with his
course complicated by rejection and CMV infection. CMV level
currently undetectable. At baseline, he has intermittent
abdominal pain and diarrhea. His loperamide was held due to
concern for infection, but his home pain and immunosuppressive
medications were continued. He underwent EGD on ___ but
biopsies were not taken. He should have repeat EGD with biopsies
performed in the next ___ weeks to evaluate for rejection.
# Malnutrition s/p J tube
Tube feeds initially held in setting of worsening abdominal
pain. Slowly re-introduced and advanced to goal after
improvement of pain. TwoCal HN @ 100 mL/hr x 10 hours ___
kcal, 85 g pro, ~700 mL H20)
CHRONIC ISSUES:
===============
# Hypercoagulable state
# History of PE/DVT
# Chronic thrombosis of PV/SMV/splenic vein c/b portal
hypertension
He was continued on his home enoxaparin 80 mg SC daily.
# Vascular soft tissue mass in anterior LUQ
Seen on CT scan from ___. There was concern that this mass
may be contributing to his current presentation but his mass
appeared stable in size and vascular on CT imaging during this
admission.
# Hx of CMV infection
Last VL undetectable.
# MGUS
Stable. Followed by Dr. ___.
# Hypertension
Held home metoprolol and amlodipine; re-started on discharge.
# Acid suppression
On admission, home regimen was omeprazole 40 mg BID. He received
IV pantoprozole and ranitidine while in patient. The ranitidine
will be continued for six weeks, at which point he will require
alternative forms of acid suppression therapy. One consideration
is misoprostol, which has been shown to suppress acid production
and protect gastric mucosa in patients on NSAIDs.
TRANSITIONAL ISSUES:
====================
[] Initiate iron transfusions when patient is not acutely ill;
as patient does not have a duodenum, oral iron will not be
absorbed and patient will need intravenous iron. Also follow-up
B12/folate levels
[] Ensure repeat EGD with biopsies of both stomach and small
bowel to assess for improvement in ulcer and for rejection, if
ulcer has not improved despite treatment with PPI and H2
___ need to consider additional therapies such as
misoprostol
[] Follow up H. pylori stool antigen (pending on discharge)
[] Consider repeat colonoscopy for work-up of chronic diarrhea
[] Patient currently getting 2L of NS per week and recently had
an acute-on-chronic kidney injury. F/u with Dr. ___ to trend
___ and determine whether more fluids are needed.
[] J-tube check on ___ as an outpatient
[] Started on PPI IV 40mg daily (to be continued for 6 weeks),
and ranitidine daily (to be continued for 6 weeks). After this
point, patient should be started on omeprazole 40mg PO daily and
consider initiation of misoprostol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fentanyl Patch 62.5 mcg/h TD Q72H
2. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Mycophenolate Mofetil 500 mg PO BID
4. Omeprazole 40 mg PO BID
5. PredniSONE 5 mg PO DAILY
6. Tacrolimus 2 mg PO Q8H
7. Vitamin D 500 UNIT PO DAILY
8. Enoxaparin Sodium 80 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
9. LOPERamide 4 mg PO TID:PRN constipation
10. amLODIPine 5 mg PO DAILY
11. Magnesium Oxide 400 mg PO BID
12. Metoprolol Tartrate 25 mg PO BID
13. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg IV Q24H
RX *pantoprazole 40 mg 40 mg IV daily Disp #*42 Vial Refills:*0
2. Ranitidine 300 mg PO QHS
RX *ranitidine HCl 300 mg 1 tablet(s) by mouth at bedtime Disp
#*45 Tablet Refills:*0
3. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram/10 mL 1 suspension(s) by mouth four times
a day Disp #*120 Packet Refills:*0
4. amLODIPine 5 mg PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Enoxaparin Sodium 80 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
7. Fentanyl Patch 62.5 mcg/h TD Q72H
8. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
9. LOPERamide 4 mg PO TID:PRN constipation
10. Magnesium Oxide 400 mg PO BID
11. Metoprolol Tartrate 25 mg PO BID
12. Mycophenolate Mofetil 500 mg PO BID
13. PredniSONE 5 mg PO DAILY
14. Tacrolimus 2 mg PO Q8H
15. Vitamin D 500 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- G-J anastomosis ulcer
- Acute kidney injury
Secondary Diagnosis
- Portal vein thrombosis c/b portal hypertension s/p
liver/pancreas/small intestine transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted to the hospital because you were having severe
abdominal pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had a procedure called an endoscopy, and it showed that
you had a new bleeding ulcer and irritation in your stomach. We
gave you medications to reduce the acid in your stomach and help
the ulcer heal.
- We checked your J tube and Hickman line and do not think they
are infected.
- You had lab tests sent, but they did not show a clear source
of infection, so we did not continue to treat you with
antibiotics.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below).
Once the intravenous PPI medication is set up, you should take
that daily. Until then, continue taking your oral PPI twice
daily.
- Please follow up with your doctors at ___, and continue to
discuss further treatment at their facility.
- Keep your follow up appointments with your doctors.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10320861-DS-20 | 10,320,861 | 25,915,776 | DS | 20 | 2127-03-11 00:00:00 | 2127-03-11 21:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aldactone / senna / CytoGam
Attending: ___
Chief Complaint:
Fevers, chills, abdominal pain
Major Surgical or Invasive Procedure:
___ TEE
___ EGD
___ midline placement
History of Present Illness:
In brief, this is a ___ year-old man with complicated PMH
including hypercoagulable state of unknown etiology with chronic
thrombosis of portal vein/SMV/splenic vein resulting in portal
hypertension (currently on Lovenox) and cirrhosis now s/p
liver/pancreas/small intestine transplant ___ at ___, on
tacrolimus, mycophenolate, prednisone), as well as
PE/DVT/splenectomy, congenital cystic adenomatoid malformation
s/p LLL in ___, MGUS and CKD stage III who presented with
abdominal pain, nausea, vomiting and fever.
On interview today, patient states he is still having severe
abdominal pain and nausea with minimal improvement with IV
dilaudid and Zofran. Upon discussion with daughter, appears
patient was in usual state of health until an acute onset of
abdominal pain. After he had the pain, she accessed his
indwelling hickman to give IVF (the first time it had been
accessed in months). He then presented to the ___ ED where he
was found to have a temp to 105.6.
ROS: Full 10 point ROS otherwise negative.
Past Medical History:
- L-sided CVA ___
- Hypercoagulable d/o (unclear etiology. Extensive workup has
been unrevealing)
- Lung/liver granulomas
- DVTs/PEs - ___
- Portal & meseneteric vein thrombus
- S/p TIPS ___, revision ___
- S/p LL lobectomy for granulomas ___
- S/p exploratory Laparotomy (___) ___ for
intra-abdominal hemorrhage after paracentesis.
- S/p splenectomy
- Nodular regenerative hyperplasia
- Osteoporosis
- S/p liver/small intestine/pancreas transplant in ___ at
___
- MGUS
- Left pleural effusion, s/p thoracentesis ___
- CMV infection, viral loads negative since ___
- Serratia infection - peritoneal fluid w/ Serratia Marcescens
on ___, carbapenem intermediate/resistant. Hematoma
___ w/ S. marcescens, cipro resistant.
- Hx MAC bacteremia s/p 9 months imipenem, tigecycline, amikacin
Social History:
___
Family History:
- Sister has hypercoagulable state (antiphospholipid syndrome):
had stroke at age ___, also history of miscarriages
- Sister vaginal cancer
- Mother had TIA and has APS
- Maternal uncles, MI's in ___
- Father: sarcoidosis, MI, prothrombin deficiency
- No family history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS:24 HR Data (last updated ___ @ 1519) Temp: 100.6 (Tm
102.4), BP: 107/61 (103-114/58-69), HR: 89 (82-94), RR: 17
(___), O2 sat: 95% (95-98), O2 delivery: Ra, Wt: 181.44
lb/82.3
kg
GENERAL: Uncomfortable appearing, lying in fetal position
HEENT: AT/NC, EOMI, PERRL
NECK: supple
HEART: RRR, S1/S2, no murmurs appreciated
CHEST: ___ port c/d/I w/o surrounding erythema
LUNGS: CTAB, no wheezes, rales
ABDOMEN: non-distended, tender in all quadrants with involuntary
guarding worse in epigastric region and surrounding J tube site,
soft, no peritoneal signs. Has small abrasion on abdomen that is
superficial and does not appear infected.
EXTREMITIES: no edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.1, 144 / 80, 61, 17, 99% Ra
General Appearance: Well-groomed, in NAD.
HEENT: Atraumatic, normocephalic. Sclera anicteric b/l. MMM. No
oropharyngeal lesions. No LAD.
Lungs: Equal chest rise. Good air movement. No increased work of
breathing. CTAB. No wheezes, rales, or rhonchi.
CV: RRR. Normal S1, S2. No murmurs, gallops, or rubs. No carotid
bruits b/l.
Abdomen: Non-distended. Bowel sounds present. TTP in epigastric
region and LUQ with involuntary guarding. No rebound tenderness.
Extremities: No edema, clubbing, or cyanosis.
Skin: No rashes or lesions.
Neuro: A+O to person, place, and time. CN III-XII grossly
intact.
Pertinent Results:
ADMISSION LABS
==============
___ 07:50PM BLOOD WBC-16.0* RBC-3.55* Hgb-7.9* Hct-26.8*
MCV-76* MCH-22.3* MCHC-29.5* RDW-18.3* RDWSD-49.9* Plt ___
___ 07:50PM BLOOD Neuts-86.3* Lymphs-8.6* Monos-4.3*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-13.78* AbsLymp-1.38
AbsMono-0.68 AbsEos-0.00* AbsBaso-0.02
___ 07:50PM BLOOD ___ PTT-25.5 ___
___ 07:50PM BLOOD Glucose-88 UreaN-24* Creat-2.3* Na-135
K-5.2 Cl-101 HCO3-25 AnGap-9*
___ 07:50PM BLOOD ALT-15 AST-31 AlkPhos-60 TotBili-0.3
___ 07:50PM BLOOD Lipase-12
___ 07:50PM BLOOD cTropnT-<0.01
___ 07:50PM BLOOD Albumin-3.4* Calcium-9.0 Phos-1.1*
Mg-1.3*
___ 10:03PM BLOOD tacroFK-4.4*
___ 07:52PM BLOOD ___ pO2-26* pCO2-44 pH-7.41
calTCO2-29 Base XS-1
___ 07:52PM BLOOD Lactate-2.1*
PERTINENT INTERVAL LABS
=======================
___ 06:00AM BLOOD WBC-7.9 Lymph-51 Abs ___ CD3%-70
Abs CD3-2817* CD4%-22 Abs CD4-871 CD8%-43 Abs CD8-1718*
CD4/CD8-0.51*
___ 06:00AM BLOOD Hapto-182
___ 06:00AM BLOOD IgG-1065
___ 06:50AM BLOOD Vanco-21.3*
___ 07:25AM BLOOD CMV VL-DETECTED
___ 06:00AM BLOOD CMV VL-NOT DETECT
___ 06:00AM BLOOD EBV -NOT DETECT
DISCHARGE LABS
==============
___ 08:05AM BLOOD WBC-9.4 RBC-3.50* Hgb-7.9* Hct-26.1*
MCV-75* MCH-22.6* MCHC-30.3* RDW-19.6* RDWSD-53.0* Plt ___
___ 08:05AM BLOOD Glucose-117* UreaN-14 Creat-1.7* Na-140
K-4.4 Cl-99 HCO3-27 AnGap-14
___ 08:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8
___ 08:05AM BLOOD tacroFK-4.8*
IMAGING
=======
CXR (___)
-------------
IMPRESSION:
Streaky opacities in lung bases, likely atelectasis, though
infection is
difficult to exclude in the correct clinical setting. Mild
pulmonary vascular
congestion with decreased small left pleural effusion.
CT A/P WO CON (___)
IMPRESSION:
1. Limited study due to suboptimal p.o. contrast and lack of IV
contrast.
Within this limitation, there are no acute findings.
2. Unchanged appearance of soft tissue masses in the lower
mediastinum and
upper abdomen.
ABDOMEN X-RAY (___)
IMPRESSION:
No evidence for obstruction or free air. Gastrostomy tube
projecting over the
left upper quadrant.
CTA A/P (___)
------------------
IMPRESSION:
1. No evidence of perforation, obstruction, or bowel ischemia.
Patent
vasculature as described above.
2. Similar appearance of the extensive heterogeneous soft tissue
masses
surrounding the esophagus with extension into the left upper
quadrant and in
the anterior inferior mediastinum with heterogeneous internal
enhancement and
abnormal ectatic vessels with areas of probable pseudoaneurysm
formation.
3. Unchanged small to moderate nonhemorrhagic left pleural
effusion.
TTE (___)
--------------
The left atrium is mildly dilated. The right atrium is mildly
enlarged. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular
systolic function. Quantitative biplane left ventricular
ejection fraction is 67 %. Left ventricular cardiac
index is normal (>2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. No
ventricular septal defect is seen. 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) appear
structurally normal. No masses or
vegetations are seen on the aortic valve. No abscess is seen.
There is no aortic valve stenosis. There is no
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 trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. No mass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is physiologic
tricuspid regurgitation. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal biventricular cavity sizes, regional/global
systolic function. No valvular
pathology or pathologic flow identified. Mild pulmonary artery
systolic hypertension.
TEE (___)
--------------
There is no evidence for an atrial septal defect by 2D/color
Doppler. Overall left ventricular systolic
function is normal. The right ventricle has normal free wall
motion. There are no aortic arch atheroma
with no atheroma in the descending aorta. The aortic valve
leaflets (3) appear structurally normal. No
masses or vegetations are seen on the aortic valve. No abscess
is seen. There is no 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 physiologic mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. No
mass/vegetation are seen on the tricuspid
valve. No abscess is seen. There is physiologic tricuspid
regurgitation. The pulmonary artery systolic
pressure could not be estimated.
IMPRESSION: No discrete vegetation or abscess seen and no
pathologic flow seen. Normal global
biventricular systolic function.
EGD (___)
---------------
1) Normal mucosa in the whole esophagus
2) Anastamosis with erythema, friable, heaped up mucosa (biopsy)
3) Normal mucosa in the examined duodenum
MICROBIOLOGY
============
__________________________________________________________
___ 5:53 pm STOOL CONSISTENCY: WATERY Source:
Stool.
OVA + PARASITES (Pending):
__________________________________________________________
___ 4:53 pm CATHETER TIP-IV Source: hickman.
**FINAL REPORT ___
WOUND CULTURE (Final ___: No significant growth.
__________________________________________________________
___ 9:40 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 5:45 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:04 am BLOOD CULTURE ' #1.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 5:20 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:02 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:50 am BLOOD CULTURE Source: Line-Hickman #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:09 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test ___ enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
__________________________________________________________
___ 3:09 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
__________________________________________________________
___ 12:41 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Susceptibility testing performed on culture # 490-1648W
(___).
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
__________________________________________________________
___ 12:23 pm BLOOD CULTURE Source: Line-hick.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Susceptibility testing performed on culture # 490-1648W
(___).
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
__________________________________________________________
___ 12:15 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 7:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Susceptibility testing performed on culture # 490-___
___.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___
12:16PM.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
__________________________________________________________
___ 7:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___
11:38AM.
GRAM POSITIVE COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Brief Hospital Course:
=========
SUMMARY
=========
Mr. ___ is a ___ yo M with hx of hypercoagulable state with
chronic thrombosis of portal vein/SMV/splenic vein resulting in
portal hypertension/cirrhosis now s/p liver/pancreas/small
intestine transplant ___ at ___, as well as
PE/DVT/splenectomy who presented with fever to 105,
leukocytosis, and abdominal pain and was found to have a port
associated MSSA bacteremia. Patient was treated with IV
cefazolin with clinical improvement.
ACTIVE ISSUES
==============
#MSSA bacteremia
#Altered mental status
#Fevers, leukocytosis
#Lactic acidosis
Patient presented with severe abdominal pain, nausea, vomiting,
fever to 105, and leukocytosis with left shift concerning for
infectious process especially with immunocompromised state.
Patient was initially started on broad spectrum antibiotics with
Vanc/Cefepime/Flagyl. Intra-abdominal infection felt not likely
given CT and CTA A/P negative for intra-abdominal pain. LFTs wnl
suggest against cholangitis and lipase normal. 2x Blood cultures
from ___ positive for MSSA. Transplant ID consulted who felt
___ was likely colonized with MSSA as was not accessed
in months and was recently accessed after acute onset abdominal
pain. Antibiotics were narrowed to IV cefazolin. ___ port
removed ___. Patient underwent a TTE and TEE which were both
negative for endocarditis. Patient had a midline placed ___
with plan to continue IV antibiotics at home and to continue for
3 weeks since last negative blood culture ___. Patient to have
weekly labs done with OPAT. Patient does not need a replacement
port as was only getting IVF ___ times every few months; since
this is a possible source
of infection, will not replace port and will recommend patient
get IVF intermittently from his PCP if needed vs increasing free
water flushes with tube feeds.
# Acute onset abdominal pain
# Nausea/vomiting
Patient presented after a sudden onset abdominal pain worse in
the epigastric region that caused him to double over in pain.
Pain was out of proportion to exam and given history of
hypercoagulable state, initially concerned for mesenteric
ischemia. also initially concerned for perforation given history
of G-J anastomosis ulcer. Had CTA A/P negative for
intra-abdominal free air or mesenteric ischemia but was notable
for an occluded SMA and concern was raised that could had
impaired flow state to SMA territories especially when in low
flow state (dehydration, sepsis). Abdominal pain resolved with
aggressive fluid resuscitation. Patient underwent broad
intrabdominal infectious workup including CT abd/pelvis,
including fecal cultures, norovirus, CMV PCR, ova and parasites
which were all negative.
#G-J ulcer
#Gastritis
#Acid suppression
EGD on ___ notable for severe gastritis with mucosal
inflammation and contact bleeding as well as a single
non-bleeding 5mm ulcer in the G-J anastomosis. On last
admission, started on IV PPI BID given concern for poor
absorption of PO PPI and discharged on 6 week course IV PPI, H2
blocker but apparently insurance did not cover for IV PPI and
ended up only on PO omeprazole 40 mg daily. Due to concern that
G-J ulcer could be contributing to abdominal pain and concern
that ulcer could be due to ongoing treatment with MMF, patient
underwent EGD on ___ which showed resolution of G-J ulcer.
Biopsies of area were taken and are pending at discharge.
Patient was continued on sucralfate, and PO omeprazole 40mg BID.
#S/p liver/pancreas/small intestine transplant: Transplated at
___ in ___. Course complicated by rejection early on. Also
with history of CMV infection treated with valcyte. Due to
complicated history, the primary team remained in contact with
the ___ transplant team regarding management of
immunosuppression. As above, Transplant ID was consulted and
checked CMV and EBC viral loads which were notable for an
elevated EBV PCR to 853 copies/mL. We discussed these results
with the transplant team and decision was made to discontinued
MMF. Patient will be discharged on prednisone 10mg daily and
tacrolimus 2mg TID for immunosuppression. Per discussion with
patient's transplant care coordinator, patient will be contacted
for follow-up with transplant hepatologist and transplant ID
specialist within ___ weeks after discharge.
___ on post-transplant CKD
History of CKD stage III (baseline Cr ~2). Cr 2.3 on
presentation. Suspect most likely prerenal azotemia in setting
of GI losses, poor PO intake, and sepsis. Post-transplant CKD
thought to be secondary to amikacin toxicity and tacrolimus
induced renal vasoconstriction. Patient was given aggressive IVF
hydration and ___ resolved. Discharge Creatinine is 1.7. Lovenox
was initially held and started on heparin gtt but restarted once
___ resolved.
#Malnutrition s/p J tube:
#Hypomagnesemia
#Hypophosphatemia
Patient continued on tube feeds while here while allowing for PO
intake as patient tolerates. Patient had been getting IVF via
___ but had not needed for several months. Will be
discharged without ___ so will need to have IVF via PIV with
PCP or should have free water flushes increased if felt to be
dehydrated.
#Microcytic anemia
Hgb 7.6 from baseline ___. Iron studies in ___ demonstrated Fe
deficiency anemia, with very low iron, Tsat 3.9%. Received 1 u
PRBCs for a hgb of 6.4 with appropriate response. No evidence of
GI bleeding, unclear cause of anemia but suspect has chronic
anemia from severe iron deficiency. Discharge hgb 7.9.
# Hypercoagulable state
# History of PE/DVT
# Chronic thrombosis of PV/SMV/splenic vein:
Initially held lovenox and switched to heparin gtt due to ___.
Once renal function improved, transitioned back to lovenox.
CHRONIC ISSUES
==============
# Vascular soft tissue mass in anterior LUQ:
Seen on CT scan from ___, redemonstrated ___. Appears
stable in size on admission CT. The mass appears to be vascular.
Held off on biopsy on last admission as mass is stable and
appears vascular. Was discussed with transplant team with ___
and will follow-up with them.
# Hx of CMV infection:
Previously treated, last VL undetectable here on ___.
# Hypertension:
Restarted home metoprolol and amlodipine on discharge
# Other medications:
Continued home mag oxide 400 mg BID, calcium, vitamin D
====================
TRANSITIONAL ISSUES
====================
[ ] MSSA Bacteremia: Patient had a midline placed ___ with plan
to continue IV cefazolin q8hrs at home and to continue for 3
weeks since last negative blood culture (___). Will have
weekly labs drawn with OPAT team.
[ ] History of G-J ulcer: Patient underwent EGD on ___ which
showed resolution of G-J ulcer. Biopsies of area were taken and
are pending at discharge. Will continue on PO omeprazole 40mg
BID
[ ] Immunosuppression: We discussed results of elevated EBV PCR
to 853 copies on labs here with the ___ transplant team and
decision was made to discontinued MMF. Patient will be
discharged on prednisone 10mg daily and tacrolimus 2mg TID for
immunosuppression.
[ ] Microcytic anemia: Was given 1U PRBC here. Suspect still
iron deficient. Would recheck iron studies as outpatient once
acute issues resolved and consider IV iron once infection
resolved.
[ ] IGG subclasses 1, 2, 3, 4 were checked but test pending at
discharge. Will follow-up results
[ ] Will be discharged without Hickman port. If dehydrated
should increase free water flushes through GJ tube or be
coordinated for outpatient IVF infusions.
# CODE: Presumed FULL
# CONTACT: Name of health care proxy: ___
___: sister
Phone number: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcium Carbonate 500 mg PO DAILY
2. Enoxaparin Sodium 80 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
3. Fentanyl Patch 100 mcg/h TD Q72H
4. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
5. LOPERamide 4 mg PO TID:PRN constipation
6. Mycophenolate Mofetil 250 mg PO BID
7. PredniSONE 5 mg PO DAILY
8. Tacrolimus 2 mg PO Q8H
9. Vitamin D ___ UNIT PO DAILY
10. Metoprolol Tartrate 25 mg PO BID
11. amLODIPine 5 mg PO DAILY
12. Sucralfate 1 gm PO QID
13. Magnesium Oxide 400 mg PO BID
14. Omeprazole 40 mg PO BID
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV Every 8
hours Disp #*50 Intravenous Bag Refills:*0
2. Sucralfate 1 gm PO BID
RX *sucralfate 1 gram 1 tablet(s) by mouth Twice a day Disp #*60
Tablet Refills:*0
3. amLODIPine 5 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Enoxaparin Sodium 80 mg SC QPM
6. Fentanyl Patch 100 mcg/h TD Q72H
7. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
8. LOPERamide 4 mg PO TID:PRN constipation
9. Magnesium Oxide 400 mg PO BID
10. Metoprolol Tartrate 25 mg PO BID
11. Omeprazole 40 mg PO BID
12. PredniSONE 5 mg PO DAILY
13. Tacrolimus 2 mg PO Q8H
14. Vitamin D ___ UNIT PO DAILY
15.Outpatient Lab Work
B___.61
CBC with differential, BUN, Cr, LFTs, ESR, CRP
Date: Weekly until ___
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
==================
PRIMARY DIAGNOSIS
==================
MSSA Bacteremia secondary to ___ infection
===================
SECONDARY DIAGNOSIS
===================
Abdominal pain
___ on CKD
History of liver/pancreas/small intestine transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear. Mr. ___,
It was a pleasure taking care of you.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you had severe
abdominal pain and a fever and were found to have an infection
in your blood from your port.
WHAT WAS DONE WHILE I WAS HERE?
- You were given antibiotics to treat your infection.
- You also received one unit of blood because your blood count
was low.
- You had two types of echocardiograms, which are ultrasounds to
look at your heart.
- They were both normal and showed no infection inside of your
heart.
- You had an EGD, which is an endoscopy, to look at your
esophagus, stomach, and first part of your small intestine. This
was normal and showed no ulcers.
WHAT DO I NEED TO DO ONCE I LEAVE THE HOSPITAL?
- Your transplant coordinator, ___, at ___ will be in
contact with you to coordinate your appointments with your ___
physicians since you missed your most recent scheduled
appointments.
- After discussing with your transplant specialists, it was
decided to hold one of your immunosuppressant medication called
mycophenalate mofetil. Please continue to hold this medication
until you follow-up with your transplant specialist.
- You had a serious blood infection and will need to be on IV
antibiotics for several more weeks. Your last day of IV
antibiotics will be ___. You will be followed by our
infectious disease specialists to make sure you are tolerating
the antibiotics well and your infection is resolving.
- You need to follow-up with Dr. ___. You will see the PA in
Dr. ___ office on ___.
Be well,
Your ___ Care Team
Followup Instructions:
___
|
10320946-DS-5 | 10,320,946 | 27,190,456 | DS | 5 | 2115-09-21 00:00:00 | 2115-09-22 20:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
levofloxacin
Attending: ___.
Chief Complaint:
Chest Pain, Shortness of Breath
Major Surgical or Invasive Procedure:
___ - Right Upper Chest Wall Mass Excisional Biopsy
History of Present Illness:
Ms. ___ is a ___ female with history of
seizure disorder and asthma/COPD who presents with shortness of
breath and chest pain.
Patient reports that she started feeling unwell around ___.
She went on vacation at the end of ___ to the ___ but
was not feeling more fatigued and not able to do her usual
___ activities. Then in ___ she was feeling awful with
shortness of breath. She was diagnosed with pneumonia by her PCP
and completed ___ course of levofloxacin. Her shortness of breath
improved after about two weeks but is still not back to her
baseline. She feels particularly more short of breath while
climbing stairs of which she has four flights in her apartment
building. She also notes intermittent bilateral chest pain and
right-sided back pain for the past five days. At times the pain
is quite severe. She believes it is musculoskeletal and denies
relation to exertion. She denies associated radiation,
nausea/vomiting, and diaphoresis.
She denies previous bleeding issues. She reports her last
mammogram was about two weeks ago and was negative. She also had
a colonoscopy about ___ years ago that showed polyps and
recommended follow-up in ___ years.
She reports mild non-bloody cough with clear sputum production.
She also notes palpitations. She denies fevers/chills, drenching
night sweats, weight loss, abdominal pain, nausea/vomiting,
diarrhea, constipation, dysuria, and hematuria.
In the ED, initial vitals: 98.3 101 135/84 18 98% RA. Labs
notable for WBC 10.1, H/H 14.0/42.3, Plt 443, Na 136, K 4.1, and
BUN/Cr ___. Imaging notable for CT chest with left hilar mass
and cavitary lesion in the superior segment of the right lower
lobe. Patient was given nothing. Atrius Oncology was consulted
and recommended admission to medicine. Vitals prior to transfer:
98.3 96 147/84 17 97% RA.
On arrival to the floor, patient reports ___ left-sided chest
pain and right-sided back pain. She otherwise is feeling well
and has no additional concerns.
Past Medical History:
- Seizure Disorder
- Hyperlipidemia
- Colonic Adenoma
- Cataracts
- Asthma/COPD
- s/p cholecystectomy
Social History:
___
Family History:
Father with rheumatoid arthritis. Mother with heart disease,
breast cancer, and myasthenia ___. Maternal grandmother with
breast cancer.
Physical Exam:
========================
Admission Physical Exam:
========================
Vitals: Temp 98.0, BP 175/81, HR 101, RR 18, O2 sat 98% RA.
General: Alert, oriented, resting comfortably in bed, in no
acute distress.
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, oropharynx clear.
Neck: Supple, JVP not elevated, no LAD.
Chest: Right upper chest wall just inferior to the clavicle with
2cm round soft tissue swelling, mobile without tenderness.
Lungs: Diffuse wheezing bilaterally.
CV: RRR, normal s1/s2, no m/r/g.
Abdomen: Soft, non-distended, non-tender, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: A&Ox3, CNII-XII intact, gross strength and sensation
intact bilaterally.
========================
Discharge Physical Exam:
========================
Vitals: Temp 97.8/98.3, BP 139/67, HR 100, RR 18, O2 sat 99% RA.
General: Alert, oriented, resting comfortably in bed, in no
acute distress.
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, oropharynx clear.
Neck: Supple, JVP not elevated, no LAD.
Chest: Right upper chest wall 4cm well-healing incision.
Lungs: Scattered wheezing bilaterally.
CV: RRR, normal s1/s2, no m/r/g.
Abdomen: Soft, non-distended, non-tender, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: A&Ox3, CNII-XII intact, gross strength and sensation
intact bilaterally.
Pertinent Results:
===============
Admission Labs:
===============
___ 11:48AM BLOOD WBC-10.1* RBC-4.63 Hgb-14.0 Hct-42.3
MCV-91 MCH-30.2 MCHC-33.1 RDW-12.8 RDWSD-42.4 Plt ___
___ 11:48AM BLOOD Neuts-72.6* ___ Monos-6.6
Eos-0.6* Baso-0.5 Im ___ AbsNeut-7.35* AbsLymp-1.95
AbsMono-0.67 AbsEos-0.06 AbsBaso-0.05
___ 10:00PM BLOOD ___
___ 11:48AM BLOOD Glucose-80 UreaN-8 Creat-0.6 Na-136 K-4.1
Cl-97 HCO3-28 AnGap-15
___ 11:48AM BLOOD ALT-12 AST-14 LD(LDH)-189 AlkPhos-103
TotBili-0.2
___ 11:48AM BLOOD cTropnT-<0.01 proBNP-457*
___ 11:48AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.0
===============
Discharge Labs:
===============
___ 05:25AM BLOOD WBC-9.4 RBC-4.10 Hgb-12.3 Hct-37.1 MCV-91
MCH-30.0 MCHC-33.2 RDW-12.8 RDWSD-42.2 Plt ___
=============
Microbiology:
=============
None
========
Imaging:
========
CXR ___
Impression: Right mid lung opacity with central lucency
concerning for pneumonia though difficult to exclude a cavitary
lesion. Recommend CT to further assess.
CT Chest w/ Contrast ___
1. Findings concerning for primary lung cancer with left hilar
mass and cavitary lesion in the superior segment of the right
lower lobe. Additional soft tissue implant in the right upper
chest wall which is concerning for metastatic disease and may be
amenable to percutaneous biopsy.
2. Tumor encasement of the left pulmonary artery with possible
thrombosis within the left upper lobe branches.
3. Indeterminate hypodense lesion within the liver which may be
further evaluated with MRI.
4. Thickening of the left adrenal gland, nonspecific.
CTA Torso ___
1. 6.3 cm cavitary right lung base mass with invasion into the
chest wall.
2. 4.8 cm left mediastinal/hilar mass with invasion and
occlusion of the the left upper lobe pulmonary artery and left
apical segment pulmonary vein as detailed above.
3. Scattered other pulmonary nodules.
4. Mediastinal, porta hepatis, and left gastric adenopathy. Left
adrenal nodularity. Findings are suggestive of metastases.
5. Pneumobilia. Correlate with patient's history of possible
hepaticoduodenostomy, not in OMR.
MRI Head w/ and w/o Contrast ___
1. 8 mm left frontal lobe metastatic lesion.
2. Tiny and dural enhancement in the left frontal lobe could be
due to a small meningioma or metastasis.
3. A tiny right frontal enhancement with adjacent bony
thickening is likely due to an incidental meningioma.
4. 10 mm left parotid lesion could be due to enlarged lymph node
or pleomorphic adenoma.
==========
Pathology:
==========
Right Chest Wall Mass Lesion ___
Impression: Squamous cell carcinoma. While no lymphoid tissue is
seen; the mass may represent a replaced lymph node; correlation
with imaging is advised. The immunochemical profile for the
tumor is as follows:
Positive: CK7 and p63.
Negative: CK20, TTF-1 and Napsin.
Brief Hospital Course:
Ms. ___ is a ___ female with history of
seizure disorder and asthma/COPD who presents with shortness of
breath and chest pain found to have left hilar mass and RLL
cavitary lesion concerning for malignancy.
# Metastatic Lung Squamous Cell Carcinoma: CT chest with left
hilar mass and cavitary lesion in the superior segment of the
right lower lobe as well as additional soft tissue implant in
the right upper chest wall which is concerning for metastatic
disease. Atrius Oncology was consulted for assistance with
malignancy work-up. Initial concern for PE in the left pulmonary
artery. Patient underwent further evaluation for PE with a CTA
chest which showed no PE but did note invasion and occlusion of
the the left upper lobe pulmonary artery and left apical segment
pulmonary vein. She underwent a biopsy of the right upper chest
wall mass by General Surgery on ___. She then had further
staging imaging. CT abdomen/pelvis showed mediastinal, porta
hepatis, and left gastric adenopathy as well as left adrenal
nodularity which were suggestive of metastases. MRI brain showed
an 8 mm left frontal lobe metastatic lesion. Radiation Oncology
was consulted and she will likely have radiation to her brain
metastasis. Her pathology from her chest wall mass returned as
squamous cell carcinoma. She will follow-up with Oncology,
Radiation Oncology, and Palliative Care.
# Chest Pain: Does not sound typical for cardiac chest pain.
Likely musculoskeletal vs. pain related to her lung mass. EKG
reassuring and troponin negative. Pain was controlled with
Tylenol and Oxycodone.
# Shortness of Breath/COPD: Currently appears breathing
comfortably. Likely component of COPD as well as pulmonary
malignancy. Continued home albuterol.
# Seizure Disorder: Continued home keppra.
====================
Transitional Issues:
====================
- Please ensure follow-up with Oncology, Radiation Oncology, and
Palliative Care.
- Patient started on oxycodone for chest pain likely secondary
to malignancy. Please continue to monitor pain and treat
symptoms.
- Patient started on trazodone for insomnia. Please continue to
monitor and adjust medications as needed.
- Code Status: Full Code
- Contact: ___ (friend/HCP) ___ (day)
___ (night)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 750 mg PO BID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
3. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. LevETIRAcetam 750 mg PO BID
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg Take 1 tablet by mouth every 6 hours Disp
#*28 Tablet Refills:*0
5. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg Take 1 tablet by mouth at night Disp #*14
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Metastatic Lung Squamous Cell Carcinoma
Secondary Diagnosis:
- Asthma/COPD
- Seizure Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital with
chest pain and shortness of breath. You had a CT scan of your
chest which showed findings concerning for cancer, particularly
lung cancer.
Given this concern, you underwent biopsy of a mass on your right
upper chest wall. The biopsy showed a type of lung cancer called
squamous cell carcinoma.
You also underwent further imaging of your brain and abdomen.
This imaging showed a small lesion in the brain as well as the
adrenal gland that were concerning for metastasis or spread of
the cancer. You met with Radiation Oncology who you will see to
have radiation to the brain. You also met with Oncology who you
will see to discuss chemotherapy options to treat your cancer.
Finally, you met with Palliative Care who you will see to help
manage your symptoms.
You were discharged with prescriptions for oxycodone and
trazodone. The oxycodone will help manage your pain. Please
avoid taking this medication if driving as it can cause
drowsiness. Please call your primary care physician if you have
worsening pain that is not improved with oxycodone.
Please follow-up with your appointments as below. Please note
that you have two Oncology appointments, one with Dr. ___ at
___ and one with Dr. ___ at ___.
You are also scheduled to see Dr. ___ in ___
___ clinic on this ___. Please expect a call from the
___ office tomorrow to review a questionnaire.
If you have any questions, please call them at ___.
All the best,
Your ___ Team
Followup Instructions:
___
|
10321613-DS-15 | 10,321,613 | 27,206,262 | DS | 15 | 2159-05-17 00:00:00 | 2159-05-18 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / cefazolin
Attending: ___.
Chief Complaint:
SOB, confusion, weight gain
Major Surgical or Invasive Procedure:
Right heart catheterization ___
History of Present Illness:
___ PMH aortic stenosis s/p ___ TAVR, afib on Coumadin s/p
PPM, HFpEF, HTN, HLD, NIDDM, COPD on home BIPAP and nocturnal O2
2L, OSA on CPAP, and AAA s/p repair, multifactorial anemia,
recent hospitalization for CHF exacerbation in ___
(discharged ___, who presented with weight gain and
confusion.
Per wife, patient gained 15 pounds since discharge in ___. He
was seen in cardiology clinic last ___, and torsemide dose
was increased from 60 mg to 80 mg. Since then, the wife noted
that her husband has been shaky and "dehydrated" but at the same
time he has been gaining weight. Patient was found this evening
to be confused and with lethargy. He has had no fever or chills,
no cough or shortness of breath. No notable bilateral lower
extremity edema.
In the ED initial vitals were: 97.3 90 144/79 16 85% on RA ->
96% on 5 L
EKG: AF at a rate of 94, non specific ECG changes relatively
unchanged compared to ___
Labs/studies notable for:
WBC 5.7 N:72.4 L:10.6 H/H 8.0/27.6 platelets 107
___: 33.6 PTT: 39.7 INR: 3.1
proBNP: 2266
Trop-T: 0.07
UA negative
Lactate 1.9
VBG: pH 7.34 pCO2 67 pO2 46 HCO3 38
Imaging:
- CXR:
Mild pulmonary edema and possible trace left pleural effusion.
Bibasilar opacities are likely atelectasis in the setting of low
lung volumes.
- CT head without contrast: No acute intracranial abnormalities.
Patient was given:
He was given: Furosemide 80 mg IV
He was also placed on bipap ___ to transfer given hypercarbia.
Vitals on transfer: 97.8 91 109/52 23 100%
On arrival to the CCU, patient was somnolent and on bipap. He
was alert and oriented x2, very somnolent, and awakening to loud
voice stimuli.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Diabetes (last A1c 7.2)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- A-fib on lifelong a/c (Coumadin, ___. Atrius A/c)
- Chronic Diastolic CHF
- No significant coronary artery disease on ___
3. OTHER PAST MEDICAL HISTORY
- COPD on nocturnal O2
- Abdominal aneurysm without mention of rupture
- Esophagitis
- ___ (chronic kidney disease) stage 3, GFR ___ ml/min, Cr b/l
~1.4
- Microalbuminuria
- Advanced bilateral knee osteoarthritis
- OSA on BiPAP and nocturnal O2
- BPH
Social History:
___
Family History:
Per outside records: No family history of premature
atherosclerosis or cancer.
Physical Exam:
Admission physical exam:
VS: T afebrile HR 88 BP 98/70 RR 20 O2 SAT 96% on bipap
GENERAL: Well developed, well nourished in NAD. Oriented x2.
Somnolent.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP elevated.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Notable for crackles
throughout. No wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis.
Presence of +2 peripheral edema.
PULSES: Distal pulses palpable and symmetric.
Discharge physical exam:
VS: 97.7 PO 106 / 58 L Sitting 98 18 96 RA
Ins and Outs: 24H ___ net -260
Weight: 88.4 --> 89.3 kg
GENERAL: resting in chair comfortably eating breakfast, pleasant
and conversant, no distress
HEENT: eyes mildly erythematous, non-tearing. OP clear with no
exudates.
NECK: supple. JVP on left < 10 at 90 degrees.
CARDIAC: irregularly irregular, soft systolic murmur.
LUNGS: CTAB, no wheezes or crackles.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm extremities. wearing stockings, 1+ edema
bilaterally
Pertinent Results:
Admission labs:
___ 04:33AM ___ PTT-39.7* ___
___ 04:33AM PLT COUNT-107*
___ 04:33AM WBC-5.7 RBC-2.30* HGB-8.0* HCT-27.6*
MCV-120*# MCH-34.8*# MCHC-29.0* RDW-23.8* RDWSD-103.6*
___ 04:33AM NEUTS-72.4* LYMPHS-10.6* MONOS-14.6* EOS-1.4
BASOS-0.5 NUC RBCS-0.7* IM ___ AbsNeut-4.15 AbsLymp-0.61*
AbsMono-0.84* AbsEos-0.08 AbsBaso-0.03
___ 04:33AM ALBUMIN-3.7
___ 04:33AM CK-MB-5 proBNP-___*
___ 04:33AM cTropnT-0.07*
___ 04:33AM LIPASE-22
___ 04:33AM ALT(SGPT)-16 AST(SGOT)-61* CK(CPK)-79 ALK
PHOS-84 TOT BILI-0.8
___ 04:33AM GLUCOSE-80 UREA N-62* CREAT-2.2* SODIUM-143
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15
___ 04:50AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 04:50AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:50AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:55AM LACTATE-1.9
___ 04:55AM ___ PO2-46* PCO2-67* PH-7.34* TOTAL
CO2-38* BASE XS-6
Pertinent Labs:
___ 09:39AM CK-MB-5 cTropnT-0.08*
___ 11:06AM LACTATE-1.3
___ 11:06AM ___ PO2-41* PCO2-66* PH-7.34* TOTAL
CO2-37* BASE XS-6 INTUBATED-NOT INTUBA
___ 01:21PM VIT B12-1444* HAPTOGLOB-65
___ 01:21PM ALT(SGPT)-13 AST(SGOT)-31 LD(LDH)-293* ALK
PHOS-74 TOT BILI-0.9
___ 01:21PM GLUCOSE-63* UREA N-60* CREAT-2.0* SODIUM-146*
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-16
___ 02:10PM LACTATE-1.3
___ 02:10PM ___ PO2-49* PCO2-58* PH-7.38 TOTAL
CO2-36* BASE XS-6
___ 08:39PM GLUCOSE-177* UREA N-60* CREAT-2.1*
SODIUM-147* POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-32 ANION GAP-13
___ 08:39PM CALCIUM-8.5 PHOSPHATE-4.1 MAGNESIUM-2.3
Discharge labs:
___ 07:50AM BLOOD ___ PTT-39.8* ___
___ 07:50AM BLOOD Glucose-140* UreaN-58* Creat-2.3* Na-140
K-4.0 Cl-93* HCO3-31 AnGap-16
___ 07:50AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0
Pertinent Imaging/ Studies
___ CXR
Mild to moderate pulmonary edema and possible trace left pleural
effusion.
Bibasilar opacities are likely atelectasis in the setting of low
lung volumes.
___ CT Head
No acute intracranial abnormalities.
___ Echo
The right atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF = 65%). The right ventricular free wall is hypertrophied.
The right ventricular cavity is dilated with depressed free wall
contractility. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic arch is mildly dilated.
There are focal calcifications in the aortic arch. A ___ 3
aortic valve bioprosthesis is present. The transaortic gradient
is normal for this prosthesis. The mitral valve leaflets are
mildly thickened. There is severe mitral annular calcification.
Severe [4+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
Compared with the ___ study (images reviewed) of ___ no
major change.
___ RHC
Mildly elevated bi-ventricular filling pressures.
Mild pulmonary hypertension.
Normal cardiac output and index.
Brief Hospital Course:
___ year old man with PMH aortic stenosis s/p ___ TAVR, afib
on Coumadin s/p PPM, HFpEF, HTN, HLD, NIDDM, COPD on home BIPAP
and nocturnal O2 2L, OSA on CPAP, and AAA s/p repair,
multifactorial anemia who presented with confusion and shortness
of breath found to have acute on heart failure exacerbation and
___. Problems addressed during this hospitalization are as
follows:
#ACUTE ON CHRONIC DIASTOLIC HEART FAILURE (HFpEF):
Presented with volume overload (SOB, +JVP, CXR with pulmonary
edema, ___ edema), BNP 2266 (previous BNP 5000). Etiology of
exacerbation unclear. Initially admitted to CCU where he
required BiPAP for CO2 retention (CO2 in ___, diuresis with IV
Lasix 160-200 PRN. Stabilized and transferred to heart failure
service for optimization of diuresis. RHC demonstrated mildly
elevated bi-ventricular filling pressures, mild pulmonary
hypertension, normal cardiac output and index. Treated with
Lasix gtt (rate up to 20), IV Lasix PRN, metolazone PRN, and
ultimately transitioned to PO torsemide (100-160). Discharge
torsemide dose 120 PO QD. Discharge weight 89.3 kg (admission
weight 95.6 kg).
#ACUTE HYPERCARBIC HYPOXEMIC RESPIRATORY FAILURE
#CHRONIC OBSTRUCTIVE PULMONARY DISEASE:
Presented with confusion and was found to be in hypoxemic and
hypercarbic respiratory failure. CO2 in ___; CO2 chronically
elevated according to ___ labs due to COPD. Bicarbonate
appropriately compensated for a respiratory acidosis. Placed on
BiPAP in ED and CCU. Had one trigger for AMS (lethargic,
arousable only tsternal rub). Head CT unremarkable,pCO2 not
above baseline. AMS attributed to delirium, resolved following
day, remained AAOx3 for remainder of admission.
#ACUTE ON CHRONIC RENAL FAILURE:
Admission Creatinine 2.2 (baseline Cr=2). Creatinine ranged
1.9-2.4 during admission, discharge Cr 2.3. Likely prerenal.
#ATRIAL FIBRILLATION:
Home metoprolol was increased to 25 mg q6h from 12.5 mg for rate
optimization. Home warfarin 7.5 increased to 9. INR remained
therapeutic on this dose
#TROPONINEMIA:
Elevated at 0.07 (0.04 on ___. ECG with non-specific ST-T
wave changes, unchanged from to ___. Likely demand in setting
of heart failure exacerbation in setting of ___. No chest pain.
CHRONIC ISSUES:
===============
#SEVERE AORTIC STENOSIS:
Patient is status-post TAVR on ___. ASA 81mg and Plavix
discontinued in setting of thrombocytopenia and bleeding in
foley, black stools. Post-TAVR echocardiogram showed LVEF
55-60%, peak velocity 2.4 m/sec, peak gradient 22 mm Hg, mean
gradient 12 mm Hg, valve area 1.8 cm2. TTE w/ well seated valve.
#THROMBOCYTOPENIA:
Noted to have thrombocytopenia during previous hospitalizations
with negative workup for HIT (negative antibodies, FourT score
3). Has previous diagnosis of MDS which is most likely etiology
of thrombocytopenia. Platelet count ranged 79-135 on admission,
discharge platelet 135. Will follow up with hematology/oncology
as listed.
#ANEMIA:
Hgb 8 on admission (baseline ___. Known history of MDS. ___
upper and lower endoscopy (___) negative for active bleeding
and has mild gastritis. Per heme/onc, macrocytosis likely ___
reticulocytosis. Anemia etiology less likely MDS or ___ given
___. Query hemolytic anemia; work up thus far shows negative
coombs, hapto 77, urine hemosid neg, zinc 42 (L), Copper 177
(H). transfused 1 u pRBC ___. He was continued on iron, PPI,
folate supplementation. Will follow up with hematology/oncology
as listed.
#DRY EYES:
Evaluated by ophthalmology. Found to have lower lid ectropion
OS>OD causing incomplete blink, lagophthalmos, and epiphora.
Given lacrilube ointment ___ at night with improvement. Will
follow-up with ophtho as needed.
#IDDM:
Continued home glargine, ISS.
#BPH:
Continued home tamsulosin 0.4 mg PO QHS, finasteride 5 mg PO
DAILY.
#SEVERE OSA:
BiPAP, CPAP as above.
#HLD:
Continued home atorvastatin 40 mg QHS.
#INSOMNIA:
Continued home trazodone 25 mg QHS PRN.
TRANSITIONAL ISSUES:
-Please see any changes or additions to medications.
-Discharge weight: 89.3 kg (admission weight: 95.6 kg ___
-Discharge diuretic: torsemide 120 mg PO QD
-Please check BMP within 1 week of discharge with provided
script unless outpatient cardiology appointment scheduled by
___.
-Please check INR on ___ and fax results to PCP. Discharge
warfarin dosing 9mg daily.
-Please call ophthalmology clinic (___) to schedule
follow-up appointment.
-Can consider adding spironolactone for afterload reduction.
#Contact: ___ ___
#Code Status: FULL CODE (discussed with wife)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Atorvastatin 40 mg PO QPM
3. Bisacodyl ___AILY:PRN constipation
4. Warfarin 7.5 mg PO DAILY16
5. Torsemide 80 mg PO DAILY
6. Ferrous Sulfate 325 mg PO BID
7. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN sob
8. Docusate Sodium 100 mg PO BID
9. Finasteride 5 mg PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. TraZODone 25 mg PO QHS:PRN insomnia
16. Senna 8.6 mg PO BID
17. Tiotropium Bromide 1 CAP IH DAILY
18. Multivitamins 1 TAB PO DAILY
19. Glargine 10 Units Breakfast
Glargine 20 Units Dinner
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO Q6H
RX *metoprolol tartrate 25 mg 1 (One) tablet(s) by mouth four
times a day Disp #*120 Tablet Refills:*0
2. Glargine 10 Units Breakfast
Glargine 20 Units Dinner
3. Torsemide 120 mg PO DAILY
RX *torsemide 20 mg 6 (Six) tablet(s) by mouth once a day Disp
#*180 Tablet Refills:*0
4. Warfarin 9 mg PO ONCE Duration: 1 Dose
Continue taking Warfarin 9mg daily until directed by your
___
RX *warfarin 3 mg 3 (Three) tablet(s) by mouth once a day Disp
#*90 Tablet Refills:*0
5. ___ MD to order daily dose PO DAILY16
Continue taking Warfarin 9mg daily until directed by your
___
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. Atorvastatin 40 mg PO QPM
8. Bisacodyl ___AILY:PRN constipation
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO BID
11. Finasteride 5 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 8.6 mg PO BID
17. Tamsulosin 0.4 mg PO QHS
18. Tiotropium Bromide 1 CAP IH DAILY
19. TraZODone 25 mg PO QHS:PRN insomnia
20.Outpatient Lab Work
ICD10: I50
Please draw Chem10 on ___ and fax results to Dr. ___ at
___
21.Outpatient Lab Work
ICD10: i48.1
Please draw ___ on ___ and fax results to PCP ___
at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
#Acute on chronic diastolic heart failure (HFpEF)
#Acute hypercarbic hypoxemic respiratory failure
#Acute on chronic kidney failure
SECONDARY DIAGNOSES
=====================
#Troponinemia
#Atrial fibrillation
#COPD
#THROMBOCYTOPENIA
#ANEMIA
#AORTIC STENOSIS
#IDDM
#BPH
#OSA
#HLD
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 the ___
___. You came to the hospital because you were short
of breath and more confused at home. In the hospital we found
that your heart failure had worsened, and your kidneys were also
injured. You were first treated in the Cardiac Care Unit then
transferred to the heart failure service when you became more
stable. We treated you with medication to remove the extra fluid
in your body. This medication relieved your shortness of breath
and also helped improve the function of your kidneys. You will
continue taking this medication at home.
You were also evaluated by a blood doctor ("hematologist") in
the hospital because the level of platelets in your blood were
low. Platelets help stop bleeding in your body. You are
scheduled to see a hematologist after you leave the hospital.
Your eyes became dry in the hospital as well and you were
evaluated by an eye doctor ("ophthalmologist"). You will have to
call the number listed below to schedule an appointment with the
ophthalmologist if you continue to have symptoms.
Please be sure to follow up with your doctors as listed below
and to take all of your home medications.
We wish you the best!
-Your ___ care team
Followup Instructions:
___
|
10321613-DS-17 | 10,321,613 | 20,712,693 | DS | 17 | 2159-06-14 00:00:00 | 2159-06-16 15:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / cefazolin
Attending: ___.
Chief Complaint:
Fever, fatigue, right testicular pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with history of aortic stenosis s/p
___ TAVR, afib on Coumadin s/p PPM, HFpEF, HTN, HLD, IDDM,
MDS, COPD on home BIPAP, OSA, AAA s/p repair, and multifactorial
anemia, who presented with weakness and "leg shaking" as well as
subjective fever.
Of note, he was last admitted on ___ for CHF exacerbation and
GI bleed in setting of supratherapeutic INR and was discharged
on ___. During that hospitalization he was diuresed (with lasix
gtt augemented with metolazone) to presumed euvolemia and
discharged on a stable dose of PO diuretic. His anemia and GI
bleed (presented with melena) was presumed to be a result of
gastritis
in the setting of coagulopathy. He was also transfused pRBCs to
a stable blood volume.
Patient reported stable health after discharge until ___, when
Mr. ___ noted new right testicular pain before urinating. He
reported the pain is associated with the movement of his
testicle and not urination. He denies any pain with urination or
blood in urine. He denied any increase in urinary frequency from
his baseline on diuretics.
On ___, he woke up at 2:00 AM to urinate (he often wakes up at
night to urinate into a bedside plastic urinal), and noted that
when he was attempting to stand to urinate, his legs trembled
and felt weak. He was unable to maintain stance or walk. His
wife felt that he may have a fever and took a temperature that
he believes read "100.7 F". He came in to the ___ ED via
ambulance.
He denies headaches, lightheadedness, CP, SOB, cough, N/V/D,
abdominal pain, leg swelling, rash, arthralgias and myalgias. He
has had a raspy voice since discharge on ___ (which he
attributes to prolonged intubation), but no frank cough.
In the ED, initial VS were:
T 98.5F HR 95 BP 105/51 RR 20 O2 95% RA
Exam notable for:
Cardiovascular: irregularly irregular rhythm
Respiratory: Mild crackles at bases bilaterally
Abdominal: non-tender, non-distended
Extremities: no edema
Labs showed:
WBC:12.4*# RBC:2.74* Hgb:8.8* Hct:27.7* MCV:101* MCH:32.1*
MCHC:31.8* RDW:18.7* RDWSD:69.6* Plt Ct:157
Neuts:87.4* Lymphs:2.7* Monos:8.8 Eos:0.2* Baso:0.3 Im ___
AbsNeut:10.81*# AbsLymp:0.33* AbsMono:1.09* AbsEos:0.02*
AbsBaso:0.04
___ PTT:35.3 ___
Glucose:136* UreaN:50* Creat:2.1* Na:139 K:4.6 Cl:95* HCO3:30
AnGap:14
Imaging showed:
CXR ___:
Possible pneumonia
Received:
Ceftriaxone 1g IV x1
Azithromycin 500 mg IV x1
Torsemide 100 mg PO
NS 500cc
Transfer VS were:
T 98.6 BP 124/62 HR 103 RR 18
On arrival to the floor, patient reports feeling like he
recovered his strength since presenting to the hospital. He
typically uses a walker at baseline but reports walking without
difficulty.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Diabetes (last A1c 7.2)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- A-fib on lifelong a/c (Coumadin, ___. Atrius A/c)
- Chronic Diastolic CHF
- No significant coronary artery disease on ___
3. OTHER PAST MEDICAL HISTORY
- COPD on nocturnal O2
- Abdominal aneurysm without mention of rupture
- Esophagitis
- CKD (chronic kidney disease) stage 3, GFR ___ ml/min, Cr b/l
~1.4
- Microalbuminuria
- Advanced bilateral knee osteoarthritis
- OSA on BiPAP and nocturnal O2
- BPH
Social History:
___
Family History:
Per outside records: No family history of premature
atherosclerosis or cancer.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
==================================
VS: T 98.6 BP 124/62 HR 103 RR 18
GENERAL: Sitting comfortably in arm chair, NAD
HEENT: AT/NC, EOMI, PERRL, right eye with subconjunctival
hemorrhage, MMM
NECK: supple, no LAD, no JVD appreciable above the sternal notch
HEART: irregular, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
GU: Scrotum without erythema, swelling or lesions. Right
testicle
tender to palpation.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, able to
stand from chair without assistance
SKIN: warm and well perfused, diffuse chronic bruising
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
VS: 98.7 124 / 67 79 18 96 RA
GENERAL: Sitting comfortably in arm chair eating, NAD
HEENT: AT/NC, EOMI, PERRL, right eye with subconjunctival
hemorrhage, MMM
NECK: No JVD
HEART: Irregular, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, non-distended, non-tender in all quadrants, no
rebound/guarding
GU: Scrotum without erythema, swelling or lesions. Right
testicle
mildly tender to palpation.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, able to
stand from chair without assistance
SKIN: warm and well perfused, diffuse chronic bruising
Pertinent Results:
LABS ON ADMISSION:
==================
___ 05:55AM BLOOD WBC-12.4*# RBC-2.74* Hgb-8.8* Hct-27.7*
MCV-101* MCH-32.1* MCHC-31.8* RDW-18.7* RDWSD-69.6* Plt ___
___ 05:55AM BLOOD Neuts-87.4* Lymphs-2.7* Monos-8.8
Eos-0.2* Baso-0.3 Im ___ AbsNeut-10.81*# AbsLymp-0.33*
AbsMono-1.09* AbsEos-0.02* AbsBaso-0.04
___ 05:55AM BLOOD ___ PTT-35.3 ___
___ 05:55AM BLOOD Glucose-136* UreaN-50* Creat-2.1* Na-139
K-4.6 Cl-95* HCO3-30 AnGap-14
___ 05:55AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.9
LABS ON DISCHARGE:
==================
___ 06:54AM BLOOD WBC-4.7 RBC-2.60* Hgb-8.2* Hct-26.4*
MCV-102* MCH-31.5 MCHC-31.1* RDW-18.1* RDWSD-67.7* Plt ___
___ 06:54AM BLOOD Plt ___
___ 06:54AM BLOOD Glucose-100 UreaN-52* Creat-1.9* Na-140
K-4.1 Cl-94* HCO3-31 AnGap-15
___ 06:54AM BLOOD Calcium-8.6 Phos-4.3 Mg-1.9
MICRO:
======
___ 7:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:11 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
IMAGING:
========
___ CXR:
FINDINGS:
PA and lateral views of the chest provided.
Small areas of confluent opacification at the lung bases are new
since ___ and could be pneumonia.
Despite mild cardiomegaly there are no findings suggesting acute
cardiac
decompensation. No pleural abnormality.
Patient has had TAVR. Transvenous right ventricular pacer lead
in place. The cardiomediastinal silhouette is normal. Imaged
osseous structures are intact.
No free air is seen below the right hemidiaphragm.
IMPRESSION:
Possible pneumonia.
Brief Hospital Course:
___ year old male with history of aortic stenosis s/p ___
TAVR, atrial fibrillation on Coumadin s/p PPM, HFpEF, HTN, HLD,
IDDM, MDS, COPD on home BIPAP, OSA, AAA s/p repair, and
multifactorial anemia, who presented with leg shaking,
subjective fever, and right testicular pain, found to have
epididymitis.
ACUTE ISSSUES:
==============
#Epididymitis:
He was found to have an abnormal urine analysis and tenderness
to palpation of the epididymis, suggestive of epididymitis. He
was started on ceftriaxone with improvement in his symptoms;
antibiotics were narrowed to ciprofloxacin after urine grew
pan-sensitive klebsiella.
#Bibasilar Opacities:
Patient with history of COPD and HFpEF. CXR showed minimal
bilateral opacities worsened from previous on ___, concerning
for pneumonia. He was started initially on azithromycin in
addition to ceftriaxone. He denied cough, shortness of breath,
chest pain. Lung exam was reassuring without wheezes, rales or
rhonchi. He had no elevated JVP to suggest CHF exacerbation.
Pneumonia was thought to be less likely and azithromycin was
discontinued.
CHRONIC ISSUES:
===============
# Atrial fibrillation on warfarin s/p PPM:
CHADVASC of 4. Patient was continued on his home warfarin 7.5 mg
PO daily and metoprolol tartrate 25 mg PO BID.
#Thrombocytopenia:
Chronic, may be related to his MDS. ___ with heme/onc as
outpatient. Platelets remained overall stable.
#COPD:
#OSA:
Continued home bipap, tiotropium bromide, and fluticasone
propionate.
#HFpEF:
He has had multiple prior admissions for HF exacerbation. Last
Echo (___) noted left ventricular hypertrophy with EF=65%
and right ventricular cavity dilatation with depressed free wall
contractility. He was continued on his home torsemide 100 mg PO
BID, spironolactone 25 mg PO daily, and metalazone 2.5 mg PRN.
#Hypertension:
He has continued on home metoprolol and spironolactone.
#DM:
He was continued on home regimen of glargine 10 units AM and 20
units ___ with ISS.
#MDS:
#Anemia:
History of multifactorial anemia including MDS, gastritis and
anemia of chronic disease. Baseline hgb ___. Ferrous sulfate 325
PO BID was held during the hospital stay.
#Hyperlipidemia:
Continued Atorvastatin 40 mg PO qHS.
#BPH:
Continued Tamulosin 0.4 mg PO and Finasteride 5 mg PO daily.
#CKD:
Admission creatinine 2.1, baseline 2.0. Likely secondary to
vascular disease and DM. Creatinine remained stable.
#Dry Eyes:
Continued Artificial Tears ___ DROP BOTH EYES PRN
***TRANSITIONAL ISSUES:***
[ ] Make sure patient completes 10 days of ciprofloxacin (day 1=
___, end date= ___
[ ] Ensure resolution of testicular pain, consider scrotal
ultrasound if the pain persists
#CODE: Full
#CONTACT: ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Atorvastatin 40 mg PO QPM
3. Bisacodyl ___AILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Metoprolol Tartrate 25 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID
10. Tamsulosin 0.4 mg PO QHS
11. Tiotropium Bromide 1 CAP IH DAILY
12. Torsemide 100 mg PO BID
13. Omeprazole 40 mg PO Q12H
14. Spironolactone 25 mg PO DAILY
15. Ferrous Sulfate 325 mg PO BID
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Metolazone 2.5 mg PO DAILY:PRN when recommended by your
cardiologist
18. Warfarin 7.5 mg PO DAILY16
19. Glargine 10 Units Breakfast
Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day
Disp #*13 Tablet Refills:*0
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. Finasteride 5 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Glargine 10 Units Breakfast
Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Metolazone 2.5 mg PO DAILY:PRN when recommended by your
cardiologist
11. Metoprolol Tartrate 25 mg PO BID
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Omeprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 8.6 mg PO BID
16. Spironolactone 25 mg PO DAILY
17. Tamsulosin 0.4 mg PO QHS
18. Tiotropium Bromide 1 CAP IH DAILY
19. Torsemide 100 mg PO BID
20. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Epididymitis
SECONDARY DIAGNOSIS:
Atrial fibrillation
Heart failure with preserved ejection function
Hyperlipidemia
Insulin dependent diabetes mellitus
Chronic obstructive pulmonary disease
Obstructive sleep apnea
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 came to the
hospital because you had fever, weakness, and pain in the right
testicle. You were found to have a urinary tract infection. We
treated you with antibiotics and your symptoms improved.
Make sure to continue taking the antibiotics as prescribed for a
total of 10 days (last day is ___. Please follow-up with your
doctors as ___.
We wish you all the best.
Your ___ team
Followup Instructions:
___
|
10321613-DS-18 | 10,321,613 | 27,004,889 | DS | 18 | 2159-07-09 00:00:00 | 2159-07-11 08:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / cefazolin
Attending: ___.
Chief Complaint:
fatigue, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with history of aortic stenosis s/p
___ TAVR, afib on Coumadin s/p PPM, HFpEF, HTN, HLD, IDDM,
MDS, COPD on home BIPAP, OSA, AAA s/p repair, and multifactorial
anemia, who presents with fatigue.
Of note, he was recently admitted (___) for subjective
fever and right testicular pain, found to have epididymitis. He
was treated with CTX with improvement in his symptoms with
antibiotics narrowed to ciprofloxacin to complete 10 day course
(end date ___ after urine grew pan-sensitive klebsiella.
He saw his cardiologist on ___ and per report was doing well
without dyspnea. That evening he states he woke up and was
unable
to ambulate due to worsening leg trembling. Associated symptoms
included generalized weakness in his arms and legs. Per wife, he
had difficulty breathing at home and was feeling claustrophobic.
On arrival to the ED, initial VS T 97.7 P 96 BP 122/54 RR 16 O2
97% on RA. Initial labs notable for Hb/Hct 10.7/34.5, platelets
147, ___ 22.5, PTT 40.2, INR 2.1, proBNP 1573, BUN/Cr 56/2.1, and
VBG 7.48/46/47. CXR was obtained which showed moderate
cardiomegaly and no acute cardiopulmonary process.
Patient was given home medications including omeprazole 40mg,
spironolactone 25mg, metoprolol tartartrate 25 mg, torsemide
100mg, finasteride 5mg, fluticasone propionate 110mcg 2 puff,
and
multivitamins. Of note, patient desated to mid ___ after taking
3
steps. Was admitted to medicine for further workup.
On arrival to the floor, patient confirmed the above history. He
denies fevers, chills, cough, dyspnea, orthopnea, PND, abdominal
pain, N/V, dysuria, or burning on urination.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Diabetes (last A1c 7.2)
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- A-fib on lifelong a/c (Coumadin, ___. Atrius A/c)
- Chronic Diastolic CHF
- No significant coronary artery disease on ___
3. OTHER PAST MEDICAL HISTORY
- COPD on nocturnal O2
- Abdominal aneurysm without mention of rupture
- Esophagitis
- CKD (chronic kidney disease) stage 3, GFR ___ ml/min, Cr b/l
~1.4
- Microalbuminuria
- Advanced bilateral knee osteoarthritis
- OSA on BiPAP and nocturnal O2
- BPH
Social History:
___
Family History:
Per outside records: No family history of premature
atherosclerosis or cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.6 BP 125/84 P ___ RR20 O2 96%RA
GENERAL: Comfortable, in NAD
HEENT: NC/AT, PERRL, EOMI
Neck: Supple. No cervical LND or JVD.
CV: +S1/S2. Tachycardic. Regular rhythm. No murmurs, rubs, or
gallops.
RESP: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi.
Abd: Soft, NT/ND. +BS all 4 quadrants. No rebound or guarding.
Ext: Warm, well-perfused
SKIN: Scattered ecchymoses on forearms bilaterally
NEURO: CN II-XII grossly intact, no focal neurological deficits.
Motor strength ___ all 4 extremities. Sensation intact.
DISCHARGE PHYSICAL EXAM:
VITALS: T 97.6 BP 117 / 63 HR:102 RR:18
GENERAL: elderly man, sitting up eating breakfast, NAD
HEENT: NC/AT
Neck: Supple. No JVD.
CV: +S1/S2. Tachycardic. Regular rhythm.
RESP: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi.
Abd: Soft, NT/ND. +BS. No rebound or guarding.
Ext: Warm, no edema
SKIN: Scattered ecchymoses on forearms bilaterally
NEURO: CN II-XII grossly intact, no focal neurological deficits.
Pertinent Results:
ADMISSION LABS:
___ 04:04AM BLOOD WBC-5.9 RBC-3.47*# Hgb-10.7*# Hct-34.5*#
MCV-99* MCH-30.8 MCHC-31.0* RDW-17.9* RDWSD-65.3* Plt ___
___ 04:04AM BLOOD ___ PTT-40.2* ___
___ 04:04AM BLOOD Glucose-146* UreaN-56* Creat-2.1* Na-140
K-4.2 Cl-95* HCO3-29 AnGap-16
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-6.0 RBC-3.38* Hgb-10.6* Hct-33.4*
MCV-99* MCH-31.4 MCHC-31.7* RDW-17.7* RDWSD-64.7* Plt ___
___ 07:30AM BLOOD Glucose-148* UreaN-58* Creat-2.2* Na-143
K-3.8 Cl-95* HCO3-30 AnGap-18
IMAGING:
CXR ___
No acute cardiopulmonary process. Moderate cardiomegaly.
Brief Hospital Course:
Mr. ___ is a ___ y/o M with PMH of severe AS s/p TAVR
___, afib s/p PPM on anticoagulation, HTN, HLP IDDM, MDS,
COPD, OSA on bipap, AAA s/p repair and CKD who presents with
fatigue and dyspnea. He was admitted due to desaturation to the
mid 80___ while ambulating.
#Ambulatory desaturation
#Fatigue
Patient had desaturation to the mid-___ in the ED after taking
just a few steps. He had recovered by the morning after, when he
was able to walk up and down the hall without supplemental
oxygen. He was asymptomatic, with no lightheadedness, no
shortness of breath, no weakness, no leg trembling. He had a
proBNP of 1573; however, suspicion for CHF exacerbation was low
given his BNP was actually lower than it had been previously, he
was having no shortness of breath, and no signs of lower
extremity edema. EKG was unchanged from prior EKGs. Chest xray
showed cardiomegaly but no edema or other acute processes. His
orthostatic vital signs were positive; however, the patient and
his wife insisted that this was a chronic issue and he never had
any symptoms. He and his wife are very aware of "danger signs"
for which he should be brought back to the hospital.
#Atrial fibrillation
We continued his home warfarin and metoprolol.
#HFpEF with RV dysfunction
Pro-BNP of 1573 on admission was not any higher than prior
numbers, severe AS, and CKD. ___ TTE with EF 65%,
unchanged compared to prior study. We continued his home
torsemide, spironolactone, and metolazone (prn).
# COPD
# OSA
We continued his home bipap, tiotropium bromide, and
fluticasone.
# DM
We continued his home glargine regimen.
# HTN
We continued his home metoprolol and spironolactone.
# Severe AS s/p TAVR on ___
We continued his home warfarin.
# CKD
Admission Cr 2.1, with baseline of 2.0.
# HLD
We continued his home atorvastatin.
# MDS
# Anemia
He has a history of multifactorial anemia including
MDS,gastritis, and anemia of chronic disease. Presents with
Hb/HCT of 10.7/34.5, above patient's baseline Hb ___.
# Thrombocytopenia
He presented with platelet count of 147. Chronic in nature, may
be related to his MDS. ___ with heme/onc as outpatient.
#BPH
We continued his home tamsulosin and finasteride.
>30 minutes were spent on this complicated discharge
TRANSITIONAL ISSUES:
Discharge weight: 84.7 kg
Discharge Cr: 2.2
[ ] The patient will need to follow up with his regular
cardiologist and pulmonologist.
[ ] Consider PFTs on an outpatient basis for COPD.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Atorvastatin 40 mg PO QPM
3. Bisacodyl ___AILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Metoprolol Tartrate 25 mg PO BID
8. Omeprazole 40 mg PO Q12H
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 8.6 mg PO BID
11. Spironolactone 25 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. Torsemide 100 mg PO BID
15. Warfarin 7.5 mg PO DAILY16
16. Metolazone 2.5 mg PO DAILY:PRN when recommended by your
cardiologist
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Ferrous Sulfate 325 mg PO BID
19. Glargine 10 Units Breakfast
Glargine 20 Units Dinner
20. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Atorvastatin 40 mg PO QPM
3. Bisacodyl ___AILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Glargine 10 Units Breakfast
Glargine 20 Units Dinner
9. Metolazone 2.5 mg PO DAILY:PRN when recommended by your
cardiologist
10. Metoprolol Tartrate 25 mg PO BID
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Omeprazole 40 mg PO Q12H
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO BID
15. Spironolactone 25 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Tiotropium Bromide 1 CAP IH DAILY
18. Torsemide 100 mg PO BID
19. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
fatigue
hypoxemia
Secondary
atrial fibrillation
heart failure with preserved ejection fraction
chronic obstructive pulmonary disease
obstructive sleep apnea
diabetes mellitus
hypertension
aortic stenosis
chronic kidney disease
hyperlipidemia
anemia
thrombocytopenia
benign prostate hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You presented to ___ because of weakness,
fatigue, and leg trembling. You had no shortness of breath or
swelling in your legs. Your chest xray was reassuring and your
symptoms improved on their own. Your oxygen level when walking
was reassuring as well.
It is important that you follow up with your heart doctor and
lung doctor after you leave the hospital. Weigh yourself every
morning, and call your doctor if your weight goes up more than 3
pounds.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10321613-DS-19 | 10,321,613 | 28,134,841 | DS | 19 | 2159-11-06 00:00:00 | 2159-11-12 13:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / cefazolin
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
TEE on ___
History of Present Illness:
Mr. ___ is a ___ y/o M w/ AS s/p TAVR, severe chronic
HFpEF w/ recurrent hospitalizations, Afib s/p PPM, DM, and CKD
III who p/w left lower back pain that began 2 weeks ago. He
reports that he had been in his usual state of health, working
with outpatient ___ on his ambulation, when on ___ he
took
his wife in for an ablation, and, in addition to not being able
to do his morning exercises ("150 sit ups") he sat in the
waiting
room for ___ hours. That day he felt his back start to stiffen
up. The next day, he had an appointment with Dr. ___
___ doctor), and also missed his AM exercises. At that point,
he
started having pain in the lower back that began to limit his
activities. He cancelled his ___ ___ appointment due to
pain, and for the past 1.5-2 weeks he says he has been sleeping
in a chair, rather than his bed, because he is physically unable
to get up from laying position to get out of bed (to use the
restroom for nocturia). Pain has been gradually worsening over
that time, and he feels that his legs are getting weaker. He
had
previously been walking easily with a walker, he says, and even
walking with just a cane at times, but in past few days he feels
that he cannot stably walk with even the walker.
He reports pain in the left lower back and left lateral hip
(lateral to the ASIS). He denies pain in the left leg or
radiation of the pain anywhere down the left leg or anywhere
else. Movement of the left leg in the form of hip
flexion/extension makes the pain worse. His wife reports that
his legs now shake when he stands. The patient notes that he
has
unintended leg movements that come and go. Currently he is
comfortable without pain, but pain is severe with movement and
thus limits his ability to walk.
Denies any associated numbness or tingling of the b/l
toes/feet/legs. Denies urinary retention (urinating w/ usual
frequency). Denies stool incontinence (indeed endorses
constipation that was recently helped by suppository). Denies
HA
or neck stiffness. Denies vision changes or vertigo.
Regarding recent possible PNA. He had CXR on ___ that
showed
possible LLL infiltrate. He was treated with doxy and then
azithro, which he reportedly finished on ___. He tells me that
he still has cough and feeling of chest congestion, but that
what
was initially a cough productive of yellow sputum is now
nonproductive. Denies SOB at rest. Denies DOE, but he says he
hasn't been exerting himself much to know.
Denies sore throat, chest pain, palpitations, weight gain, leg
swelling, nausea, vomiting, abdominal pain, diarrhea, dysuria,
rashes, or other skin lesions.
He endorses chronic urinary frequency & nocturia, worsened by
torsemide when taken in ___. Takes BPH meds.
He endorses chronic easy bruising from Coumadin. His wife notes
that he usually takes 7.5 mg Coumadin QPM (@1600) but because of
antibiotics recently his INR has been high and his Coumadin has
been held the past ___ afternoons.
Past Medical History:
- A-fib s/p PPM on lifelong a/c (Coumadin, managed by Atrius
A/c)
- Chronic Diastolic CHF (HFpEF w/ RV dysfunction)
- Severe AS s/p TAVR ___
- No significant coronary artery disease on ___
- Abdominal aneurysm s/p repair
- Hypertension
- Dyslipidemia
- Diabetes (last A1c 7.2)
- COPD on nocturnal O2
- OSA on BiPAP and nocturnal O20
- MDS ___/ chronic anemia
- CKD (chronic kidney disease) stage 3, GFR ___ ml/min, Cr
b/l~1.4
- Microalbuminuria
- Advanced bilateral knee osteoarthritis
- BPH
- Hx of esophagitis / gastritis
- Hx of epididymitis (___) - Hospitalized at ___. Treated
w/ CTX --> Cipro for pan-S Klebsiella
- Last ___: ___ for fatigue and hypoxia
during ambulation that apparently resolved on its own.
PSHx:
- Hx of TAVR (___)
- Hx of AAA repair
- Hx of PPM
Social History:
___
Family History:
No family history of CAD.
-Mother: lived to ___
-Father: lived to ~___
Physical Exam:
Discharge Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: irregularly irregular, no murmur, no S3, no S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:36AM BLOOD WBC-6.1 RBC-2.87* Hgb-9.1* Hct-27.9*
MCV-97 MCH-31.7 MCHC-32.6 RDW-15.2 RDWSD-53.9* Plt ___
___ 07:36AM BLOOD Glucose-119* UreaN-61* Creat-1.7* Na-140
K-4.9 Cl-94* HCO3-32 AnGap-14
___ 07:06AM BLOOD ___
___ 06:59AM BLOOD ___
MICRO:
___ 2:45 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
STREPTOCOCCUS SALIVARIUS. FINAL SENSITIVITIES.
Daptomycin Sensitivity testing per ___ (___),
___.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STREPTOCOCCUS SALIVARIUS
|
CEFTRIAXONE----------- 0.5 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 2 R
PENICILLIN G---------- 1 I
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___, ___, ON
___ AT 22:10 ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 3:10 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STREPTOCOCCUS SALIVARIUS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___, ___, ON
___ AT 22:10 ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 12:55 pm BLOOD CULTURE
Blood Culture, NGTD
___ Blood culture, NGTD at discharge
IMAGING:
TTE ___
IMPRESSION: Mild LVH with normal LV systolic function. Bilatrial
enlargement. Well functioning bioprosthetic AVR. Severe
tricuspid
regurgitation with severe pulmonary hypertension. Apical views
foreshortened.
___ MRI L spine ___ contrast
IMPRESSION:
1. Extremely limited study of the lumbar spine secondary to an
artifact from an aortic graft however no definite terminal cord
signal abnormalities identified.
2. Moderate to severe lumbar spondylosis, with severe right
neural foraminal narrowing at L4-L5 and moderate left neural
foraminal narrowing at L2-L3.
CT A/P wo contrast ___
IMPRESSION:
1. No acute fracture.
2. Status post aorto bi-iliac stent graft. Patency of the stent
graft and the presence of an endoleak cannot be determined
without IV contrast, however there is no significant change in
size of the aneurysm sac to indicate an endoleak.
3. Cholelithiasis, with no evidence of acute cholecystitis.
CXR ___
IMPRESSION:
1. Mild patchy opacities at the lung bases are new compared with
prior, possibly representing atelectasis or pneumonia.
2. Stable cardiomegaly with mild pulmonary vascular congestion.
No frank pulmonary edema or large pleural effusion.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history
of AS s/p TAVR, chronic diastolic heart failure, atrial
fibrillation and SSS s/p PPM, CKD stage 3, IDDM2, OSA on CPAP
who
presented initially with leg weakness and inability to ambulate,
then found to have fever, hypotension, bacteremia concern for
endocarditis given prosthetic valve
SUMMARY/ASSESSMENT: Mr. ___ is a ___ year old male with
history
of AS s/p TAVR, chronic diastolic heart failure, atrial
fibrillation and SSS s/p PPM, CKD stage 3, IDDM2, OSA on CPAP
who
presented initially with leg weakness and inability to ambulate,
then found to have fever, hypotension, bacteremia concern for
endocarditis given prosthetic valve
#sepsis (fever, hypotension) now resolved
#Bacteremia with Strep Salivarius- Given prosthetic valve high
clinical suspicion for endocarditis therefore both TTE and TEE
were pursued without evidence of valve involvement. Patient was
initially placed on Vancomycin given GPCs in pairs and chains
that eventually speciated to strep salivarius. ID recommended
transitioning to Ceftriaxone 2g q24 hours to complete a ___ental was consulted given possibility of a dental
source. Panorex and dental consult had low suspicion for dental
infection being the source of blood stream infection. Patient
had PICC line placed prior to discharge and was arranged with
OPAT follow-up.
# Weakness
# Atraumatic low back pain, paraspinal lumbar muscle back pain
-Suspect combination of deconditioning and metabolic acute
illness (bacteremia, PNA)
-After initiation of treatment for his infection, his weakness
has resolved today on exam and patient subjectively feels this
way as well.
-If still indicated as outpatient for any question of
myelopathy,
would need non-emergent MRI C and T spine
-Had MRI L spine with no acute process seen.
-Conservative management of paraspinal muscle pain in lumbar
region with ___, warm compress, Tylenol, low dose flexeril.
Patient was feeling back to baseline on discharge.
# Elevated troponin, demand ischemia
- no active CP or palpitations and review
of prior labs shows that he has element of chronic mild
elevation
in troponins (based on ___ labs)
- no concern for ongoing ACS by EKG as well
- likely due to CKD and CHF
# Afib and SSS s/p PPM on Coumadin
# supratherapeutic INR, now resolved
- continue home metoprolol, rates controlled. Maintained INR ___
while in house.
# Chronic diastolic heart failure: chronic, severe
- followed by Dr. ___ ___ clinic,
- his weight today is 189 lb. His dry weight is 192 lb. Will
continue home torsemide and spironolactone on discharge
# OSA
-COntinued home CPAP qhs
# CKD stage 3
- Stable, Cr at baseline.
- dose meds for reduced eGFR
- avoid NSAIDs
# IDDM2
- continued home glargine 10 QAM, 20 QPM
- QIDACHS, SSI
# BPH
- continued home tamsulosin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Bisacodyl ___AILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Metolazone 2.5 mg PO DAILY:PRN when recommended by your
cardiologist
8. Metoprolol Tartrate 25 mg PO BID
9. Multivitamins ___ 1 TAB PO DAILY
10. Omeprazole 40 mg PO Q12H
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 8.6 mg PO BID:PRN constipation
13. Spironolactone 25 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Tiotropium Bromide 1 CAP IH DAILY
16. Torsemide 100 mg PO DAILY
17. Warfarin 7.5 mg PO DAILY16
18. Torsemide 60 mg PO QPM:PRN weight gain (weight > 192 lbs)
19. Glargine 10 Units Breakfast
Glargine 20 Units Dinner
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV q24h
Disp #*16 Intravenous Bag Refills:*0
2. Glargine 10 Units Breakfast
Glargine 20 Units Dinner
3. Atorvastatin 40 mg PO QPM
4. Bisacodyl ___AILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. Finasteride 5 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Metolazone 2.5 mg PO DAILY:PRN when recommended by your
cardiologist
10. Metoprolol Tartrate 25 mg PO BID
11. Multivitamins ___ 1 TAB PO DAILY
12. Omeprazole 40 mg PO Q12H
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 8.6 mg PO BID:PRN constipation
15. Spironolactone 25 mg PO DAILY
16. Tamsulosin 0.4 mg PO QHS
17. Tiotropium Bromide 1 CAP IH DAILY
18. Torsemide 100 mg PO DAILY
19. Torsemide 60 mg PO QPM:PRN weight gain (weight > 192 lbs)
20. Warfarin 7.5 mg PO DAILY16 (HOLD UNTIL ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-strep bacteremia
-HFpEF
-Back Pain
-Poor dentition
-sepsis
-demand ischemia (elevated troponin)
-supratherapeutic INR
-CKD III
Discharge Condition:
Good
Alert and Oriented x 3
Ambulatory with a walker
Discharge Instructions:
Dear Mr. ___,
You presented to the hospital with back pain and were found to
have a blood stream infection (strep salivarius). We treated you
with antibiotics through the IV and your blood stream cleared.
We consulted infectious disease who recommended a total of 4
weeks of IV antibiotics. We ensured there was no infection on
your heart valves. When you leave the hospital it is important
that you see your PCP, and continue your home antibiotics
through the IV. You should also see the ID doctors in ___.
Followup Instructions:
___
|
10321676-DS-11 | 10,321,676 | 28,920,579 | DS | 11 | 2169-01-04 00:00:00 | 2169-01-04 21:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Aspiration pneumonia
Major Surgical or Invasive Procedure:
No major surgical or invasive procedures
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a history of
stage V CKD, RCC status post partial left nephrectomy, bipolar
disorder, HTN, gallstone pancreatitis status post
ERCP/sphincterotomy and laparoscopic cholecystectomy, gout,
spinal stenosis, and gout, who presented to ___ on ___ for
further evaluation of fever, new O2 requirement, and non bloody,
non-bilious emesis.
Patient reports he was in his usual state of health until 5AM on
___ subsequently woke with severe nausea, and subsequently
developed multiple episodes of non-bloody, non-bilious vomiting.
Denied associated abdominal pain, constipation, obstipation,
diarrhea, or abdominal
distention. Per patient and his wife, patient has had similar
episodes in the past following consumption of minimal amounts of
alcohol, and reported drinking two glasses of wine on the night
prior to symptom onset. Denied fevers or sick contact exposure.
No recent changes in diet or medications; patient ate same food
as wife the day prior to symptom onset. Also denied cough,
sputum production, or shortness of breath at home prior to
admission. No
issues with swallowing, including choking or coughing while
eating.
In the ED, initial VS were notable for;
Temp 97.2 HR 67 BP 147/91 RR 18 SaO2 94% RA
Examination was notable for:
- Good air entry bilaterally, crackles at right base, otherwise
clear lungs without wheezes.
Labs were notable for:
-WBC 10.5 Hgb 12.7 Plt 109
-Na 144 K 5.9 BUN 107 HCO3 20 BUN 87 Cr 6.3 Gluc 120
-ALT 17 AST 43 ALP 68 Lipase 79 Tbili 0.3 Alb 4.3
-Lactate 1.5
Urine studies notable for:
-Negative leuks, trace blood, negative
nitrites, 30 protein, 70 glucose, 1 RBC, 1 WBC, no bacteria, and
<1 epithelial cells.
ECG demonstrated sinus rhythm at 71 bpm, left axis deviation, Q
waves inferiorly, mild non-specific IVCD, otherwise normal
intervals, poor R wave progression, similar when compared to
prior.
CXR with right lower lobe opacification, concerning for
developing PNA and/or aspiration. CT abdomen/pelvis without
contrast re-demonstrated right lower lob consolidative
opacities, in addition to non-specific dilation of air-filled
small bower loops up to 2.4cm without evidence of wall
thickening, and multiple intermediate density right renal cysts.
Patient was given;
- IV ondansetron 4mg
- 500ml Lactated Ringer's
- PR Tylenol ___
- IV Unasyn 3g
Vital signs on transfer notable for;
Temp 99.0 HR 78 BP 126/79 RR 20 SaO2 98% 2L NC
Upon arrival to the floor, patient repeats the above story.
Currently he is feeling much better. While in the ED he was was
febrile to ___ and 100.3F, with associated rigors and chills.
Last episode of vomiting was prior to arrival, and patient
tolerated PO solids and liquids while in the ED.
REVIEW OF SYSTEMS:
-10-point review of systems was unremarkable except as per HPI.
Past Medical History:
1. Bipolar disorder.
2. Colonic adenomas.
3. Hypertension.
4. Gallstone pancreatitis.
5. Glaucoma.
6. Gout.
7. Stage 5 CKD.
8. Spinal stenosis.
9. Scoliosis.
10. GERD.
11. Oncocytoma s/p Left partial nephrectomy
Social History:
___
Family History:
Mother died at age ___. She had coronary artery disease and
possibly lymphoma. Father died at age ___ of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: Temp: 97.9 BP: 122/78 HR: 73 RR: 20 SaO2 98% 2L
GENERAL: lying in bed, not in acute distress
HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no JVP elevation
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: good air entry bilaterally, crackles at right base but
otherwise clear lungs without wheezes
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: warm, well perfused, no lower extremity edema.
NEURO: A/O x3, moving all four extremities with purpose, CNs
grossly intact
DISCHARGE PHYSICAL EXAM
VS: Temp: 97.5, BP: 115/70, HR: 71, RR 18, O2 Sat: 95% RA
GENERAL: lying in bed comfortably
HEENT: atraumatic, normocephalic, no conjunctival pallor, moist
mucous membranes
NECK: non-tender, w/o JVP elevation
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: Breathing comfortably on room air. Lung fields with
crackles at right base, otherwise clear without rhonchi or
wheezes.
ABD: +BS, non-distended. Non-tender to palpation in all four
quadrants.
EXTREMITIES: Warm and well perfused.
NEURO: Alert and oriented x3, moving all four extremities with
purpose, CNs grossly intact.
Pertinent Results:
ADMISSION LABS
___ 07:00AM BLOOD WBC-10.5* RBC-3.94* Hgb-12.7* Hct-39.7*
MCV-101* MCH-32.2* MCHC-32.0 RDW-13.7 RDWSD-50.4* Plt ___
___ 07:00AM BLOOD Glucose-120* UreaN-87* Creat-6.3* Na-144
K-5.9* Cl-107 HCO3-20* AnGap-17
___ 07:00AM BLOOD Lipase-79*
___ 07:00AM BLOOD Albumin-4.3
___ 07:09AM BLOOD Lactate-1.5 K-4.7
DISCHARGE LABS
___ 06:05AM BLOOD WBC-7.3 RBC-3.42* Hgb-10.9* Hct-34.9*
MCV-102* MCH-31.9 MCHC-31.2* RDW-14.0 RDWSD-52.3* Plt Ct-68*
___ 06:05AM BLOOD Glucose-89 UreaN-85* Creat-6.1* Na-146
K-5.3 Cl-112* HCO3-21* AnGap-13
___ 06:05AM BLOOD Calcium-9.9 Phos-4.7* Mg-2.2
Brief Hospital Course:
PATIENT SUMMARY
Mr. ___ is a ___ with PMHX pertinent for stage V CKD ___
partial left nephrectomy for RCC,lithium, urinary retention),
bipolar disorder, and gallstone pancreatitis s/p
ERCP/sphincterotomy, who was admitted to ___ on ___ for
non-bilious non-bloody vomiting following minimal alcohol
intake, fevers, and new O2 requirement, found on CXR/CT to have
findings consistent with aspiration pneumonia, with subsequent
improvement on empiric antibiotics.
ACUTE ISSUES
#Aspiration Pneumonia
The patient presented following one hour of persistent
non-bloody non-bilious emesis the morning after he consumed two
glasses of wine. Per his wife, he has had another similar
episode of emesis in the setting of minimal wine consumption in
the past. He developed an new O2 requirement and fevers in the
ED, in the absence of witnessed aspiration event, and was found
on subsequent CXR and CT abdomen/pelvis to have a right lower
lobe consolidative processes consistent with an aspiration
pneumonia. He was started on azithromycin and ceftriaxone and
improved clinically overnight, with successful wean to room air
and no further fevers or episodes of vomiting. He was discharged
on a renally-adjusted dose of amoxicillin/clavulanate (250-500
mg q24 hrs) with plan for completion of a ___hronic macrocytic anemia
Noted on labs since ___, stable this admission. Likely
medication-related in setting of febuxostat and valproic acid
use, as both xanthine oxidase inhibitors and valproic acid can
be associated with macrocytic anemia, lower suspicion for
dietary or alcohol-related etiologies given patient and wife's
report of current patterns of intake. Could consider further
work-up to include reticulocyte count, B12/folate, TSH, LFTs
pending discretion of primary outpatient gerontologist.
CHRONIC ISSUES:
#Stage V CKD: The patient has stage V CKD thought to be
secondary to partial left nephrectomy for RCC, lithium use, and
urinary retention. He has a maturing RUE fistula with plan for
dialysis initiation in ___. His Cr on admission was 6.3 and
remained stable this admission downtrending to 6.1 on the day of
discharge. His phosphate was noted to be mildly elevated at 4.7,
but this was within goal range of 3.3-5.5 and so was managed
with dietary phosphate restriction alone. He was continued on
his home calcitriol and sodium bicarbonate during the admission.
TRANSITIONAL ISSUES:
[] Macrocytic anemia: stable this admission w/ MCV in low 100s;
appears to have been present since ___ with Hb ___,
likeliest medication associated (febuxostat, divalproex), but
would re-check at outpatient gerontology follow-up appointment
and might consider further work-up at that time to r/o other
contributing etiologies.
[] Incidental findings: Multiple intermediate density right
renal cysts, may reflect hemorrhagic cysts, with the largest in
the right interpolar region stable in size from MRI of ___. Would recommend further discussion of possible non-urgent
renal ultrasound at next routine follow-up appointment with
___ Nephrology (Dr. ___.
Total discharge time spent seeing and examining the patient,
supervising housestaff, and coordinating discharge comes to 38
minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Febuxostat 40 mg PO 4X/WEEK (___)
2. Sodium Bicarbonate 1300 mg PO BID
3. Divalproex (DELayed Release) 500 mg PO BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye) BID
6. Calcitriol 0.25 mcg PO 3X/WEEK (___)
7. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q24H Aspiration
pneumonia Duration: 7 Days
Take this medication ___, with one dose daily.
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth once a day Disp #*7 Tablet Refills:*0
2. Calcitriol 0.25 mcg PO 3X/WEEK (___)
3. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic (eye)
BID
4. Divalproex (DELayed Release) 500 mg PO BID
5. Febuxostat 40 mg PO 4X/WEEK (___)
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Omeprazole 20 mg PO DAILY
8. Sodium Bicarbonate 1300 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aspiration Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Why was I admitted to the hospital?
You were admitted to the hospital for vomiting.
What happened to me while I was in the hospital?
In the hospital we obtained imaging of your chest which showed
an infection in your lungs. We treated you with antibiotics for
this infection.
What should I do after leaving the hospital?
You should finish the antibiotics that we prescribe for you on
discharge. You should also take all your other medications as
prescribed and follow-up with your outpatient providers.
Followup Instructions:
___
|
10321950-DS-6 | 10,321,950 | 23,479,232 | DS | 6 | 2138-03-09 00:00:00 | 2138-03-09 08:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Left ___ digit pain
Major Surgical or Invasive Procedure:
Incision and drainage left ___ digit
History of Present Illness:
___ RHD POD2 from I&D for flexor tenosynovitis of ___
digit presents to ED for 1d of increased pain and swelling and
drainage from his palmar surgical wound. He endorses chills. He
denies fevers, nausea, and vomiting. He reports initial
post-operative improvement but his hand swelled much worse today
than before, when only his finger was injured.
Past Medical History:
None
Social History:
___
Family History:
N/A
Physical Exam:
AFVSS
NAD, A&Ox3
LUE:
Splint/Dressing c/d/i, incision c/d
+ain/pin/u
SILT r/m/u
<2 seconds cap refill in all digits
Pertinent Results:
___ 06:10PM PLT COUNT-199
___ 06:10PM NEUTS-55.2 ___ MONOS-9.0 EOS-1.7
BASOS-0.8
___ 06:10PM WBC-7.3 RBC-4.03* HGB-13.2* HCT-36.9* MCV-92
MCH-32.9* MCHC-35.9* RDW-13.1
___ 06:10PM GLUCOSE-110* UREA N-20 CREAT-0.7 SODIUM-140
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
___ 06:13PM LACTATE-1.1
___ 06:13PM COMMENTS-GREEN TOP
Brief Hospital Course:
Patient presented to the ED on ___ after recieving and I&D for
a ___ digit flexor tenosynovitis on ___ with concern for
reinfection of left ___ digit. He was added on and taken to the
OR ___ for repeat incision and drainage of left ___ digit. He
tolerated the procedure well without complications (See
operative note for further details). He was kept in house until
___ for IV antibiotics and pain control. On the morning of
POD#2 (___) the patients pain is well controlled on PO pain
medication, he is tolerated his diet and is medically stable. He
was discharged on ___ with explicit instructions for dressing
changes, discharge medications and follow up on ___.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*60
Tablet Refills:*0
3. Clindamycin 300 mg PO Q6H Duration: 10 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*40 Capsule Refills:*0
4. Sulfameth/Trimethoprim DS 1 TAB PO BID Finish out previous
prescription
Discharge Disposition:
Home
Discharge Diagnosis:
Left ___ digit flexor tenosynovitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please keep splint on at all times unless changing your
dressings until your follow up appointment next week.
Keep left hand elevated at all times.
Change your dressings daily. Cover each incision with a small
piece of adaptic first then, place gauze over the adaptic and
wrap with kerlix. Place hand back in plaster splint and wrap
with ace bandage.
You should do daily betadine soaks with your left hand before
you put on new dressings. Put ___ squirts of betadine into a
basin of warm water and leave hand submerged for 10 minutes.
Place new dressings over incisions as described above after
soaks.
When changing dressings or doing daily soaks, move all fingers
as tolerated to keep them from getting stiff. You may extend
fingers as tolerated when they are in the splint.
Take your antibiotics for a full 10 ___ course, take your pain
medications as prescribed. You may take tylenol and ibuprofen
with your narcotic pain medication if needed.
Followup Instructions:
___
|
10322266-DS-18 | 10,322,266 | 23,812,784 | DS | 18 | 2191-09-25 00:00:00 | 2191-09-26 06:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Zyprexa / Percocet / zaleplon / tramadol /
Dilaudid
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ metastatic breast cancer and extensive abdominal procedure
history presents w/ abdominal pain and nausea/vomiting. She
reports that 2 days ago she developed b/l lower quandrant
cramping following but some mild nausea and decreased appetite.
She has been unable to eat any food since this started. She then
developed nausea and vomiting one day ago which has been
non-bloody, and tan to green colored. She denies any
fevers/chills, chest pain, or sob. She last had a bm yesterday
afternoon and can not remember the last time she passed flatus
but has been more than a day.
Past Medical History:
PMH: HTN, hypothyroidism, osteopenia, breast cancer metastatic
to bone s/p surgery, chemo, chest wall radiation, severe
depression requiring ___, OSA
PSH:
1. Cholecystectomy (___)
2. Left mastectomy complicated by tissue expander rupture (___)
3. TRAM flap (___)
4. Total abdominal hysterectomy and bilateral salpingectomy
complicated by ureter injury and repair (___)
5. Appendectomy
6. Two (2) ventral hernia repairs w/ mesh (last repair in ___
with Marlex)
7. Bilateral knee replacement
8. Repair of fracture of left wrist
9. Exploratory-lap, LOA, resection of small bowel fistula with
mesh, primary anastomosis, and repair of abdominal wall defect
with AlloDerm (___) with Dr. ___
10. Exploratory laparotomy, lysis of adhesions 3.5
hours, partial colectomy and colocolostomy, feeding
jejunostomy, drainage abdominal wall abscess and culture,
takedown of fistula, removal of Marlex mesh and closure of
enterotomy (___)
11. Laparoscopic incisional hernia with prosthetic mesh and
Lysis
of adhesions again in ___
Social History:
___
Family History:
-Mother passed away at age ___ - history of HTN
-Father passed away at age ___ - unknown causes
-Has 4 siblings alive and well. One brother passed away at age
___ from unknown causes.
She denies strong family history of cancer, diabetes,
respiratory disorders.
Physical Exam:
Discharge PE:
Gen: NAD
CV: RRR
Resp: Unlabored respirations
Abd: Abd soft, non-tender, non-distended
Ext: WWP, no edema
Pertinent Results:
ADMISSION LABS
==============
___ 10:45PM BLOOD WBC-10.8 RBC-4.83 Hgb-15.5 Hct-42.5
MCV-88 MCH-32.2* MCHC-36.5* RDW-13.9 Plt ___
___ 10:45PM BLOOD Neuts-78.6* Lymphs-11.7* Monos-8.1
Eos-1.2 Baso-0.4
___ 10:45PM BLOOD Glucose-157* UreaN-31* Creat-1.7* Na-139
K-3.4 Cl-95* HCO3-26 AnGap-21*
___ 10:45PM BLOOD ALT-16 AST-19 AlkPhos-83 TotBili-0.6
___ 10:45PM BLOOD Lipase-24
___ 10:45PM BLOOD Albumin-4.6
___ 10:51PM BLOOD Lactate-2.6*
DISCHARGE LABS
==============
___ 04:30AM BLOOD WBC-6.1 RBC-4.00* Hgb-12.5 Hct-35.9*
MCV-90 MCH-31.2 MCHC-34.8 RDW-13.8 Plt ___
___ 04:30AM BLOOD Glucose-107* UreaN-4* Creat-0.6 Na-142
K-3.3 Cl-106 HCO3-26 AnGap-13
___ 04:30AM BLOOD Calcium-9.7 Phos-3.2 Mg-1.6
RADIOLOGY
=========
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 12:01 AM
IMPRESSION:
1. New moderate small bowel dilatation proximally extending to
fecalized loop of bowel at right lower quadrant anastomosis with
decompressed distal small bowel loops an overall paucity of
bowel gas is worrisome for small bowel obstruction. No
pneumatosis.
2. New 2.3 cm area of irregular wall thickening along
mesenteric aspect of loop of jejunum is worrisome for metastatic
deposit however given location focal area of peristalsis may be
similar in appearance.
3. Mild intra and extrahepatic biliary duct dilatation with
common bile duct measuring 12 mm may be related to prior
cholecystectomy. However, appears increased compared to the
patient's contrast enhanced study dated ___. Clinical
and laboratory data correlation is recommended. If concern a
dedicated MRCP is recommended for further evaluation.
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 7:35 AM
IMPRESSION:
1. Persistent mild small bowel dilatation with fecalized loop
of bowel at right lower quadrant anastomosis with decompressed
distal small bowel loops is consistent with small bowel
obstruction. Minimal progression of oral contrast which remains
proximal to the transition point over the course of 8 hr
suggests complete obstruction.
2. Previously identified irregular wall thickening along loop
of jejunum is no longer seen and was likely related to bowel
peristalsis.
3. Mild intrahepatic and extrahepatic biliary duct dilatation
with common bile duct measuring 13 mm may be likely related to
prior cholecystectomy but appears slightly more prominent than
contrast-enhanced study from ___. Clinical and
laboratory data correlation is recommended and if clinical
concern a dedicated MRCP should be considered for further
evaluation.
ABDOMEN (SUPINE & ERECT) Study Date of ___ 3:33 ___
IMPRESSION:
The contrast material is too dilute to adequately evaluate by
conventional radiographs. Air-filled dilated loops of small
bowel are compatible with a small bowel obstruction.
Brief Hospital Course:
Ms. ___ presented to the ED on ___ with sudden onset
abdominal pain, nausea and vomiting at home, and was found to be
hypotensive and tachycardic. A CT scan was done showing small
bowel obstruction and an NGT was placed. A repeat CT scan while
she was still in the ED was concerning for complete obstruction
and incomplete decompression of the stomach. She was then
transferred to the floor for further management.
#Small bowel obstruction
Given the suspected severity of her obstruction on her CT scan,
she was added-on to the OR schedule for possible exlap. On
admission, she was kept NPO, fluid resuscitated and decompressed
with an NGT. On HD#2, she reported having flatus after walking
and her abdominal exam was improving so non-operative management
of her SBO was continued. By HD#3, she was passing flatus
regularly and had a normal bowel movement. She continued to
improve and her NGT was clamp trialled and discontinued on HD#4
without residual nausea, vomiting or abdominal pain.
#Elevated creatinine
Her creatinine was noted to be elevated on admission. Her labs
were repeated after adequate fluid resuscitation and her
creatinine returned to normal.
At time of discharge, she was tolerating a regular diet, passing
flatus, having bowel movements and not having further abdominal
pain. Her SBO was considered resolved, and she was deemed ready
to return home.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. anastrozole 0.5 mg oral DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Zolpidem Tartrate 5 mg PO QHS
7. zoledronic acid 4 mg injection every 3 months
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the ___ surgical service at ___ for
management of your small bowel obstruction. A nasogastric tube
was placed to decompress your stomach and you were placed on
bowel rest with good resolution of your obstruction. Once you
resumed passing gas and having bowel movements, the tube was
removed. At this time, you are tolerating a regular diet without
nausea or vomiting and are now ready to continue your recovery
at home.
If you develop any recurrence of your abdominal pain, nausea,
vomiting or fevers at home, please call your doctor or return to
the emergency department.
Sincerely,
Your ___ Surgical Team
Followup Instructions:
___
|
10322266-DS-20 | 10,322,266 | 29,212,054 | DS | 20 | 2191-10-30 00:00:00 | 2191-11-06 23:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Zyprexa / Percocet / zaleplon / tramadol /
Dilaudid
Attending: ___.
Chief Complaint:
Diplopia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mrs. ___ is a ___ year old right-handed woman with a
past medical history of myasthenia ___, metastatic breast
cancer (spread to chest wall s/p chemo and radiation to chest),
hypothroidism and depression who presents to our ED following 2
days of noted diplopia, worsening ptosis and "heaviness of
breathing". She states that starting ___, later in the day,
she noticed double vision- when her husband was standing to her
left, she saw "two husbands", and saw one lamp right in front of
her. The diplopia improved with closing one eye. She has noted
worsened L ptosis. That same day, she had worked with her
trainer, walking 15 minutes with assistance, she then had more
difficulty walking. Most recently, she has trouble walking more
than between 2 rooms in her house.
She reports coughing both with eating solids as well as not when
eating. She has not had difficulty swallowing liquids. After
speaking with the on-call neurologist and discussion with Dr.
___ was asked to come to the ED for further
evaluation and plan for admission for therapy.
Mrs. ___ was recently hospitalized at ___ from ___
with symptoms of pptosis, dysphagia, shallow breathing and
weakness of the neck muscles. She was admitted to the ICU for
respiratory monitoring and non-invasive ventillation. EMG on
___ supported diganosis of Myasthenia ___. Subsequent
antibody evaluation with AChR antibody, modulating antibody, and
blocking antibody were all positive. She underwent a 5 day
course of IVIG. She was strated on Mestinon. Per patient, there
was discussion of starting Cellcept for disease modifying
therapy, but concern for recurrence of breast cancer in the
setting of immunosuppression, and this medication was not
started.
On neuro ROS, positive for blurred vision, diplopia, dysphagia,
difficulty speaking, difficulty walking long distances. The pt
denies headache, loss of vision, dysarthria, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, positive for chills, cough both
with eating and at rest. Increased frequency of urination as
well
as darkened appearance of urine today, no dysuria, has been
drinking less water to avoid getting up to go to the bathroom.
The pt denies recent fever. No recent weight loss or gain.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel habits. Denies arthralgias or myalgias. Denies
rash.
Past Medical History:
- Per patient, growth in kidney being monitored, due for MRI on
___
- Bilateral knee replacements
- Cholecystectomy (___)
- Left mastectomy complicated by tissue expander rupture (___)
- TRAM flap (___)
- TAH and bilateral salpingectomy c/b ureter injury and repair
(___)
- Appendectomy
- Two (2) ventral hernia repairs w/ mesh (last repair in ___
with Marlex)
- Repair of fracture of left wrist
- Exploratory-lap, LOA, resection of small bowel fistula with
mesh, primary anastomosis, and repair of abdominal wall defect
with AlloDerm (___) with Dr. ___
- Exploratory laparotomy, lysis of adhesions 3.5 hours, partial
colectomy and colocolostomy, feeding jejunostomy, drainage
abdominal wall abscess and culture, takedown of fistula, removal
of Marlex mesh and closure of enterotomy (___)
- Laparoscopic incisional hernia with prosthetic mesh and Lysis
of adhesions again in ___
Social History:
___
Family History:
-Mother passed away at age ___ - history of HTN
-Father passed away at age ___ - unknown causes
-Has 4 siblings alive and well. One brother passed away at age
___ from unknown causes.
She denies strong family history of cancer, diabetes,
respiratory disorders.
Physical Exam:
Admission Physical exam
Vitals:
VS- T 97.7, HR 96, BP 147/84, RR 18, O2 98% on RA
NIF -30, VC 1.29
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: Bruise to R shoulder
Neurologic:
-Mental Status: Alert, oriented x 3. 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. Able to follow both midline
and appendicular commands. The pt. had good knowledge of
current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: Does not quite bury sclera fully with bilateral
horizontal eye movements, no nystagmus, eye movements otherwise
full. Reports blurred vision on extreme left gaze. Normal
saccades. L ptosis on exam.
V: Facial sensation intact to light touch, ___ strength noted
bilateral in masseter
VII: No facial droop noted. Counts to 35 in one breath. Weakness
with left eye closure and mouth closure, can overcome both
easily.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. Full neck flexion/extension.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 5 5 ___ ___ 5 5 5 5 5
R 5 4* 4* ___ ___ 5 5 5 5 5
*Decreased effort- R elbow pain
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1* 1
R 2 2 2 2 1
*prior knee surgery
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch. No extinction to DSS.
-Coordination: No intention tremor, no dysmetria on FNF
-Gait: Normal-based gait. Some unsteadiness with tandem gait.
Romberg- sways forward but no falls.
Discharge physical exam:
GEN: breathing unlabored, even in supine position. Can count to
___ in one breath.
MS: Awake, alert, language fluent without dysarthria.
CN: Minimal left ptosis. Subjective diplopia on left and up
gaze, but no tropia seen. No dysarthria or orbicularis oris
weakness. Tongue strong.
Motor: 5+ throughout with no fatigability. No weakness of neck
extensors/flexors
Pertinent Results:
LABORATORY DATA
___ 08:25AM GLUCOSE-94 UREA N-13 CREAT-0.7 SODIUM-141
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
___ 08:25AM ALT(SGPT)-20 AST(SGOT)-48* ALK PHOS-70 TOT
BILI-0.3
___ 08:25AM cTropnT-<0.01
___ 08:25AM CK-MB-1
___ 08:25AM ALBUMIN-3.8 CALCIUM-9.6 PHOSPHATE-4.0
MAGNESIUM-2.0
___ 08:25AM TSH-15*
___ 08:25AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 08:25AM WBC-5.0 RBC-3.63* HGB-11.3 HCT-34.3 MCV-95
MCH-31.1 MCHC-32.9 RDW-15.2 RDWSD-51.8*
___ 08:25AM NEUTS-70.5 LYMPHS-15.9* MONOS-10.6 EOS-2.2
BASOS-0.6 IM ___ AbsNeut-3.54 AbsLymp-0.80* AbsMono-0.53
AbsEos-0.11 AbsBaso-0.03
___ 07:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 07:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-LG
___ 07:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-2* PH-6.0 LEUK-LG
___ 07:40AM URINE RBC-0 WBC-7* BACTERIA-NONE YEAST-NONE
EPI-7 TRANS EPI-1
___ 07:40AM URINE CA OXAL-MANY
MRI RENAL:
1. Unchanged left upper pole renal cystic lesion with an
internal enhancing nodule, concerning for a cystic renal cell
carcinoma.
2. Unchanged right adrenal adenoma.
3. Hepatic steatosis.
Brief Hospital Course:
Hospital course by problem:
Ms. ___ is a ___ F with hx of metastatic breast ca on
anastrazole, renal cell carcinoma, and myasthenia ___
admitted via ED after 2 days of worsening ptosis, diplopia, and
labored breathing concerning for MG exacerbation.
1. MG exacerbation: Recently diagnosed with +AchR Ab MG s/p IVIG
x5 days, on home pyridostigmine. Admitted from the ED ___
evening, with acute exacerbation. Treated with IVIG, which she
has tolerated well for a total course of 5 days. Her Mestinon
was increased to 60mg PO TID, with notable improvement of
symptoms. GI side effects were only minimal and resolved prior
to discharge. Her visual symptoms improved with the use of an
eye patch, and fatigability has decreased on exam. Inpatient
NIFs and vital capacity were stable throughout her inpatient
stay. She tried naphazoline drops without much benefit. We did
not initiate immunosuppressive therapy during this inpatient
stay.
2. Hypothyroidism: Chronic issue. Recently found to have
iatrogenic elevation of TSH s/p prior admission. Currently back
on adequate home levothyroxine dose. During this admission found
to be downtrending to 15. Per previous endocrinology reports
will need TSH checked in one month. Continued home dose
levothyroxine 175mcg PO qam.
3. Renal cell carcinoma: Chronic stable issue followed with
serial MRIs. Scheduled for opt MRI of the kidney ___.
Rescheduled MRI as inpatient, preliminary read showing:
- Unchanged left upper pole renal cystic lesion with an internal
enhancing nodule, concerning for a cystic
renal cell carcinoma.
- Unchanged right adrenal adenoma.
- Hepatic steatosis.
4. Hypertension: Chronic issue on home lisinopril 10mg po daily
s/p previous admission when her HCTZ was discontinued. Did have
persistent SBP elevation while admitted. Antihypertensive
regimen was restored to her prior home regimen: lisinopril to
20mg daily and HCTZ 25mg daily.
5. Infiltrating ductal breast ca stage IV: Known stable issue
managed on home anastrazole, which we have continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. anastrozole 1 mg oral DAILY
2. Levothyroxine Sodium 175 mcg PO DAILY
3. ALPRAZolam 0.5 mg PO TID:PRN anxiety
4. Simvastatin 20 mg PO QPM
5. zoledronic acid 4 mg injection Every 3 months
6. Pyridostigmine Bromide 30 mg PO TID W/MEALS
7. TraZODone 50 mg PO QHS:PRN insomnia
8. Multivitamins 1 TAB PO DAILY
9. Vitamin D 5000 UNIT PO DAILY
10. Calcium Carbonate 500 mg PO TID
11. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. anastrozole 1 mg oral DAILY
3. Levothyroxine Sodium 175 mcg PO DAILY
4. Pyridostigmine Bromide 60 mg PO TID
RX *pyridostigmine bromide 60 mg 1 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*1
5. Simvastatin 20 mg PO QPM
6. TraZODone 50 mg PO QHS:PRN insomnia
7. zoledronic acid 4 mg injection Every 3 months
8. Multivitamins 1 TAB PO DAILY
9. Vitamin D 5000 UNIT PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Hydrochlorothiazide 25 mg PO DAILY
12. Calcium Carbonate 500 mg PO TID
13. Cyanocobalamin 1000 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Myasthenia ___
Hypertension
Renal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___ Neurology service for treatment of
your myasthenia ___. ___ received IVIG for 5 days and
tolerated this well. We increased your Mestinon to 60mg three
times daily and ___ should continue this at home. We recommend
continuing light exercise early in the morning. Air
conditioning is recommended this ___ to minimize your
symptoms. ___ will continue myasthenia treatment on an
outpatient basis under the care of your neurologist, Dr.
___. If in the future, ___ should seek urgent medical
attention if ___ develop sudden shortness of breath, difficulty
swallowing, weakness or worsening of your vision.
While ___ were in the hospital, ___ had elevated blood pressures
and we restarted your home blood pressure medications. ___
should call your PCP tomorrow to have this rechecked.
We were also able to obtain the MRI of your pelvis which ___ can
review with your urologist and PCP.
Followup Instructions:
___
|
10322266-DS-21 | 10,322,266 | 27,120,900 | DS | 21 | 2192-02-16 00:00:00 | 2192-02-17 18:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Zyprexa / Percocet / zaleplon / tramadol /
Dilaudid
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with a history of metastatic
breast cancer, myasthenia ___, and recurrent small bowel
obstructions, previously managed conservatively, presented to
the ___ ED with RLQ pain of 1 day duration. She describes a
cramping sensation that started at noon the day prior to
presentation, initially located in the R flank and subsequently
migrating to the RLQ. She denies any migration of her pain, and
describes similarity of the camps to her previous small bowel
obstruction episode. The symptoms started in the setting of
increased vegetable, fruit, and soup intake the day prior.
Furthermore, she was started on a 10 day course of Bactrim for
presumed bronchitis, after a negative chest x-ray, having one
more dose to complete the course. She denies nausea, and had no
emesis episodes prior to presentation. She did have one episode
of emesis after ingesting PO contrast. She further denies any
changes in her bowel regimen, she has been passing gas and
having bowel movements up to the time of presentation. She
describes experiencing transient chills, but has been afebrile.
The patient had previously presented on ___ with abdominal
pain and multiple vomiting episodes. At that point the patient
was managed conservatively with NGT placement, NPO/IVF and was
discharged on hospital day 6.
Past Medical History:
- Per patient, growth in kidney being monitored, due for MRI on
___
- Bilateral knee replacements
- Cholecystectomy (___)
- Left mastectomy complicated by tissue expander rupture (___)
- TRAM flap (___)
- TAH and bilateral salpingectomy c/b ureter injury and repair
(___)
- Appendectomy
- Two (2) ventral hernia repairs w/ mesh (last repair in ___
with Marlex)
- Repair of fracture of left wrist
- Exploratory-lap, LOA, resection of small bowel fistula with
mesh, primary anastomosis, and repair of abdominal wall defect
with AlloDerm (___) with Dr. ___
- Exploratory laparotomy, lysis of adhesions 3.5 hours, partial
colectomy and colocolostomy, feeding jejunostomy, drainage
abdominal wall abscess and culture, takedown of fistula, removal
of Marlex mesh and closure of enterotomy (___)
- Laparoscopic incisional hernia with prosthetic mesh and Lysis
of adhesions again in ___
Social History:
___
Family History:
-Mother passed away at age ___ - history of HTN
-Father passed away at age ___ - unknown causes
-Has 4 siblings alive and well. One brother passed away at age
___ from unknown causes.
She denies strong family history of cancer, diabetes,
respiratory disorders.
Physical Exam:
Vitals:
T98.7, BP 152/68, HR 76, RR 20, Satting 95% on RA
General: No acute distress, alert and oriented X3
HEENT: atraumatic, normocephalic, oral mucosa moist, neck full
ROM
CV: regular rate and rhythm, normal S1, S2; no murmurs, rubs, or
gallops
Resp: clear breath sounds bilaterally
Abd: very mild RLQ tenderness, abdomen soft, non distended,
absent rebound
tenderness.
Extremities: no clubbing or cyanosis. No edema noted.
Pertinent Results:
On Admission:
___ 02:14AM BLOOD WBC-8.8# RBC-4.59 Hgb-12.8 Hct-40.0
MCV-87 MCH-27.9 MCHC-32.0 RDW-15.2 RDWSD-47.9* Plt ___
___ 02:14AM BLOOD Glucose-137* UreaN-22* Creat-1.3* Na-136
K-4.0 Cl-94* HCO3-30 AnGap-16
___ 10:50AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.0
___ 02:38AM BLOOD Lactate-2.0
___ 04:56PM BLOOD Lactate-1.1
On Discharge:
___ 09:18AM BLOOD WBC-3.1* RBC-3.79* Hgb-10.4* Hct-33.5*
MCV-88 MCH-27.4 MCHC-31.0* RDW-14.9 RDWSD-47.7* Plt ___
___ 09:18AM BLOOD Glucose-74 UreaN-9 Creat-0.8 Na-137
K-3.0* Cl-98 HCO3-28 AnGap-14
___ 09:18AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.9
___ 06:12AM BLOOD Lactate-1.0
Imaging:
CT abdomen and pelvis ___: 1. Multiple loops of
fluid-filled and dilated small bowel culminating in a small
bowel feces sign adjacent to an anastomotic site within the
right lower quadrant. These findings are compatible with small
bowel obstruction, in a similar location to the patient's prior
SBO on ___. Stranding is noted surrounding several loops
small bowel lower lower quadrant, but there is no evidence of
overt perforation, pneumatosis, or portal venous gas. 2. Stable,
known 3.5 cm exophytic renal cell carcinoma extending from the
superior pole of the left kidney, better characterized by prior
renal MRI. 3. Stable, right adrenal adenoma, also better
characterized on prior MRI. 4. Persistent, mild-moderate and
extrahepatic biliary ductal dilation has
perhaps slightly improved as compared to the prior CT
examination. Findings may be secondary to the patient's post
cholecystectomy state, but could be better evaluated by ___ if
clinically indicated.
CXR ___:
Lung volumes remain low. There is a moderate left-sided pleural
effusion, this appears to have increased slightly in extent
compared to the prior study. Multiple surgical clips project
over the left mid lung. There has been interval placement of a
nasogastric tube, the tip is in the stomach however the side
hole appears to be at the gastroesophageal junction and CT could
be advanced several cm.
CXR ___:
As compared to ___, the tube tip is visualized
within the body of the stomach. The lung volumes are very low
with basal atelectasis, slightly improved since the prior
examination. No pulmonary edema, pleural effusions or
pneumothorax.
Brief Hospital Course:
Ms. ___ initially presented to the ED on ___ with
complaints of abdominal pain. In the ED she was given fluids and
a CT abd was obtained. The CT abd revealed multiple loops of
dilated bowel with a distinct transition point in the RLQ. At
this point she was made NPO and placed on IV fluids. An NG tube
was placed and placement was verified with a Chest xray. She was
started on IV Ciprofloxacin and Flagyl as well.
The patient has been diagnosed with Myasthenia ___ and thus
neurology was consulted early on during her admission for
recomendations regarding her treatment. She would be given
Mycophenolate mofetil 1000 mg IV for treatment. She has been
doing IVIG treatments 2 times per week every two weeks and would
be due for a treatment on ___ and ___
which she recieved with proper premedication. Neurology followed
closely throughout the admission. See inpatient neuro progress
notes for a more extensive description of the neurologic
monitoring during her admission.
Neuro: The patient was alert and oriented throughout
hospitalization.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On POD3, the NGT
was removed and the diet was advanced sequentially 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, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a full
liquid diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 10 mg PO DAILY
2. Gabapentin 200 mg PO TID
3. Anastrozole 1 mg PO DAILY
4. Diazepam 10 mg PO Q6H:PRN as prescribed
5. zoledronic acid 4 mg intravenous Q 3 MONTHS
6. Tizanidine ___ mg PO Frequency is Unknown As directed by
prescriber
7. Simvastatin 20 mg PO QPM
8. Mycophenolate Mofetil 1000 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
11. Pyridostigmine Bromide 60 mg PO Frequency is Unknown five
times daily
12. Calcium Carbonate 500 mg PO TID:PRN as prescribed
13. Sulfameth/Trimethoprim DS 1 TAB PO BID
14. Hydrochlorothiazide 25 mg PO DAILY
15. Levothyroxine Sodium 175 mcg PO DAILY
16. Cyanocobalamin 1000 mcg PO DAILY
17. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Diazepam 10 mg PO Q6H:PRN as prescribed
2. Gabapentin 200 mg PO TID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Levothyroxine Sodium 175 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Mycophenolate Mofetil Suspension 1500 mg PO BID
RX *mycophenolate mofetil 200 mg/mL 7.5 ml by mouth twice a day
Refills:*0
7. Simvastatin 20 mg PO QPM
8. Tizanidine ___ mg PO ONCE As directed by prescriber Duration:
1 Dose
9. Anastrozole 1 mg PO DAILY
10. Calcium Carbonate 500 mg PO TID:PRN as prescribed
11. Cyanocobalamin 1000 mcg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO BID
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. Vitamin D 5000 UNIT PO DAILY
16. zoledronic acid 4 mg INTRAVENOUS Q 3 MONTHS
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Myasthenia ___
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 a small bowel
obstruction, which was treated conservatively with bowel rest,
intravenous fluids and ___ tube decompression. Given
return of bowel function and resolution of pain, it is likely
that your bowel obstruction has resolved. You are now
tolerating a full liquid diet and should gradually transition to
a low residue diet (see handout) beginning in the next few days.
Please not the additional following 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. Please crush all
medications. Also, please take any new medications as
prescribed.
Followup Instructions:
___
|
10322361-DS-19 | 10,322,361 | 22,057,791 | DS | 19 | 2186-01-08 00:00:00 | 2186-01-08 20:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cymbalta / Lyrica / Fentanyl
Attending: ___.
Chief Complaint:
numbness and weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with PVD s/p BLE
stenting, two separate occasions of stage IA/B NSCLC s/p
resection x 2 (RML, ___ and LLL, ___, and pancreatic
adenocarcinoma on gemcitabine/abraxane who presents with
numbness
and weakness.
She was recently admitted ___ to ___ for fatigue and decreased
PO intake found to be orthostatic and dehydrated with ___ which
improved after IVF resuscitation. She was evaluated with CTA due
to tachycardia which was negative.
She woke up the morning of ___ feeling weak in lower
extremities. Also noted numbness on buttocks after getting out
of
car that radiated down to her bilateral legs. She reports poor
PO
intake. She denies any back pain and bowel or bladder
incontinence.
On arrival to the ED, initial vitals were 98.3 118 118/54 18 96%
RA. Neurological exam was intact. Labs were notable for WBC 3.9,
H/H 7.8/24.9, Plt 217, Na 143, K 3.9, BUN/Cr ___, ALt 122,
AST
174, trop T < 0.01 x 2, and UA negative. Urine culture was sent.
CXR was negative. Patient was given 1L LR. Prior to transfer
vitals were 98.8 85 183/69 15 99% RA.
On arrival to the floor, patient reports numbness has resolved.
She denies fevers/chills, night sweats, headache, vision
changes,
dizziness/lightheadedness, shortness of breath, cough,
hemoptysis, chest pain, palpitations, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per OMR:
"two separate occasions of Stage IA/B ___ s/p resection x 2
(RML, ___ and LLL, ___ who was seen by Dr. ___ in
early ___ with complains of intermittent nausea, vomiting
and early satiety. EGD was performed which showed chronic
gastritis and H. pylori infection, for which she was treated
accordingly. CT scan was
performed which raised the concern for an abnormality in the
pancreatic head. Subsequent MRI was performed which confirmed
an
ill-defined 6mm focus in the posterior pancreatic head
concerning
for neoplasm.
Patient was referred to Dr. ___ underwent EUS on ___
which demonstrated a 5 x 7mm cystic lesion in the pancreatic
head/uncinate with abnormal surrounding parenchyma that was
poorly defined, measuring approximately 1.5cm. FNA returned
atypical, but concerning for adenocarcinoma.
She was admitted to ___ ___ with increased pain,
N/V, dehydration and elevated lipase, managed conservatively
with
rehydration. Continued to have low-level symptoms since that
time, some felt to be related to Prevpac for HP treatment.
Repeat EUS was performed on ___ with similar findings as prior
endosonographic study, FNB performed of abnormal panenchyma
which
returned positive for moderately-differentiated adenocarcinoma.
Referred to ___ to discuss treatment options. She was seen on
___ and the assessment was that she had locally advance
disease and the recommendation was for treatment with
gemcitabine
and abraxane with palliative intent.
___ C1D1 Abraxane/Gemcitabine
___ C1D8 Abraxane/Gemcitabine - Held
___ C1D15 Abraxane/Gemcitabine"
PAST MEDICAL HISTORY:
-NSCL adenocarcinoma (RML s/p VATS x2 (stage IA/B, T1N0M0, ___
and LLL s/p lobectomy (stage IA/B , T1N0M0, ___, no adjuvant
chemotherapy (followed by Dr. ___ Dr.
___ Nodule
-HTN
-HLD
-PVD s/p B/L common iliac stenting (___)
-H/O C. diff colitis following lung surgery
Social History:
___
Family History:
Sister had premenopausal uterine cancer and another sister with
breast cancer. Mother with lung CA.
Physical Exam:
===================
ADMISSION PHYSICAL EXAM:
===================
VS: Temp 98.5, BP 148/77, HR 90, RR 18, O2 sat 99% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
===================
DISCHARGE PHYSICAL EXAM:
===================
___ 1507 Temp: 98.6 PO BP: 127/76 HR: 107 RR: 18 O2 sat:
99% O2 delivery: RA
GENERAL: Pleasant woman, in no distress, sitting up in bed
comfortably
HEENT: Anicteric, PERLL, EOMI, OP clear.
CARDIAC: RRR, ___ systolic murmur at LUSB.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, CNII-XII
grossly intact, normal heel-to-shin, sensation to fine touch and
proprioception intact in lower extremities. Strength ___ in L
quadriceps otherwise ___ in all muscle groups. No saddle
anesthesia. No pain to palpation of lumbar spine. Normal range
of motion of spine with flexion, extension and rotation
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
Pertinent Results:
LABS ON ADMISSION:
===================
___ 10:50AM WBC-3.3* RBC-4.21 HGB-8.8* HCT-28.5* MCV-68*
MCH-20.9* MCHC-30.9* RDW-17.7* RDWSD-40.2
___ 10:50AM NEUTS-40 ___ MONOS-8 EOS-3 BASOS-0 NUC
RBCS-2.7* AbsNeut-1.32* AbsLymp-1.62 AbsMono-0.26 AbsEos-0.10
AbsBaso-0.00*
___ 10:50AM ALBUMIN-3.4* CALCIUM-9.6 PHOSPHATE-2.4*
MAGNESIUM-2.1
___ 10:50AM ALT(SGPT)-55* AST(SGOT)-61* ALK PHOS-76 TOT
BILI-0.3
___ 10:50AM UREA N-8 CREAT-0.9 SODIUM-141 POTASSIUM-3.8
CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
___ 03:42PM NEUTS-61.8 ___ MONOS-7.9 EOS-0.0*
BASOS-0.3 NUC RBCS-1.3* IM ___ AbsNeut-2.42 AbsLymp-1.14*
AbsMono-0.31 AbsEos-0.00* AbsBaso-0.01
___ 03:42PM WBC-3.9* RBC-3.64* HGB-7.8* HCT-24.9* MCV-68*
MCH-21.4* MCHC-31.3* RDW-17.8* RDWSD-41.2
___ 03:42PM ALBUMIN-3.4*
___ 03:42PM cTropnT-<0.01
___ 03:42PM LIPASE-95*
___ 03:42PM ALT(SGPT)-122* AST(SGOT)-174* ALK PHOS-75 TOT
BILI-0.5
___ 03:42PM GLUCOSE-81 UREA N-15 CREAT-1.1 SODIUM-143
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-24 ANION GAP-13
___ 06:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 06:06PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
MICRO:
======
UCx: mixed flora
STUDIES:
========
CXR ___: No acute cardiopulmonary abnormality.
RUQUS ___:
1. Patent hepatic vasculature. There is however a blunted
systolic waveform in the main hepatic artery and decreased
resistive index which can be seen in the setting of proximal
arterial narrowing in the setting of known common hepatic
arterial involvement of the patient's pancreatic malignancy.
2. Cholelithiasis without gallbladder wall thickening.
LABS ON DISCHARGE:
==================
___ 05:30AM BLOOD WBC-5.2 RBC-3.92 Hgb-8.6* Hct-26.8*
MCV-68* MCH-21.9* MCHC-32.1 RDW-19.0* RDWSD-44.4 Plt ___
___:30AM BLOOD ___ PTT-32.2 ___
___ 05:30AM BLOOD Glucose-102* UreaN-11 Creat-0.8 Na-139
K-4.2 Cl-104 HCO3-25 AnGap-10
___ 02:00PM BLOOD ALT-111* AST-89* AlkPhos-83 TotBili-1.0
___ 05:30AM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.8 Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ female with PVD s/p BLE
stenting, two separate occasions of stage IA/B NSCLC s/p
resection x 2 (RML, ___ and LLL, ___, and pancreatic
adenocarcinoma on gemcitabine/abraxane who presents with
numbness
and weakness, now resolved. Her course was complicated by
transaminitis likely secondary to chemotherapy side effects, by
___ resolved with IVF, anemia of malignancy s/p 1u pRBC.
TRANSITIONAL ISSUES:
[] patient noted to have abdominal bruit on exam c/f hepatic
artery obstruction v RAS v aortic calcification. Please
correlate on upcoming CTA pancreas scheduled for ___
[] given repeat AKIs and dehydration, valsartan-hctz was
switched for amlodipine.
[] repeat LFTs as outpatient
# Cancer-Related Fatigue:
# Weakness/Numbness: fatigue and weakness/numbness likely
secondary to recent chemotherapy. Numbness resolved without
intervention.
# Acute Kidney Injury: Cr 1.1 on admission with baseline of
0.6-0.8. Mild ___ secondary to hypovolemia from decreased PO
intake compounded by anti-hypertensive use
(valsartan/hydrochlorothiazide). Improved to baseline with 1L
IVF overnight.
# Fever: Patient had one temperature to 100.9 while admitted.
Urine without infection, CXR clean, RUQUS without biliary
dilation, and overall patient not complaining of any obvious
localizing symptoms. It is possible this is due to malignancy
itself. She has been informed that if she has any additional
fever or feels unwell after discharge, to notify her MD
immediately.
# Anemia in Malignancy: Hgb drop likely dilutional as no signs
of active bleeding or hemolysis. Patient received 1u pRBC on
___.
# Transaminitis: ___ be related to chemotherapy as both
gemcitabine and paclitaxel can cause transaminitis. Patient has
had mild transaminitis since chemo initiation but currently
ALT/AST significantly higher and rising on repeat
today.Alternatively, would be concerned for PVT given
pro-coagulant effect of malignancy. Unlikely to be related to
biliary obstruction as bili/alk phos are completely normal.
RUQUS was obtained and showed some possible narrowing of the
hepatic artery (iso known disease there) but no evidence of
thrombosis or other concerning lesions. LFTs peaked and improved
prior to d/c. Patient's oncologist Dr. ___ of this
issue.
# Hypertension: held hypertensives overnight. Given recurrent
dehydration and ___, she was switched to amlodipine for blood
pressure control.
# PVD: Continued home ASA
# Severe Malnutrition: Continued supplementation with
ensure/frappes and MVI
She was discharged to home with services on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 162 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Mirtazapine 7.5 mg PO QHS
4. Omeprazole 20 mg PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Pravastatin 20 mg PO QPM
8. Senna 8.6 mg PO BID:PRN constipation
9. Vitamin A ___ UNIT PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Ascorbic Acid ___ mg PO DAILY
12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
13. valsartan-hydrochlorothiazide 320-25 mg oral DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Thiamine 100 mg PO DAILY
16. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 162 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Mirtazapine 7.5 mg PO QHS
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Pravastatin 20 mg PO QPM
12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
13. Senna 8.6 mg PO BID:PRN constipation
14. Thiamine 100 mg PO DAILY
15. Vitamin A ___ UNIT PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
Numbness and tingling
Transaminitis
Anemia of malignancy
Hypertension
SECONDARY
Pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___!
You came to the hospital because you were having numbness in
your legs. The numbness resolved on its own, but we found that
your liver tests were abnormal. You had an ultrasound of your
liver which showed some possible narrowing of one of the
arteries that feeds blood to the liver, but was otherwise
normal. We think the lab results were likely related to your
chemotherapy which can cause this sometimes. Reassuringly, your
liver tests started to come down on their own, and you were safe
for discharge.
While in the hospital, you also received a unit of blood because
of your chronically low blood counts. Because you had worsening
kidney tests likely due to mild dehydration, we stopped your
blood pressure medication. We exchanged it with another one that
affects the kidneys less.
You did have one fever while admitted, however this was
self-limited and we did not find any obvious source of
infection. If you have another fever at home, please contact
your doctor.
Please continue with our chemotherapy care as advised by your
Oncology team. Remember to stay hydrated and to drink lots of
fluids.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10322361-DS-21 | 10,322,361 | 29,208,836 | DS | 21 | 2186-06-24 00:00:00 | 2186-06-24 20:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cymbalta / Lyrica / Fentanyl
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
===============
Admission labs
===============
___ 11:20AM BLOOD WBC-4.9 RBC-3.93 Hgb-8.7* Hct-28.5*
MCV-73* MCH-22.1* MCHC-30.5* RDW-17.0* RDWSD-41.7 Plt ___
___ 11:20AM BLOOD Neuts-68.5 Lymphs-14.8* Monos-14.5*
Eos-1.6 Baso-0.4 Im ___ AbsNeut-3.34 AbsLymp-0.72*
AbsMono-0.71 AbsEos-0.08 AbsBaso-0.02
___ 11:20AM BLOOD Plt ___
___ 11:20AM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-141
K-3.6 Cl-106 HCO3-24 AnGap-11
===============
Pertinent labs
===============
___ 03:01AM BLOOD ___ PTT-36.7* ___
___ 06:20AM BLOOD ___ PTT-39.2* ___
___ 08:15PM BLOOD Neuts-69.8 Lymphs-15.7* Monos-13.1*
Eos-0.6* Baso-0.3 Im ___ AbsNeut-4.30 AbsLymp-0.97*
AbsMono-0.81* AbsEos-0.04 AbsBaso-0.02
===============
Discharge labs
===============
___ 05:45AM BLOOD WBC-5.2 RBC-3.64* Hgb-8.3* Hct-26.8*
MCV-74* MCH-22.8* MCHC-31.0* RDW-19.0* RDWSD-47.9* Plt ___
___ 05:45AM BLOOD Glucose-92 UreaN-12 Creat-0.9 Na-141
K-3.9 Cl-106 HCO3-24 AnGap-11
___ 05:45AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
===============
Studies
===============
CTA Abdomen/Pelvis (___):
1. Large proximal right thigh intramuscular hematoma within the
sartorius
measuring up to 13.4 cm with a small focus of active arterial
extravasation.
2. Small bilateral pleural effusions, new from prior study.
3. Fiducial markers within the pancreatic head tumor, not
substantially
changed from prior study with unchanged soft tissue encasement
of the celiac,
common hepatic, SMA, and partial encasement of the portal vein
confluence.
4. Stable right adrenal gland nodule and thickening of the left
adrenal gland.
5. Bilateral common and external iliac artery stents appear
patent and in
stable position. Unchanged occlusion of the celiac artery
origin and
extensive atherosclerotic disease.
6. Diverticulosis without evidence of diverticulitis.
7. Trace free fluid within pelvis.
Right Unilateral UE US (___):
There is normal flow with respiratory variation in the bilateral
subclavian veins. The central/inferior aspect the right internal
jugular vein is diminutive, and contains internal echogenic
debris. The vessel does not fully compress and lacks
wall-to-wall flow on color Doppler imaging compatible with
nonocclusive deep vein thrombosis. The right axillary, and
brachial veins are patent, show normal color flow, spectral
doppler, and compressibility. The right basilic, and cephalic
veins are patent, compressible and show normal color flow.
IMPRESSION:
Nonocclusive likely port associated deep vein thrombosis within
the
central/inferior right internal jugular vein.
===============
Microbiology
===============
None
Brief Hospital Course:
Transitional issues:
===================
[] At recommendation of hematology team, patient apixaban for
IVC clot is being held at time of discharge. Please ensure
patient attends ___ follow up Heme-Onc appt to consider
re-initiation
[] Patient takes aspirin for history of iliac stents (___)
however, per outpatient cardiology note, may not require
anti-platelet therapy for this indication while on apixaban. Asa
held at time of discharge, would consider holding for duration
of apixaban therapy.
[] Systolic murmur and ?abdominal bruit. Consider TTE and
abdominal ultrasound for AAA.
[] Had small bilateral pleural effusions on admission CTA.
Please follow-up and repeat CT or chest x-ray as could be
malignant in etiology.
[] Patient was intermittently hypertensive during
hospitalization and blood pressures should be closely monitored
[] Please recheck EKG for QTC monitoring as on Zofran and
prochlorperazine.
ASSESSMENT AND PLAN:
====================
___ female past medical history of pancreatic
adenocarcinoma (s/p gemcitabine and radiation), stage Ia/b NSCLC
s/p resection (RML ___ and LLL ___, htn, and right IJ clot on
apixaban admitted with right thigh hematoma and hypertension.
Patient remained hemodynamically stable, requiring 1 unit of
packed red cells with improving pain and size of right thigh
hematoma.
ACUTE ISSUES:
=============
#Right thigh hematoma
#Acute on Chronic microcytic anemia
Patient presented with likely atraumatic right thigh hematoma in
the setting of being on anticoagulation for right IJ thrombus in
setting of possible 'bumping of leg' at home. Had CT scan with
some arterial extravasation. Seen by ACS/vascular
surg/interventional radiology who recommended conservative
management with compression and serial H&H's and her hemoglobin
stabilized without surgical intervention. Per hematology recs,
anticoagulation was recommended to be held at discharge until
follow-up with hematology/oncologist. Of note, patient has
chronic microcytic anemia is likely in the setting of her
chemotherapy, malnutrition, as well as anemia of chronic
disease.
#Right IJ thrombus.
#DVT prophylaxis
Patient on apixaban for right IJ thrombus in the setting of
right port-A-Cath. Noted incidentally on CT scan ___. Given
her active bleeding in the right thigh, held apixaban during
hospital course. While patient has a relatively high risk of
clotting due to her malignancy and history of clots,
anticoagulation was still held in setting of active bleed on
admission. Placed TEDs for ppx. Given clot still present on
repeat U/S on ___, discussed anticoagulation with hematology,
and it was recommended that anticoagulation be held until
outpatient follow-up with hematology/oncology.
#Hypertension
Patient with history of hypertension previously managed on
amlodipine, however was discontinued due to hypotension per
patient's report. In the emergency department, she had systolic
blood pressures greater than 200. She was restarted on
amlodipine 10 mg p.o. She was asymptomatic throughout her stay
(no headache/nausea/vomiting/blurry vision/chest pain/shortness
of breath). While patient continued to be hypertensive with SBP
to 180's and 190's on day of discharge, her blood pressure also
dropped 115/73 with a single dose of hydralazine 25 mg. Given
the lability of her blood pressures, she was discharged with
amlodipine as her sole antihypertensive, to avoid any issues
with decreased perfusion. Will need hypertension evaluation as
an outpatient to determine if needs a second agent given
persistently hypertensive on amlodipine.
#Stage III pancreatic adenocarcinoma
Patient of Dr. ___ completed her treatment with Gemzar
on ___. She completed her radiation treatment on
___. CA ___ was normal on most recent check. She is
scheduled to have a CT scan on ___. Continued on home
oxycodone and Creon.
CHRONIC ISSUES:
===============
#Peripheral vascular disease
#Hyperlipidemia
Continue home pravastatin. Aspirin was held at discharge, with
planning for resumption of aspirin to be discussed at follow-up
hematology/oncology appointment.
#Chronic constipation
Continued home docusate. Ordered miralax and senna PRN during
hospitalization. Counseled patient on discharge to consistently
use PRN miralax and senna in order to ensure she has bowel
movements.
#Stage Ia/B lung adenocarcinoma
Status post resection. Patient with a lung nodule that is
followed by CT scans that has been stable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 162 mg PO DAILY
2. Creon ___ CAP PO TID W/MEALS
3. Mirtazapine 7.5 mg PO QHS
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
7. Docusate Sodium 100 mg PO BID
8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Pravastatin 20 mg PO QPM
11. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
12. Senna 8.6 mg PO BID:PRN constipation
13. Apixaban 5 mg PO BID
14. bee pollen 500 mg oral Daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. bee pollen 500 mg oral Daily
4. Creon ___ CAP PO TID W/MEALS
5. Docusate Sodium 100 mg PO BID
6. Mirtazapine 7.5 mg PO QHS
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Pravastatin 20 mg PO QPM
13. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
14. Senna 8.6 mg PO BID:PRN constipation
15. HELD- Apixaban 5 mg PO BID This medication was held. Do not
restart Apixaban until you discuss with your
hematologist/oncologist
16. HELD- Aspirin 162 mg PO DAILY This medication was held. Do
not restart Aspirin until you discuss with your
hematologist/oncologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary issues:
Right thigh hematoma
Right IJ thrombus
Hypertension
Secondary issues:
Stage III Pancreatic adenocarcinoma
Peripheral vascular disease
Chronic constipation
Stage Ia/B lung adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
===================================
- You were admitted because you had right leg pain and were
found to be bleeding into your leg.
What happened while I was in the hospital?
==========================================
- You were evaluate by the trauma surgery and radiology teams
who determined that you did not require any procedure as the
bleeding was improving on its own.
- We applied a bandage that put pressure on the area of blood.
This helped the bleeding stop.
- You had your blood counts monitored and they remained stable
- Your aspirin and apixaban were held. We discussed the case
with the hematology team and they recommended holding these
until your next outpatient appointment with your
hematologist/oncologist.
-We repeated the ultrasound of your neck that showed that the
blood clot was unchanged
What should I do after leaving the hospital?
============================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10322363-DS-11 | 10,322,363 | 26,073,616 | DS | 11 | 2131-08-08 00:00:00 | 2131-08-08 16:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Valtrex / Telfa dressing
Attending: ___.
Chief Complaint:
bloody diarrhea
Major Surgical or Invasive Procedure:
Colonoscopy ___
History of Present Illness:
Mr ___ is a ___ year old male with a history of type 1
neurofibromatosis and significant coronary artery disease who is
now transferred from ___ for ischemic colitis.
Mr ___ symptoms began suddenly on the afternoon of ___.
After drinking a hot chocolate, he experienced the sudden onset
of b/l LQ abdominal pain LLQ > RLQ. Described as sharp/constant
in nature. His symptoms have been exacerbated by food, incl
water. Within a few hours he also developed nausea/vomiting and
bloody bowel movements (first BM he had was bloody). N/V
resolved after a few hours, but he has since had multiple
episodes of bloody diarrhea. Last eipsode was at 0800 on ___.
Has not eaten significantly since onset given pain, and has not
taken any medications for 2 days.
He subsequently presented to his PCP on the morning of ___
Presented to PCP this AM who referred to ___. At ___
___, labs notable for WBC 21, lactate 1.8, hgb 15.7. CT
abdomen c/w ischemic colitis. Recv'd 1L NS and ertapenem at OSH
___.
Patient currently reports continued LLQ abdominal pain. Denies
fevers, chills, dizziness, chest pain, shortness of breath,
nausea, vomiting, diarrhea, dysuria. Reports occasional bloody
BM since ___ that he attributed to hemorrhoids. Last
colonoscopy ___. Family history of "colitis", aunt
required resection.
___ COURSE
In the ___, initial vitals were: 3 98.3 97 131/65 93% RA
- Labs were significant for WBC 20k, otherwise unremarkable
- The patient was given hydromorphone
Vitals prior to transfer were: 2 99.6 104 126/73 12 94% RA
Past Medical History:
1. CAD: ___: 3.0 x 15 mm Vision BMS to proximal Cx; LHC at
___ in ___: 40% ostial LM. 99% mid LAD lesion. Cx with
patent stent. RCA mid diffuse disease. s/p three Xience stents
to the LAD. Pressure wire of LM -lesion insignificant. ___
pt had cardiac cath and 2 overlapping DES to the RCA
2. Neurofibromatosis, Type 1. ___ chest CT: plaque in
thoracic aorta, coronaries. No pulmonary abnormality. Patient
reports stable intracranial mass, ? d/t neurofibromatosis
3. Prostate cancer s/p radical prostatectomy
4. Obesity
5. ___ esophagus, esophageal stricture s/p dilations
6. Umbilical hernia s/p repair
7. Hemorrhoids s/p surgery x 3 with remote bleeding
8. Asthma
9. B/L leg pain: prior non-invasive testing without evidence of
PAD
10. Shingles , post herpetic trigeminal neuralgia
11. DJD of knees s/p left knee replacement
12. Spinal stenosis/ cervical radiculopathy. Patient reports 10
prior spinal surgeries
13. Osteoporosis
14. s/p resection of skin cancers
15. s/p cholecystectomy
___. Essential Hypertension
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Reported
family history of 'colitis', aunt reportedly had a resection.
Physical Exam:
==================
ADMISSION EXAM:
==================
Vitals: 98.4 133/82 80 18 91/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Faint rales in LLL that improve with coughm but
otherwise clear to auscultation bilaterally with good movement
in all fields. Abdomen: Soft, TTP difusely, but worse in LLQ.
non-distended, bowel sounds hypoactive, no organomegaly, no
rebound or guarding
GU: No foley
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Skin: Multiple scattered neurofibromas
=================
DISCHARGE EXAM:
=================
VITALS: Tm/c 99.3, 116/54, 52, 18, 89-92RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple
RESP: few bibasilar crackles, otherwise clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: +BS, soft, nondistended, tender to palpation in left lower
quadrant. No rebound, no guarding.
GU: no foley
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: multiple nodules over face and body consistent with
neurofibromatosis
Pertinent Results:
=================
ADMISSION LABS:
=================
___ 07:05PM WBC-20.0*# RBC-4.77 HGB-14.6 HCT-45.1 MCV-95
MCH-30.6 MCHC-32.4 RDW-14.0 RDWSD-48.7*
___ 07:05PM NEUTS-76.2* LYMPHS-15.0* MONOS-7.5 EOS-0.3*
BASOS-0.5 IM ___ AbsNeut-15.24* AbsLymp-3.00 AbsMono-1.50*
AbsEos-0.06 AbsBaso-0.10*
___ 07:05PM PLT COUNT-256
___ 07:05PM ___ PTT-30.4 ___
___ 07:05PM GLUCOSE-91 UREA N-14 CREAT-1.0 SODIUM-138
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-16
___ 07:05PM ALT(SGPT)-13 AST(SGOT)-19 ALK PHOS-140* TOT
BILI-1.2
___ 07:05PM ALBUMIN-3.6
___ 07:16PM LACTATE-1.5
=================
DISCHARGE LABS:
=================
___ 09:03AM BLOOD WBC-8.3 RBC-4.59* Hgb-13.9 Hct-42.7
MCV-93 MCH-30.3 MCHC-32.6 RDW-13.7 RDWSD-46.3 Plt ___
===========
IMAGING:
===========
OSH CT READ:
Impression:
1. Abnormal bowel wall thickening distal transverse and left
colon
with surrounding inflammatory changes in the small amount of
pericolonic fluid consistent with ischemic colitis. No
diverticula in
this area. No perforation or bowel wall pneumatosis.
2. Extensive sigmoid diverticula without diverticulitis.
3. Left paramidline sphghelian hernia.
4. Other findings as described above
CXR ___: The atelectasis in the left midlung. Low lung
volumes likely contribute to the findings suggestive of mild
pulmonary vascular congestion.
CT ABDOMEN/PELVIS ___:
1. Continued wall thickening and mucosal hyperenhancement of
the left colon concerning for colitis, inflammatory, infectious
or ischemic in etiology with ischemia being a possibility as
this is a watershed area for the SMA and ___.
2. Patent celiac and SMA. Narrowing of the ___ at its origin
but the artery is patent.
CXR ___:
Minimal increased opacity at the right lung base likely reflects
atelectasis.
Continued attention on followup recommended.
ABDOMINAL DUPLEX ___:
IMPRESSION:
Difficult ultrasound study due to the technical limitations.
Mildly elevated velocities are visualized within the celiac and
superior mesenteric arteries however there are only mild
elevations and there is no evidence of a severe stenosis.
Correlation with a recent CT scan is suggested.
COLONOSCOPY ___:
Impression: Erythema, friability and ulceration in the splenic
flexure and descending colon (biopsy)
Given the patient's comfort and fair prep, the colonoscope was
intubated to the right colon. Mucosa in the transverse and right
colon appeared normal. Limited views of the cecum with within
normal limits.
Otherwise normal sigmoidoscopy to ascending colon
Recommendations: - follow-up biopsies
- continue supportive care and C.diff management
============
OLD RECORDS:
============
Colonoscopy ___: Impression: Normal mucosa in the whole
colon
Diverticulosis of the sigmoid colon. Grade 3 internal
hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
ASSESSMENT/PLAN: ___ year old man with a history of type 1
neurofibromatosis and CAD s/p multiple stents, spinal stenosis,
who is now transferred from ___ for ischemic colitis.
# Colitis: Patient with convincing history of acute pain
followed by bloody BMs, history of vascular disease, and
evidence of territorial colitis on OSH CT imaging, confirmed
with CTA here. Received ertapenem at OSH and fluids. ACS
evaluated and there were no immediate surgical interventions.
Precipitant for acute ischemia unclear at this time plaque
rupture vs med effect vs VTE. Lactate has remained normal.
Mesenteric duplex show increased velocities in SMA/celiac
arteries but no stenosis. GI consulted and did colonscopy which
revealed ulcerations in splenic flexure down to descending colon
in a linear manner without pseudomembranes. Appearance was most
consistent with ischemic colitis which was healing. Biopsies
also taken. Of note patient was continued on cipro/flagyl from
day 1 of admission as he had a leukocytosis. C.diff came back
positive on ___ with PO vanc commencement and Cipro/flagyl
dc'd. Other stool studies non-revealing. Patient was discharged
pain-free.
#Hypotension: On ___, patient's anti-hypertensives were
restarted and patient's SBP in the ___, however patient
asymptomatic and not orthostatic. Anti-hypertensives were
discontinued and were recommended to be restarted as an
outpatient as patient's BP would tolerate. BP had normalized on
day of discharge.
# Leukocytosis: Patient with wbc 20 on admission, given
ertapenem at OSH. Slight decrease in wbc to 18 on ___. Patient
has remained afebrile. Most likely this is secondary to
infectous colitis from C.diff. Patient's white cell count
normalized on day of discharge. PO vanc should be continued
until ___.
# Hypoxia: Patient reports his oxygen always is low when he
receives narcotics. No AMS. Lung exam with few crackles at
bases. ECHO ___ showed EF 60%. CXR showed left lung atelectasis
and some pulmonary congestion, but not overwhelming. Initially
no evidence of edema on exam. However breathing comfortably on
RA after 24 hours..
# CAD: Continued aspirin, clopidogrel, atorvastatin
# Neurofibromatosis: Stable
# HTN: Discontinued before discharge. Should be restarted as an
outpatient
# GERD: Continued pantoprazole
TRANSITIONAL ISSUUES:
-please continue PO vancomycin 125mg q6h until ___
-please f/u GI biopsies
-please f/u final stool studies
-patient underwent CTA on ___ which r/o PE but incidental
hypodense nodules in left thyroid lobe were visualized and
follow-up with
non-emergent ultrasound is recommended as an outpatient.
-please restart BP meds as BP tolerates at next PCP ___. BP
meds were held in setting of patient having ischemic colitis.
#CODE: full
#COMMUNICATION: ___ (wife): ___ cell
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 20 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Atorvastatin 40 mg PO QPM
6. Clopidogrel 75 mg PO DAILY
7. Atenolol 100 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
10. Pantoprazole 40 mg PO Q24H
11. Amlodipine 5 mg PO DAILY
12. FoLIC Acid ___ mcg PO DAILY
Discharge Medications:
1. Amitriptyline 20 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
7. FoLIC Acid ___ mcg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*48 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Ischemic Colitis
C.diff infection
Hypoxia
SECONDARY DIAGNOSIS:
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital for abdominal pain and bloody diarrhea.
___ were evaluated by our Gastroenterologists and Surgeons. ___
underwent a colonoscopy which revealed some ulcerations
consistent with ischemic colitis. ___ were treated with
antibiotics after your C.diff test came back positive. ___ will
need to continue the antibiotics for a total of two weeks (start
date ___- stop date ___
___ had low oxygen levels, which were thought to be due to
narcotic pain medications given to ___ during this
hospitalization which resolved after the medications were
stopped.
We wish ___ the best of health,
Your medical team at ___
Followup Instructions:
___
|
10322458-DS-6 | 10,322,458 | 20,882,025 | DS | 6 | 2166-12-08 00:00:00 | 2166-12-12 22:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
latex
Attending: ___.
Chief Complaint:
Trauma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ male presents with the above s/p bicycle accident. Pt
was
biking down steep hill when his bike tire caught on something in
road and he flipped over handlebars. No loss of consciousness.
Helmeted.
Landed on R side and R shoulder.
Taken to ___ where CT head and C spine were
negative.
Imaging there revealed R 8th rib fx, small R sided PTX (___),
R
clavicle fx, and R pubic ramus fx at junction of superior pubic
ramus.
Past Medical History:
Glaucoma
Asthma
Social History:
___
Family History:
Non-contributory
Physical Exam:
General - NAD, conversant
HEENT: PERRLA, EOM intact, head normocephalic, atraumatic,
sclera anicteric
Cardiovascular RRR
Lungs Decreased breath sounds on R, no crackles, no increased
work of breathing
Skin - No rashes, skin warm, well perfused, no erythematous
areas
Abdomen - Normal bowel sounds, abdomen soft and non-tender
Extremities - No edema, cyanosis or clubbing
Musculoskeletal - ___ strength, limited range of motion R
shoulder secondary to pain
Neurological Alert and oriented x 3, CN ___ grossly intact.
Pertinent Results:
___ 07:27AM BLOOD WBC-8.9 RBC-4.94 Hgb-14.6 Hct-45.3 MCV-92
MCH-29.6 MCHC-32.2 RDW-13.6 RDWSD-45.6 Plt ___
___ 09:55PM BLOOD WBC-13.1* RBC-5.20 Hgb-15.3 Hct-47.6
MCV-92 MCH-29.4 MCHC-32.1 RDW-13.2 RDWSD-44.5 Plt ___
___ 09:55PM BLOOD Neuts-82.7* Lymphs-8.9* Monos-7.5
Eos-0.1* Baso-0.3 Im ___ AbsNeut-10.84* AbsLymp-1.17*
AbsMono-0.98* AbsEos-0.01* AbsBaso-0.04
___ 07:27AM BLOOD Plt ___
___ 07:27AM BLOOD Glucose-88 UreaN-24* Creat-1.0 Na-141
K-3.7 Cl-106 HCO3-24 AnGap-15
___ 09:55PM BLOOD Glucose-103* UreaN-27* Creat-1.2 Na-136
K-5.0 Cl-104 HCO3-22 AnGap-15
Brief Hospital Course:
The patient presented to the Emergency Department on ___ as a Trauma transferred from ___ following a
cycling accident. Upon arrival to ED the images obtained at the
OSH were reviewed and identified a R 8th rib fx, small R sided
pneumothorax (___), R clavicle fx, and R pubic ramus fx at
junction of superior pubic ramus.
Given findings, the patient was transported to the ward for
further observation. He was evaluated by the Orthopedic Surgery
team and was sent home with a right upper extremity sling and
axillary crutches.
Neuro: The patient was alert and oriented throughout
hospitalization. His pain was well controlled.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
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:
Albuterol Inhaler ___ puff q4h
___ 10 mg PO daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN asthma
5. Montelukast 10 mg PO DAILY asthma
Discharge Disposition:
Home
Discharge Diagnosis:
Small right pneumothorax
R displaced clavicle fracture
R rib fracture 8th rib
R pubic ramus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
you were admitted to ___ surgery service after sustaining a
bike accident, you had multiple fractures including your ___
bone on the Rt Rt ribs and Fx in your pelvic bones. You were
treated with pain medication and was observed.
you had a CT head and C spine that were negative.
Imaging there revealed R 8th rib fx, small R sided pneumothorax
treated conservatively.
You were seen by orthopedics that recommended you can bear
weight on your Rt leg as tolerated and also recommended to avoid
bear weight on your Rt hand.
CXR on the day of your discharge showed residual PTX with no
increase.
you are now ready to be d/c home with the following
recommendation:
* Rib fractures can cause severe pain and subsequently cause
you to take shallow breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Please resume all regular home medications, unless
specifically advised not to take a particular medication. Also,
please take any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications
Followup Instructions:
___
|
10322592-DS-7 | 10,322,592 | 26,023,713 | DS | 7 | 2197-01-19 00:00:00 | 2197-01-20 10:00:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / birth control
Attending: ___.
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of HTN, hypothyroidism who presented to ED s/p 4days
of atraumatic back pain x3 days. Began on ___ upon awakening,
progressively worsening, until ___ morning when patient could
not move and called EMS. Used aleve at home for pain and
exercises from her chiropractor but did not improve, worsen s/p
exercises. Has had a hx of lumbar subluxation, but does not see
her chiropractor regularly - only when symptomatic. She called
EMS and per run report she noted ___ mid back pain x 3 days."
No radiation of pain down legs. Pain awakens patient at night
with any movement. Denies recent trauma, change activity,
bowel/bladder incontinence, chiropractor manipulation. She
denies history of nephrolithiasis, fever/chills, weight loss,
dysuria.
In the ED, initial vitals were: ___ pain, Afebrile, HR 86,
117/57, 97%RA
Past Medical History:
ADHD
BACK PAIN
DEPRESSION
HYPOTHYROIDISM
COLONIC ADENOMA
BASAL CELL CARCINOMA
Social History:
___
Family History:
Father - aneurysm
Aunt - ___ Cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
Vital Signs: 98.2 143/84 65 16 99% RA
General: Alert, oriented, lying on side
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding.
Trunk: no tenderness to palpation along spinous process.
Tenderness to palpation at left lower lumbar paraspinal region.
Negative straight leg raise bilaterally, but leg raise does
elicit bilateral lower back spasm. No CVA tenderness
GU: Foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE PHYSICAL EXAM
Vitals: 98.1 ___ 18 97%RA UOP: 300cc (w/o foley)
GENERAL - Comfortably sleeping, well-appearing lying in bed
HEENT - sclerae anicteric, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - breathing comfortably, CTAB
ABDOMEN - +BS, soft/NT/ND, no masses or HSM
BACK - no misalignment or visible trauma on inspection. No
spinal tenderness to palpation. Mild, diffuse left lower
paraspinal tenderness.
GU - no foley
EXTREMITIES - WWP, no c/c, no edema
NEURO - awake, A&Ox3, CNIII-XII intact, strength: ___ upper
extremities, ___ hip flexion bilaterally limited by effort/pain.
Intact dorsiflexion and plantar Sensation intact. Able to sit up
on side of bed with legs to the floor. Deferred gait.
Pertinent Results:
ADMISSION LABS
___ 02:50PM URINE HOURS-RANDOM
___ 02:50PM URINE UCG-NEGATIVE
___ 02:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 05:25AM BLOOD WBC-5.8 RBC-3.49* Hgb-11.2 Hct-34.1
MCV-98 MCH-32.1* MCHC-32.8 RDW-13.6 RDWSD-49.1* Plt ___
___ 05:25AM BLOOD Plt ___
___ 05:25AM BLOOD Glucose-117* UreaN-22* Creat-0.7 Na-138
K-4.1 Cl-102 HCO3-29 AnGap-11
___ 05:25AM BLOOD ALT-15 AST-16 AlkPhos-63 TotBili-0.3
___ 05:25AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
DISCHARGE LABS
___ 10:45AM BLOOD WBC-5.9 RBC-3.52* Hgb-11.2 Hct-34.7
MCV-99* MCH-31.8 MCHC-32.3 RDW-13.5 RDWSD-48.5* Plt ___
___ 10:45AM BLOOD Plt ___
___ 10:45AM BLOOD Glucose-108* UreaN-22* Creat-0.7 Na-140
K-5.2* Cl-103 HCO3-29 AnGap-13
___ 10:45AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8
___ 10:45AM BLOOD VitB12-469 Folate-10.9
___ 10:45AM BLOOD %HbA1c-5.1 eAG-100
___ 10:45AM BLOOD TSH-4.4*
IMAGING
___
IMPRESSION:
1. No evidence of cord compression.
2. Lumbar spondylosis, minimally progressed compared to the
prior exam from ___.
Brief Hospital Course:
___ w/ hx ADHD, HTN, OSA admitted for lower back pain most
likely due to left lumbar muscle spasms.
#Acute on chronic back pain - Patient called EMS on day of
admission because she could not get up from bed due to back pain
x 3 days. Only red flag sign was age > ___, without any
urinary/fecal incontinence, trauma, malignancy, weight loss, or
fever. Not immunosuppressed or on steroids. Previous MRI lumbar
spine in ___ showed lumbar disk herniation and degenerative
joint disease. Due to weakness to hip flexion bilaterally, MRI
lumbar spine repeated, unchanged from prior without signs of
cord compression. Pain most likely due to muscle spasms which
limited her mobility. Pain controlled with Flexeril, Tylenol,
Oxycodone and Naproxen. Patient ambulated with assistance and
pain improved before discharge.
#Hypertension - On admission, SBP remained on low ___ (baseline
130s). Received Received 1L IVF and improved to SBP 120s. Held
home lisinopril and HCTZ while in house and held lisinopril on
discharge.
#Depression - Continued home citalopram
#ADHD - Held home Adderall as nonformulary
#Hypothyroid - On thyroid pork (non-formulary), held while in
house
#OSA - not using CPAP at home past ___ due to insurance.
Restarted CPAP while in house.
TRANSITIONAL ISSUES:
1. Naproxen 500mg PO Q12h for 14 days for acute lower back pain.
Can follow up with ___ as outpatient if not improving with simple
mobility and anti-inflammatories.
2. BP within low-normal range while holding HCTZ and lisinopril.
Lisinopril held on discharge. Can restart as outpatient if
elevated at follow up.
Code: Full
Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. dextroamphetamine-amphetamine 30 mg oral BID
2. Lisinopril 10 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. thyroid, pork (bulk) 1 tablet miscellaneous DAILY
6. Magnesium Oxide 250 mg PO BID
7. melatonin 3 mg oral QHS
Discharge Medications:
1. Cyclobenzaprine 10 mg PO TID:PRN back pain
2. Docusate Sodium 100 mg PO BID Constipation
3. Famotidine 20 mg PO Q12H
4. Naproxen 500 mg PO Q12H
5. Senna 8.6 mg PO BID:PRN Constipation
6. Citalopram 10 mg PO DAILY
7. dextroamphetamine-amphetamine 30 mg oral BID
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Magnesium Oxide 250 mg PO BID
10. melatonin 3 mg oral QHS
11. thyroid, pork (bulk) 1 tablet miscellaneous DAILY
12. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until you speak with your PCP
13.Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Low back pain
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive.
Activity Status: Independent
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of severe back pain.
An MRI did not show any signs of nerve damage. It is very
important that you take the naproxen as an anti-inflammatory for
2 weeks and that you continue to stay mobile. Staying in bed
will worsen your pain. You can follow up with your PCP about ___
referral to ___ if necessary.
Sincerely,
Your ___ Team
PAIN CONTROL:
-If you continue to have muscle spasms, please take Flexeril
10mg for a maximum of three times per day
-If you continue to have pain after taking the Flexeril, please
take Naproxen 500mg every 12 hours
DANGER SIGNS:
-Please call your PCP ___ return to the emergency department
if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- 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:
___
|
10322797-DS-10 | 10,322,797 | 26,650,843 | DS | 10 | 2167-02-06 00:00:00 | 2167-02-06 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:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a pleasant ___
speaking ___ M with hx of paroxysmal A. fib not on
anticoagulation, DM hyperlipidemia, GERD, severe aortic
stenosis,
osteoarthritis who was brought in by his son today with multiple
concerns including 1+ week of general weakness myalgias,
rhinorrhea, cough and pre-syncope, which has resulted in him not
being able to go to his adult day care. Pts son states that his
blood pressures have been labile, as high as 200/120, however
prior to coming into the hospital he had hypotension to 70/40,
was therefore given fluids en route to the hospital by EMS.
Denies any recent changes in BP meds. Also endorses dysuria x1
month with dark urine, sometimes bloody, chronic burning
epigastric pain, CP with ambulation and non-bloody vomiting
without abd pain or diarrhea. No fevers.
In the ED, initial vitals were: 97.4 60 124/70 18 97% RA. Labs
were notable for creatinine of 1.4 ___ 1.0), BNP 881. Flu was
negative. CXR showed no acute process.
On arrival to the floor, pt endorses mild nausea, feels a little
dizzy and has burning epigastric pain. Denies CP/SOB. In
regards to his dysuria, pt has discussed this with his PCP who
recommend urology referral which has not occurred yet. Per his
son, although he does have some memory difficulties, he usually
knows where he is and what the date is. Currently able to state
that he is at ___ and knows date. Has been eating normally.
Denies bloody/dark stools however states he did have blood in
his
stools a month ago which he discussed with his PCP who thought
it
was due to hemorrhoids. Pt tells me that he has chest pressure
when he walks which is substernal and radiating to the shoulder.
He had a stress test in ___ which was WNL.
Past Medical History:
HTN
afib
aortic stenosis
DM2
BPH
HLD
GERD
Constipation
external hemorrhoids
h/o gastric ulcer
vit d def
gastric ulcer
GERD
OA
Social History:
___
Family History:
mother with "heart
issue"
Physical Exam:
Constitutional: Alert, oriented, no acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, ___ SEM
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
Pertinent Results:
___ 04:50PM BLOOD WBC-7.4 RBC-3.90* Hgb-11.9* Hct-35.5*
MCV-91 MCH-30.5 MCHC-33.5 RDW-12.7 RDWSD-41.4 Plt ___
___ 05:40AM BLOOD WBC-6.1 RBC-3.77* Hgb-11.4* Hct-32.9*
MCV-87 MCH-30.2 MCHC-34.7 RDW-12.3 RDWSD-39.5 Plt ___
___ 06:40AM BLOOD WBC-5.8 RBC-4.16* Hgb-12.5* Hct-35.8*
MCV-86 MCH-30.0 MCHC-34.9 RDW-12.3 RDWSD-38.5 Plt ___
___ 06:15AM BLOOD WBC-5.8 RBC-3.97* Hgb-12.0* Hct-34.4*
MCV-87 MCH-30.2 MCHC-34.9 RDW-12.2 RDWSD-38.9 Plt ___
___ 04:50PM BLOOD Glucose-211* UreaN-24* Creat-1.4* Na-141
K-4.6 Cl-105 HCO3-24 AnGap-12
___ 05:40AM BLOOD Glucose-176* UreaN-24* Creat-1.2 Na-142
K-4.0 Cl-107 HCO3-22 AnGap-13
___ 06:40AM BLOOD Glucose-159* UreaN-17 Creat-1.1 Na-141
K-4.1 Cl-106 HCO3-22 AnGap-13
___ 06:15AM BLOOD Glucose-143* UreaN-20 Creat-1.2 Na-142
K-4.2 Cl-104 HCO3-25 AnGap-13
___ 11:50AM BLOOD ALT-17 AST-17 AlkPhos-101 TotBili-0.4
___ 04:50PM BLOOD ALT-14 AST-15 CK(CPK)-48 AlkPhos-88
TotBili-0.3
___ 04:50PM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD cTropnT-<0.01
ECHO
IMPRESSION: Mild to moderate symmetric left ventricular
hypertrophy with normal cavity size and
hyperdynamic LV systolic function. RV apex appears hypokinetic.
Moderate to severe, borderline
severe aortic stenosis. Mild aortic regurgitation, may be
underestimated. Elevated PCWP.
Compared with the prior TTE ___ RV apex now appears
hypokinetic on side by side imaging. Mean
AoV gradient is slightly higher, however ___ remains in the
modereate to severe, borderline severe range.
___ indexed is now in the severe range.
Brief Hospital Course:
Mr ___ is a pleasant ___ speaking
___ M with hx of paroxysmal A. fib not on
anticoagulation, DM hyperlipidemia, GERD, aortic stenosis,
osteoarthritis who was brought in by his son today with multiple
concerns, most notably URI sxs, dysuria and pre-syncope, was
found to be hypotensive
# pre-syncope
# Orthostatic hypotension
Sxs resolved by the time of arrival to the ED. Pt continues to
have mild dizziness however pressures remain stable. Per sons
report, pressures have been labile and he is on quite a few BP
meds which may be contributing, notably he is on both alfuzosin
and doxazosin which could result in hypotension esp I/s/o known
severe AS. While he states that he has been eating and drinking
normally, he has a new ___ and dehydration may also be a
contributing factor. He endorses some CP however had nl stress
___
yrs ago, no ekg changes, normal trop x1 so ACS unlikely.
Concern
remains high for worsening AS. On reading most recent
cardiology
note from ___ of this year, they were anticipating that he would
need a valve replacement in ___ yrs. No e/o systemic
infx/sepsis
-orthostatics vitals improved today, encouraged oral hydration,
no signs of fluid overload
-ECHO done with moderate to severe aortic stenosis and RV
hypokinesis which was reviewed by cardiology, they are also
aware of an episode of SVT overnight which was self limiting.
Cardiology not recommending any additional work up inpatient and
OP follow up with his Cardiologist has been arranged.
-cultures negative so far
# dysuria: x1.5 months, no e/o systemic infection currently,
non-toxic appearing
-UA repeated negative again and negative urine culture
-OP referral to urology recommended, his PCP can refer him to
Urology
# ___: pre-renal vs obstructive I/s/o known BPH. Less likely
cardio-renal as no e/o CHF exacerbation currently.
-hold ___, BP stable, continue to hold on discharge and decision
to restart per his PCP
# Cough: c/f URI vs bronchitis. No e/o PNA on CXR. Improved.
# afib: currently rate controlled, not on anticoagulation
-cont bblocker
-cont asa
# DM: ISS
# BPH: cont home doxazosin, will hold alfuzosin given
hypotension. PVRs reasonable here around 100cc, alfuzosin held
through discharge.
# anemia: near recent ___ with no e/o active bleeding. Prior
iron
studies suggestive of AOCD.
Case discussed with Cardiology today.
patient and son updated and agreeable with plan of discharge
home today.
Total time spent in counseling patient and discharge
coordination is >30 mins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 2 mg PO DAILY
2. melatonin 1 mg oral QHS
3. Vitamin D ___ UNIT PO 1X/WEEK (___)
4. Losartan Potassium 100 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Docusate Sodium 100 mg PO BID
7. Propranolol 20 mg PO BID
8. Proctozone-HC (hydrocorTISone) 2.5 % topical BID
9. amLODIPine 2.5 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO QHS
11. metFORMIN 1,000 mg oral QAM
12. alfuzosin 10 mg oral DAILY
13. Januvia (SITagliptin) 100 mg oral DAILY
14. Atorvastatin 20 mg PO QPM
15. Aspirin 81 mg PO DAILY
16. Nexium 40 mg Other DAILY
17. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine [Pyridium] 100 mg 1 tablet(s) by mouth three
times a day Disp #*20 Tablet Refills:*0
2. amLODIPine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Doxazosin 2 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Januvia (SITagliptin) 100 mg oral DAILY
10. melatonin 1 mg oral QHS
11. MetFORMIN (Glucophage) 500 mg PO QHS
12. metFORMIN 1,000 mg oral QAM
13. Nexium 40 mg Other DAILY
14. Proctozone-HC (hydrocorTISone) 2.5 % topical BID
15. Propranolol 20 mg PO BID
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
17. HELD- alfuzosin 10 mg oral DAILY This medication was held.
Do not restart alfuzosin until untill cleared from your PCP to
do so
18. HELD- Losartan Potassium 100 mg PO DAILY This medication
was held. Do not restart Losartan Potassium until cleared from
your PCP to do so
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostatic Hypotension
Moderate to severe aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with dizziness. You were found to have low blood
pressures standing up and dehydration. Your medications were
adjusted and your were given IV fluids here. Your Dizziness is
better. You had an ECHO here and you were seen by cardiology
team here. You are medically stable for discharge home today
with your family.
Please stay adequately hydrated at home.
Please take all the medications as prescribed
We wish you all the best!
Followup Instructions:
___
|
10323196-DS-17 | 10,323,196 | 23,607,405 | DS | 17 | 2170-05-16 00:00:00 | 2170-05-16 17:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right both bone forearm fracture
Major Surgical or Invasive Procedure:
___: Open reduction, internal fixation of right side both
bone forearm fracture
History of Present Illness:
Ms. ___ is a ___ RHD with no PMH who presents for right arm
injury. Reports at 930 am was out with her horses when one of
them got spooked and kicked her with its hind legs. Denies head
strike or LOC. Reports bleeding from an abrasion. Reports went
to ___ in ___ and was transferred here
for orthopedic management. Xrays notable for open comminuted
fracture of the radius and ulna. She was given oxycodone on
arrival. Denies any numbness or weakness in the arm just pain in
the forearm. Reports the abrasion was washed out prior. Denies
any other symptoms including fever, chills, chest pain, cough,
SOB, n/v/d.
Past Medical History:
Denies
Social History:
___
Family History:
denies
Physical Exam:
Right upper extremity:
- dressings/splint c/d/I
- interval improvement of deformity from presentation
- Mild edema, no erythema, induration
- Soft, non-tender arm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Pertinent Results:
See OMR for pertinent results
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 open both bone forearm fracture and was admitted
to the orthopedic surgery service. The patient pre-operatively
received ceftriaxone and vancomycin for concern of a
farm-contaminated wound given her mechanism was kicked by horse.
The patient was taken to the operating room on ___ for open
reduction, internal fixation, 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 did not require
physical therapy in house and it was determined that discharge
to home was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing for ADLs only in the right upper extremity, and
will be not be discharged on medications 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:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours as
needed Disp #*84 Tablet Refills:*0
4. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
right both bone forearm fracture
Discharge Condition:
regular
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 for activities of daily living
ONLY. Do not lift anything heavier than a cup of coffee with the
right arm. Full range of motion as tolerated.
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- No need for medical anticoagulation
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Followup Instructions:
___
|
10323402-DS-8 | 10,323,402 | 29,512,882 | DS | 8 | 2175-05-13 00:00:00 | 2175-05-13 17:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with a history of stage IIIA
(T2 N1) rectal adenocarcinoma s/p laparoscopic proctectomy with
colonic J-pouch anal anastomosis and diverting loop ileostomy
and reversal of ileostomy with end-to-end anastomosis ___,
adjuvant folfox completed ___ with recurrent small bowel
obstructions who is presenting with nausea, vomiting, abdominal
pain since ___, found to have small bowel thickening on CT
concerning for ileus vs partial SBO. Patient states that she
gets bowel obstructions about every 6 months, usually managed
expectantly at home. This one started on ___, and she has had
no PO intake nor any bowel movements since then. She reports
that she feels dizzy and dry. She did vomit numerous times over
the last 2 days.
In the ED, initial vitals were:98.6 97 133/102 20 100%.
Labs were notable for: lactate 3.6, Bicarb 19, BUN 21. CT
abdomen/pelvis showed Mildly dilated loops of fluid-filled small
bowel which appeared to taper gradually without a clearly
defined transition point.
Patient was given: 2L NS, morphine, zofran and admitted to
Medicine.
On the floor, patient reports improvement in her dizziness and
dryness. She otherwise has no complaints, and complains of no
pain.
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:
-Rectal adenocarcinoma: stage IIIA (T2 N1) rectal adenocarcinoma
s/p laparoscopic proctectomy with colonic J-pouch anal
anastomosis and diverting loop ileostomy and reversal of
ileostomy with end-to-end anastomosis ___, adjuvant folfox
completed ___
-Recurrent small bowel obstructions, most recently admitted to
___ ___
-Appendectomy
-Five laparoscopies in the setting of endometriosis and
infertility
-LOA x 2
-oophorectomy
-anxiety
Social History:
___
Family History:
-Father: ___
-Mother: bladder cancer
-Brother: EtOH
-Sister: ___ cancer
Physical Exam:
On Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, 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
diminished, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
On Discharge:
VS: 98.6/98.2; 105-126/70-77; 76-90; 18; 96-100% RA
GEN: resting comfortably in bed, NAD, AAOx3, pleasant,
conversational
HEENT: NCAT, MMM
NECK: No JVD
CV: RR, S1+S2, NMRG
RESP: CTABL, no w/r/r
ABD: SNTND, normoactive BS
GU: Deferred
EXT: WWP, no edema
NEURO: CN II-XII grossly intact, MAE
Pertinent Results:
On Admission:
___ 11:30AM BLOOD WBC-11.5*# RBC-5.12 Hgb-15.5 Hct-42.2
MCV-82# MCH-30.2 MCHC-36.6*# RDW-12.9 Plt ___
___ 01:34PM BLOOD ___ PTT-30.1 ___
___ 11:30AM BLOOD Glucose-135* UreaN-21* Creat-0.8 Na-141
K-3.4 Cl-102 HCO3-19* AnGap-23*
___ 11:30AM BLOOD ALT-28 AST-22 AlkPhos-79 TotBili-1.0
___ 12:02PM BLOOD Lactate-3.6*
___ 07:57PM BLOOD Lactate-1.1
On Discharge:
___ 04:54AM BLOOD WBC-7.5 RBC-4.09* Hgb-12.3# Hct-34.9*
MCV-85 MCH-30.2 MCHC-35.4* RDW-12.7 Plt ___
___ 04:54AM BLOOD ___ PTT-27.5 ___
___ 04:54AM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-139
K-3.2* Cl-107 HCO3-26 AnGap-9
___ 04:54AM BLOOD ALT-16 AST-18 LD(LDH)-202 AlkPhos-58
TotBili-0.6
___ 04:54AM BLOOD Albumin-3.6 Calcium-8.5 Phos-3.2 Mg-2.2
Microbiology:
___ Bcx: NGTD
IMAGING:
___ CT A/P w/Contrast:
IMPRESSION:
1. Mildly dilated loops of fluid-filled small bowel which
appeared to taper gradually without a clearly defined transition
point. Findings may represent ileus versus early/developing
small-bowel obstruction.
2. Hypoenhancing and heterogeneous thickened endometrium
measuring 2.5 cm, new since prior and atypical in a patient of
this age group. Underlying neoplasm cannot be excluded.
Recommend outpatient pelvic ultrasound and consider GYN
consultation for further evaluation. Alternatively, this
appearance could represent a fluid-filled endometrial cavity
secondary to cervical stenosis.
3. Small hiatus hernia.
4. Hepatic steatosis.
___ Transvaginal pelvic ultrasound:
IMPRESSION:
Heterogeneously thickened endometrium measuring up to 29 mm,
with marked
internal vascularity. These findings are concerning for
endometrial
carcinoma. GYN consultation recommended.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of stage IIIA
(T2 N1) rectal adenocarcinoma s/p laparoscopic proctectomy with
colonic J-pouch anal anastomosis and diverting loop ileostomy
and reversal of ileostomy with end-to-end anastomosis ___,
adjuvant folfox completed ___ with recurrent small bowel
obstructions who is presenting with nausea, vomiting, abdominal
pain since ___, found to have small bowel thickening on CT
concerning for ileus vs partial SBO.
#Partial SBO: Pt was felt to have SBO given presentation,
history and imaging findings. She was given bowel rest/IVF and
her symptoms resolved the day after hospitalization. She
tolerated full liquids well and was discharged..
#Hyperlactatemia: Resolved. Was likely from poor PO intake and
hypovolemia. Resolved with IVF resuscitation.
#Incidental finding of thickened endometrial stripe: Pt
w/incidental finding of thickened endometrial stripe with
internal vascularity. Pelvic ultrasound was concerning for
possible endometrial carcinoma. Pt was discharged with a plan to
f/u with her OB-GYN, who was also contacted regarding results.
#Anxiety: Resumed home medications on discharge
TRANSITIONAL ISSUES:
[]Patient needs to follow up with GYN regarding thickened
endometrium
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO DAILY
2. Lorazepam 0.5 mg PO PRN anxiety
Discharge Medications:
1. Lorazepam 0.5 mg PO PRN anxiety
2. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
partial SBO
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for evaluation of a small bowel
obstruction. While you were here, you were found to have a
partial SBO which improved with IV fluids and bowel rest. On
the day of discharge you tolerated a liquid diet, which you
should continue until you feel ready to resume normal food.
Please keep your appointments and see Dr. ___ at your earliest
convenience.
While you were here, you had a pelvic ultrasound which showed an
area of thickening. You should follow up with your OB/GYN to
discuss what this could be, and what steps to take
diagnostically.
Followup Instructions:
___
|
10323492-DS-18 | 10,323,492 | 20,551,947 | DS | 18 | 2129-02-01 00:00:00 | 2129-02-01 19:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone
Attending: ___
Chief Complaint:
epigastric pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo ___ s/p en bloc radical hysterectomy/BSO/rectosigmoid
resection, small bowel resection and anastomosis, end colostomy,
for stage IIIC possible fallopian tube primary adenocarcinoma,
intestinal type, on ___ s/p cycle 1 of FOLFOX, presenting
with N/V, abdominal pain x 1 day starting ___ AM. She had been
having mild abd discomfort ___ weeks ago with N/V and was seen
in
ED with CT c/f enteritis. She was started on Cipro/Flagyl ___
and is completing a 2 week course with improvement of her N/V
and
pain. This AM, she had breakfast and soon after had significant
epigastric pain with an episode of emesis and nausea around
1130.
No futher emesis since. She presented to the ED for eval.
She continues to have epigastric pain that comes in waves,
improved with APAP. No CP/SOB, F/C, diarrhea, Dizziness,
dysuria,
hematuria, vaginal bleeding, rectal bleeding. She did not have
flatus today and minimal stool on her ostomy bag until after her
PO contrast, which led to passage of some loose stool.
no known sick contacts.
ROS otherwise neg
Past Medical History:
PAST MEDICAL HISTORY:
- benign positional vertigo
- thyroid nodule
- osteopenia
- tinnitus
- Denies hypertension, diabetes, asthma, thromboembolic disease
- stage IIIC possible fallopian tube primary adenocarcinoma
PAST SURGICAL HISTORY:
- ___ en bloc radical hysterectomy/BSO/rectosigmoid resection,
small bowel resection and anastomosis, end colostomy
- ___ arthroscopy of right knee
- ___ vulvar cyst excision
POB Hx: G2P1
- ___ TAB
- ___ SVD
PGYN:
- LMP ___
- Used estring x ___ yrs, no other hormonal replacement therapy
- Denies history of abnormal Pap smears; last Pap/HPV neg/neg
___
- Denies history of pelvic infections or sexually transmitted
infections
Social History:
___
Family History:
- Mother had MI age ___
- Father died of myeloma age ___
- MGM diagnosed with colon cancer in her ___
- Maternal first cousin diagnosed with breast cancer in her
early
___
- No known family history of uterine, ovarian, or cervical
cancer
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, non tender, nondistended, normoactive bowel sounds,
incision, no rebound/guarding
___: nontender, nonedematous
Pertinent Results:
___ 05:37AM BLOOD WBC-5.7 RBC-3.89* Hgb-11.1* Hct-34.3
MCV-88 MCH-28.5 MCHC-32.4 RDW-14.1 RDWSD-45.0 Plt ___
___ 06:14AM BLOOD WBC-6.6 RBC-4.05 Hgb-11.7 Hct-35.6 MCV-88
MCH-28.9 MCHC-32.9 RDW-14.1 RDWSD-45.1 Plt ___
___ 03:10PM BLOOD WBC-10.9*# RBC-4.39 Hgb-12.6 Hct-38.3
MCV-87 MCH-28.7 MCHC-32.9 RDW-14.1 RDWSD-43.8 Plt ___
___ 05:37AM BLOOD Neuts-42.5 ___ Monos-11.8
Eos-0.9* Baso-1.0 Im ___ AbsNeut-2.44 AbsLymp-2.50
AbsMono-0.68 AbsEos-0.05 AbsBaso-0.06
___ 06:14AM BLOOD Neuts-42.8 ___ Monos-9.6 Eos-1.2
Baso-0.8 Im ___ AbsNeut-2.82# AbsLymp-2.96 AbsMono-0.63
AbsEos-0.08 AbsBaso-0.05
___ 03:10PM BLOOD Neuts-79.7* Lymphs-15.3* Monos-3.9*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-8.69*# AbsLymp-1.67
AbsMono-0.42 AbsEos-0.01* AbsBaso-0.04
___ 05:37AM BLOOD Glucose-81 UreaN-4* Creat-0.6 Na-143
K-4.0 Cl-105 HCO3-24 AnGap-18
___ 06:14AM BLOOD Glucose-102* UreaN-5* Creat-0.6 Na-143
K-3.6 Cl-105 HCO3-28 AnGap-14
___ 03:10PM BLOOD Glucose-102* UreaN-7 Creat-0.6 Na-142
K-3.8 Cl-101 HCO3-25 AnGap-20
___ 03:10PM BLOOD ALT-79* AST-49* AlkPhos-92 TotBili-0.4
___ 03:10PM BLOOD Lipase-77*
___ 05:37AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.1
___ 06:14AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.3
___ 03:10PM BLOOD Albumin-3.6
___ 03:16PM BLOOD Lactate-1.0
Brief Hospital Course:
Ms. ___ was admitted to the gynecologic oncology service for
management of a small bowel obstruction. On admission a CT scan
showed a small-bowel obstruction with the transition point at
the anastomosis in the left lower quadrant. A nasogastric tube
was placed. She was kept NPO and put on maintenance IV fluids.
Once her nausea resolved and her NG tube output decreased, her
NG tube was clamped, which she tolerated well. Her NG tube was
removed on ___ (day after admission), and her diet was
gradually advanced. She was tolerating a regular diet by
___. She was seen by nutrition for dietary counseling.
Of note, she was continued on her 2-week course of cipro/flagyl
through ___ for her enteritis, diagnosed prior to admission.
By ___, she was tolerating a regular diet and was
symptomatically improved. She was then discharged home in stable
condition with outpatient follow-up scheduled.
Medications on Admission:
Medications - Prescription
CIPROFLOXACIN HCL [CIPRO] - Cipro 500 mg tablet. 1 tablet(s) by
mouth twice a day
IBUPROFEN - ibuprofen 400 mg tablet. 1 tablet(s) by mouth every
four (4) hours -6 hours/last dose was ___ - (Prescribed by
Other Provider)
LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth three
times a day as needed for nausea, anxiety
METRONIDAZOLE [FLAGYL] - Flagyl 500 mg tablet. 1 tablet(s) by
mouth twice a day
ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by
mouth every eight (8) hours as needed for nausea ICD 10
Code:C57.00 Malignant neoplasm of unspecified fallopian tube
PNV W/O CALCIUM-IRON FUM-FA [M-VIT] - M-Vit 27 mg-1 mg tablet. 1
tablet(s) by mouth once a day - (Prescribed by Other Provider)
PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg
tablet.
1 tablet(s) by mouth every six (6) hours as needed for nausea
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by
mouth
every six (6) hours as needed for pain - (Prescribed by Other
Provider)
CALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft
Chew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once
a
day - (Prescribed by Other Provider)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth twice a day - (Prescribed by Other Provider)
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
2. MetroNIDAZOLE 500 mg PO BID
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:
Dear Ms. ___,
.
You were admitted to the gynecologic oncology service with a
small bowel obstruction. You were managed conservatively, with a
NG tube and with backing down on your diet. Your symptoms
resolved. You have recovered well, and the team feels that you
are safe to be discharged home. Please follow these
instructions:
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10323492-DS-20 | 10,323,492 | 24,179,340 | DS | 20 | 2129-04-06 00:00:00 | 2129-04-07 20:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / oxycodone
Attending: ___.
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
NGT placement and removal
History of Present Illness:
___ with stage IIIC possible fallopian tube primary
adenocarcinoma, intestinal type s/p ex-lap, radical
hysterectomy, BSO, small bowel resection, rectosigmoid
resection, omentectomy, pelvic LND, end colostomy, cysto on
___ currently in cycle 4 of chemotherapy (FOLFOX) s/p
recent high grade SBO managed
conservatively with NGT ___.
Today she reports onset of abdominal pain coinciding with
absence of ostomy output (stool nor flatus) since the morning,
similar to previous presentation. She began to experience nausea
and emesis x2 over the course of the day prompting her
presentation for care. Still with no ostomy output s/p NGT
placement for 400cc. Denies fevers, chills, chest pain,
shortness of breath, dysuria, leg swelling, rash.
Past Medical History:
ONCOLOGIC HISTORY:
- ___: had constipation, abdominal pain, CT scan that showed
a complex multiloculated predominantly cystic 11.5 x 9 x 8.7 cm
pelvic mass w/ intracystic mural solid subcomponents that was
highly suspicious for ovarian neoplasm. No pelvic ascites was
visualized. The liver had several variably sized lesions that
appeared most consistent radiographically with cysts.
- ___: negative endometrial biopsy
- ___: CA125 of 58, a CEA of 10.2 and a ___ of 16,480.
- ___: diagnostic laparoscopy that was converted to
laparotomy with type 2 radical oophorectomy inclusive of an en
bloc radical hysterectomy, bilateral salpingo-oophorectomy,
rectosigmoid resection with an omentectomy, bilateral pelvic
lymph node dissection, small bowel resection, end colostomy, and
cystoscopy. Pathology of her tumor tissue returned as metastatic
adenocarcinoma,intestinal type. Adenocarcinoma was present in
the
bilateral ovaries, bilateral fallopian tubes and omentum. The
tumor showed transmural mesorectal infiltration without a
mucosal
lesion. Metastatic mesenteric implants were present on the small
bowel mesentery and cecum without mucosal lesions. The umbiical
nodule was positive for disease. Six of 30 pericolonic lymph
nodes and 1 of 5 pelvic lymph nodes were positive for disease.
Washings were also positive. While a fallopian tube primary was
favored, evaluation for an intestinal or pancreaticobiliary
primary was recommended.
- ___: negative colonsocopy
- ___: port placed
- ___ - ___: admitted for partial SBO (conservative
management)
- ___: C1D1 FOLFOX
- ___: C1D15 FOLFOX
- ___ - ___: ED for abdominal pain, nausea, given antibx
for
colitis
- ___ - ___: admitted for SBO (conservative management with
NGT)
- ___: C2D1 FOLFOX
- ___: C3D1 FOLFOX
- ___: C3D15: held FOLFOX fro neutropenia, received neulasta
- ___: NGT placement for high grade SBO with resolution,
discharged ___
- ___ C4D1: FOLFOX
Social History:
___
Family History:
denies bleeding/clotting disorders, gyn/GI malignancies, breast
cancer
Physical Exam:
Admission exam:
Gen: NAD
HEENT: NGT in place with 400cc brown/green output
CV: RRR
Pulm: CTAB, normal work of breathing
Abd: soft, mildly distended, tympanic with hyperactive bowel
sounds. Ostomy bag without air or stool, last changed this
morning, ostomy pink.
Pelvic: deferred
Ext: no edema
Discharge exam:
Gen - NAD
CV - RRR
Lungs - CTAB
Abd - soft, NT, ND, no r/g, +bowel sounds, + gas and brown stool
in ostomy bag, osotmy pink
Ext - nontender, no edema
Pertinent Results:
___ 05:27AM BLOOD WBC-4.9 RBC-3.04* Hgb-8.9* Hct-27.6*
MCV-91 MCH-29.3 MCHC-32.2 RDW-17.5* RDWSD-58.2* Plt ___
___ 05:00AM BLOOD WBC-5.4# RBC-3.39* Hgb-9.9* Hct-29.7*
MCV-88 MCH-29.2 MCHC-33.3 RDW-17.8* RDWSD-57.1* Plt ___
___ 07:41PM BLOOD WBC-17.9*# RBC-3.92 Hgb-11.5 Hct-35.0
MCV-89 MCH-29.3 MCHC-32.9 RDW-18.1* RDWSD-59.1* Plt ___
___ 05:00AM BLOOD Neuts-64.2 ___ Monos-4.3*
Eos-0.2* Baso-0.6 Im ___ AbsNeut-3.44# AbsLymp-1.61
AbsMono-0.23 AbsEos-0.01* AbsBaso-0.03
___ 07:41PM BLOOD Neuts-92.0* Lymphs-4.9* Monos-2.3*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-16.48*# AbsLymp-0.87*
AbsMono-0.42 AbsEos-0.00* AbsBaso-0.03
___ 07:41PM BLOOD ALT-29 AST-28 AlkPhos-133* TotBili-0.8
___ 05:27AM BLOOD Glucose-100 UreaN-9 Creat-0.6 Na-140
K-3.7 Cl-107 HCO3-25 AnGap-12
Brief Hospital Course:
Ms. ___ was admitted to the gyn/onc service with an SBO.
Given her symptoms were similar to prior recent presentations
and she had no peritoneal signs on examination, imaging was
referred. An NGT was placed for bowel rest/decompression in the
ED. Her white blood cell count was noted to be elevated, but
there was no clinical evidence of infection (normal exam,
normal lactate). A repeat CBC on hospital day 1 showed a normal
WBC
She was managed conservatively during her admission with an NG
tube.
On hospital day 3, she began noticing more stool and gas in her
ostomy. She had minimal residual on an NGT clamp trial. Her NGT
was removed and her diet was
advanced without issue. On hospital day #3 she was tolerating a
regular
diet. She was discharged home in stable condition with
outpatient follow-up planned.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
HYDROMORPHONE - hydromorphone 2 mg tablet. ___ tablet(s) by
mouth
every ___ hours as needed for pain
LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth three
times a day as needed for nausea, anxiety
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
capsule(s) by mouth once a day
ONDANSETRON HCL - ondansetron HCl 8 mg tablet. 1 tablet(s) by
mouth every eight (8) hours as needed for nausea ICD 10
Code:C57.00 Malignant neoplasm of unspecified fallopian tube
PRENATAL VITS-IRON FUM-FOLIC [M-VIT] - M-Vit 27 mg-1 mg tablet.
1
tablet(s) by mouth once a day - (Prescribed by Other Provider)
PROCHLORPERAZINE MALEATE - prochlorperazine maleate 10 mg
tablet.
1 tablet(s) by mouth every six (6) hours as needed for nausea
Medications - OTC
ACETAMINOPHEN - acetaminophen 500 mg tablet. 1 tablet(s) by
mouth
every six (6) hours as needed for pain - (Prescribed by Other
Provider)
CALCIUM-VITAMIN D3-VITAMIN K [CALCIUM SOFT CHEW] - Calcium Soft
Chew 500 mg-1,000 unit-40 mcg tablet. 1 tablet(s) by mouth once
a
day - (Prescribed by Other Provider)
CETIRIZINE [ALL DAY ALLERGY (CETIRIZINE)] - All Day Allergy
(cetirizine) 10 mg tablet. 1 tablet(s) by mouth once a day -
(Prescribed by Other Provider; ___)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. 1 capsule(s)
by
mouth twice a day - (Prescribed by Other Provider)
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
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:
Dear Ms. ___,
.
It is always a pleasure to take care of you and we are glad you
are feeling improved and ready to go home. You were admitted to
the gynecology oncology service for management of a small bowel
obstruction. You were managed conservatively with antiemetics,
pain medications, and an NG tube. You had return of bowel
function and your diet was advanced. You have recovered well and
the team feels that you are safe to be discharged home. Please
follow the instructions:
.
* Take a stool softener to prevent constipation. You were
prescribed Colace. If you continue to feel constipated and have
not had a bowel movement within 48hrs of leaving the hospital
you can take a gentle laxative such as milk of magnesium.
* Do not take more than 4000mg acetaminophen (tylenol) in 24
hrs.
* Please continue a low residual diet (avoid high-fiber foods,
like whole-grain breads and cereals, nuts, seeds, raw or dried
fruits, and vegetables). If symptoms resume such as pain and
cramping, please resume low residual diet and call office.
* It is safe to walk up stairs.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10323608-DS-19 | 10,323,608 | 27,783,366 | DS | 19 | 2151-05-29 00:00:00 | 2151-05-30 14:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___ Midline placement
History of Present Illness:
Previously healthy ___ year old woman who presents with neck
pain
and fevers, found to have positive blood culture with GPCs and
CT
Neck with possible phlegmon.
On ___ she was seen in primary care clinic for 3 days of
fevers
to 102, sore throat, and generalized body aches. Apparently she
had initially started to feel better over those 3 days but then
felt worse again. She was diagnosed with influenza like illness
and treated with 5 days of oseltamivir. Strep testing reportedly
negative.
The next day on ___ she went to ___ for sudden onset of severe
pain in the back which radiated into the L neck and L arm. She
was still febrile at that time to 101. This was felt to be
musculoskeletal and she was Rx'd Flexeril.
On ___ she returned and was seen for ongoing shoulder and back
pain and diagnosed with L sided cervical radiculopathy.
Gabapentin added. she had persistent fevers and had a CXR which
showed no acute process and blood culture from that date that
remains without growth. A CBC on ___ showed a leukocytosis to
12.4.
On ___ she called clinic again with persistent fevers and was
referred to the ED.
In the ED, initial vitals were 99.9 134 134/72 18 100% RA. Her
HR later came down to the low 100s and her temp spiked to 103.
her exam was notable for a well-appearing woman not in distress.
She had a normal neurologic exam and full neck range of motion,
negative kernig and bradzinski signs. There was focal tenderness
over the L trapezius. The rest of the exam was normal.
Labs were notable for WBC of 12 -> 9, 13.4 -> 11. Chem and LFTs
were unremarkable. She had a mildly elevated BNP of 194 and
negative troponin. UA showed some WBC and bacteruria but in the
setting of ___ epis. A blood culture returned positive for GPCs
in ___ bottles.
She was initially placed in observation and given fluids and
oseltamivir, but on return of positive blood culture she was
given vancomycin and zosyyn and decision made to admit. In total
it looks like she received around 5 liters of fluid over her
whole ED course including boluses and maintenance fluid.
CT neck obtained showing "Mild prominence of the palatine and
lingual tonsils, likely reactive to recent upper respiratory
infection. No fluid collection. as well as Soft tissue
prominence
in the left supraclavicular region and along the left side of
the
thyroid gland. Prominent but subcentimeter left level 4 and
level
5 lymph nodes. Findings may represent early phlegmonous change."
On arrival to the floor, pt confirms above history. she is
feeling febrile and like a rigor is coming on. Rigors started
last night and has had about ___ episodes since then. Continues
to have neck, upper back and arm pain but this is slightly
improved from earlier. general headache and dizziness, no focal
head tenderness. no nausea/vomiting, no
weakness/numbness/tingling, no palpitations, no dyspnea, no
cough, no myalgia or joint pain, no neck stiffness. Able to
drink
PO without problem. Kids have not been sick. Notes she had PNA
in
___. Gabepentin and cyclobenzaprine have not been very
helpful, and she would prefer not to take them anymore (she
stopped as outpatient). She finished outpatient Tamiflu course.
REVIEW OF SYSTEMS: per HPI otherwise negative
Past Medical History:
GYN hx:
LMP: ___
No hx abnormal paps
OB hx: G1P0
PMH: None
PSH:
L breast lumpectomy - benign
L ACL repair
Social History:
___
Family History:
non-contributory
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM
==========================
VS: 99.8 PO 115 / 75 L Lying 97 18 99 Ra
GENERAL: Pleasant, lying in bed, slightly uncomfortable and
shaking
HEENT: pharynx nonerythematous without exudate, tonsils
difficult to see but mildly enlarged
NECK: tender in left cervical/supraclavicular region with some
overlying erythema, no elevated JVD
CARDIAC: tachycardic and regular rhythm, no murmurs, rubs, or
gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended
EXT: Warm, well perfused, no lower extremity edema
NEURO: Alert, oriented, motor and sensory function grossly
intact, moving extremities without pain or hesitation, negative
Brudzinski sign
SKIN: No significant rashes, feels warm
========================
DISCHARGE PHYSICAL EXAM
========================
GENERAL: Young woman in no acute distress
CARDIAC: regular rate and rhythm, no murmurs
LUNG: decreased breath sounds at the bilateral bases, no
wheezing
ABD: Normal bowel sounds, soft, nontender, nondistended
EXT: Warm, well perfused, no lower extremity edema
NEURO: Alert, oriented, motor and sensory function grossly
intact, moving extremities without pain or hesitation
Pertinent Results:
========================
ADMISSION LAB RESULTS
========================
___ 09:05PM BLOOD WBC-12.0* RBC-4.53 Hgb-13.4 Hct-40.9
MCV-90 MCH-29.6 MCHC-32.8 RDW-13.0 RDWSD-43.2 Plt ___
___ 09:05PM BLOOD Neuts-83.2* Lymphs-11.0* Monos-5.1
Eos-0.1* Baso-0.2 Im ___ AbsNeut-9.96* AbsLymp-1.32
AbsMono-0.61 AbsEos-0.01* AbsBaso-0.02
___ 09:05PM BLOOD Plt ___
___ 09:05PM BLOOD Glucose-110* UreaN-13 Creat-0.6 Na-135
K-4.4 Cl-100 HCO3-24 AnGap-11
___ 09:05PM BLOOD ALT-14 AST-21 AlkPhos-88 TotBili-0.2
___ 09:05PM BLOOD Lipase-25
___ 09:05PM BLOOD cTropnT-<0.01
___ 09:05PM BLOOD proBNP-194*
___ 09:05PM BLOOD Albumin-3.9
___ 09:12PM BLOOD Lactate-1.2
===============
MICRO DATA
===============
___ 9:06 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BETA STREPTOCOCCUS GROUP A. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP A
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ (___),
___ @
12:00PM.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
__________________________________________________________
___ 12:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
========================
DISCHARGE LAB RESULTS
========================
___ 05:39AM BLOOD WBC-6.5 RBC-3.95 Hgb-11.5 Hct-35.5 MCV-90
MCH-29.1 MCHC-32.4 RDW-13.1 RDWSD-43.3 Plt ___
___ 03:59AM BLOOD Neuts-70.1 ___ Monos-5.1 Eos-0.1*
Baso-0.2 Im ___ AbsNeut-5.67 AbsLymp-1.95 AbsMono-0.41
AbsEos-0.01* AbsBaso-0.02
___ 05:39AM BLOOD Plt ___
___ 05:53AM BLOOD ___
___ 05:39AM BLOOD Glucose-88 UreaN-6 Creat-0.5 Na-140 K-4.4
Cl-105 HCO3-24 AnGap-11
___ 05:39AM BLOOD ALT-114* AST-127* LD(LDH)-275*
AlkPhos-125* TotBili-0.3
___ 03:59AM BLOOD IgA-<50* IgM-122
=====================
IMAGING AND REPORTS
=====================
CT NECK WITH CONTRAST ___
IMPRESSION:
1. Mild prominence of the palatine and lingual tonsils, likely
reactive to
recent upper respiratory infection. No fluid collection.
2. Soft tissue prominence is seen in the left supraclavicular
region and along the left side of the thyroid gland. Prominent
but subcentimeter left level 4 and level 5 lymph nodes.
Findings may represent early phlegmonous change. Close clinical
attention is recommended.
3. Mild maxillary sinus disease.
CHEST X-RAY ___
IMPRESSION:
Interval increase in asymmetric right-sided pulmonary
congestion.
TRANSTHORACIC ECHO ___
IMPRESSION: Trace aortic regurgitation with normal valve
morphology. Mild mitral regurgitation with normal valve
morphology. Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global systolic
function.
RUQ ULTRASOUND ___
IMPRESSION:
Normal abdominal ultrasound. A 9 mm hemangioma is again seen in
the right
lobe of the liver, stable compared to the abdomen ultrasound of
___.
Brief Hospital Course:
SUMMARY:
___ w/ no significant medical history who presented with fever
and neck pain, and was found to have group A strep bacteremia
and early phlegmon in the left supraclavicular region, which
were felt to be secondary to untreated strep pharyngitis. She
was treated with IV antibiotics and improved. During
hospitalization she was noted to have elevated LFTs of unknown
etiology. Pt appeared well and the abnormal LFTs were mild, and
after discussion with pt, plan was to have them re-drawn 2d
after d/c to be followed up by in-hospital team as well as f/u
with PCP 1 week after d/c. Therefore, she was discharged with
home antibiotics with plan for 14d of therapy through midline
and f/u with ID and PCP.
=======================
TRANSITIONAL ISSUES
=======================
- F/u appts: PCP, ID
- F/u labs: CBC to evaluate for resolution of anemia, LFTs to
evaluate transaminitis, repeat Ig levels to document
- Abnormal LFTs: Unclear etiology. RUQUS negative for acute
pathology. Repeat LFTs to be drawn on ___ (LFTs) and
followed up by inpatient team. Repeat LFTs at next PCP visit
should also be drawn to monitor and further w/u should be
considered.
- ID:
[ ] Abx: 2 week course of ceftriaxone (___), will plan
to f/u w/ ID
[ ] Recurrent infections: during inpt Ig levels were drawn and
IgA was abnormal. Consider re-sending after infection resolved
and consider further testing for immunodeficency
- CONTACT: Name of health care proxy: ___,
Relationship: husband, Phone number: ___
ACUTE ISSUES:
=============
# Sepsis
# Group A strep bacteremia
# Cervical soft tissue inflammation
Patient developed fevers and sore throat around ___ and was
seen in her ___ clinic, where rapid strep was negative. She
was treated with oseltamivir for suspected flu. She then
developed sudden onset severe left neck and arm pain. She
remained febrile for a period of about 10 days. She then
presented to the ED, where initial blood cultures returned
positive with GPC. A CT neck showed prominent tonsils and a soft
tissue prominence in the left supraclavicular region, but no
defined fluid collection. She was started on empiric vancomycin
and ampicillin-sulbactam. Her cultures returned with group A
streptococcus, and her antibiotics were narrowed to ceftriaxone
with assistance from the infectious disease team. Overall, her
picture appears consistent with undiagnosed strep pharyngitis
that progressed to strep bacteremia. A TTE was done and did not
reveal any valvular vegetations. ___ was not pursued given that
patient only met 2 minor Duke criteria and she reported no
high-risk activities like IVDU. She underwent placement of
midline on ___ and was discharged with plan to follow up with
infectious disease clinic. She is planned for a two week course
of ceftriaxone (___).
# Hypoxemia
Within a day of her admission, Ms ___ developed hypoxemia
overnight. A chest x-ray revealed bilateral congestion. She was
given 1 dose of IV Lasix with good response and was eventually
weaned off supplemental oxygen. This event was likely triggered
by large volume IV fluid repletion while in the ED, with
possible contribution of ARDS-like physiology while ___.
At discharge, she was saturating well on room air both at rest
and with ambulation.
# Transaminitis
# Nausea
Patient developed nausea and elevated liver enzymes several days
into her admission. This was thought to either be secondary to
treatment with ampicillin-sulbactam or septic emboli secondary
to bacteremia. Her liver enzymes fluctuated throughout her
course, but remained elevated on the date of planned discharge.
She underwent RUQUS that showed a stable liver hemangioma, which
would not explain her acute transaminitis. Plan is to obtain
labs on ___ (two days after discharge) and monitor LFTs. She
will also see her PCP on ___.
# Anemia
Admission Hb was 13 and trended down to 10. This was attributed
to sepsis. Discharge Hb was 11.5.
# IgA deficiency
Patient was evaluated for possible immunosuppression given her
unusual presentation. She had numerous recent infections
including pneumonia as well. Her immunoglobulin levels were
evaluated and she was found to have low IgA (<50). This could be
reflective of her acute illness. However, would consider
re-evaluating outpatient to determine if this is a chronic
issue.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg
intrauterine DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 50 mL IV Every
24 hours Disp #*10 Intravenous Bag Refills:*0
2. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg
intrauterine DAILY
3.Outpatient Lab Work
___ ICD-10-CM Diagnosis Code A40.0
Please obtain AST, ALT, LDH, Alk phos, total bilirubin
Draw on ___
Fax to: ___, ___ Service, Attn:
Dr. ___, fax ___, ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Sepsis
-Group A streptococcal bacteremia
-Group A streptococcal pharyngitis
SECONDARY:
-Transaminitis
-Anemia secondary to sepsis
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 ___.
WHY WERE YOU IN THE HOSPITAL?
- You were admitted to the hospital for fevers.
WHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL?
- You were found to have bacteria in your blood that likely came
from a previous Strep throat infection.
- You had a CAT scan that showed some swelling in your neck that
was related to the infection.
- You were started on intravenous antibiotics.
- You had an echocardiogram done, which showed nothing abnormal
in your heart.
- You had a midline placed on ___ for you to receive
antibiotics at home.
- You had an ultrasound of your liver on ___ that showed a
hemangioma (a non-harmful collection of blood vessels) that was
unchanged from a previous study.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
- Continue to take all your medicines as prescribed below.
- Show up to your appointments as listed below.
- Please have your blood drawn on ___ and have them
fax to: ___, ___ Service, Attn:
Dr. ___, fax ___, ph ___
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10323890-DS-11 | 10,323,890 | 23,498,941 | DS | 11 | 2117-12-26 00:00:00 | 2117-12-26 21:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hemoptysis, Cough, Dyspnea, Pain
Major Surgical or Invasive Procedure:
Plasmapheresis line and removal
Plasmapheresis x4 sessions
History of Present Illness:
She was diagnosed with Goodpasture syndrome earlier this month.
In ___, she presented to ___ with chest pain,
shortness of breath, and hemoptysis and had a bronchoscopy which
did not show DAH but cultures were positive for pansensitive
E.coli. She was treated with antibiotics as well as a course of
steroids for possible "inflammatory pneumonitis." She was
readmitted in ___ with similar complaints but did not
improve with antibiotics. Autoimmune workup was revealing for
elevated anti-GBM Ab (1.8). She also had a positive
Blastomycosis
urine Ag that resulted after discharge. She presented again to
___ on ___ with worsening shortness of breath, chest
pain, and hemoptysis and was transferred to ___ for higher
level of care. She was treated with itraconazole for
blastomycosis (however the positive urine antigen was below
quantifiable level and her serum blasto testing was negative).
She had a VATS biopsy on ___. Pathology showed DAH ___
capillaritis consistent with lung involvement of Goodpasture
syndrome. On ___, she was started on prednisone 40 mg daily and
Bactrim for PJP ppx by her pulmonologist, Dr. ___. The
following day, she was seen by Dr. ___ who
recommended starting azathioprine.
Since then, she has presented to the ED at ___ three
times. On ___, she came in with pleuritic chest pain and
shortness of breath and had a CT angio chest that showed no PE
and no acute changes.
She presented to the ED at ___ on ___ for chest pain,
shortness of breath, low back pain, nausea, and vomiting.
The bilateral flank pain was thought to have a large
musculoskeletal component and she was discharged home with
planned close follow up with her outpatient providers. She
declined a CT abdomen to evaluate for nephrolithiasis.
She represented to the ED on ___ with worsening hemoptysis and
shortness of breath. CXR showed diffuse bilateral opacities. CT
chest/abd/pelvis showed GGOs and no PE as well as a
non-obstructing R renal calculus. She was administered broad
spectrum antibiotics and transferred to ___ for higher level
of
care.
Speaking with ___ today, she confirms the history above. She
reports that she started to have bilateral low back pain about a
week ago which is sharp, intermittent, radiating to the flanks,
and associated with nausea and vomiting ___ episodes of
vomiting
over the last week). Nothing seems to alleviate or worsen the
pain. She has not noticed any change in the color of her urine.
She has had some vaginal discomfort for the past few days, but
no
dysuria.
She called Dr. ___ on ___, who recommended that she stop
the
azathioprine because the low back/flank pain could be a side
effect. She stopped it on ___. Since then, she has felt like
her
pleuritic chest pain, shortness of breath, and hemoptysis have
worsened. Prior to returning to the ED on ___, she had coughed
up about a half a cup of blood - the most she has ever produced
in 24 hours. No fevers/chills. No sputum production. No sick
contacts. Her pleuritic chest pain moves around - right now it
is
substernal and bilateral on her anterior chest. She has been
more
short of breath than usual in the past few days - just walking a
few steps to the bathroom causes her to become short of breath.
She also endorses lightheadedness/dizziness while walking. No
presyncope. No palpitations. No ___ edema. No joint pain or
rashes. No significant weight loss or gain in the last month.
___ course:
VS: T 98.6, HR 110s-120s, BP 110s-120s/50s-70s, RR ___, Spo2
97-98% on 2L O2
Labs: WBC 15.9 (neutrophilic predominant), H/H 9.6/31.8, Plt
391,
INR 1, PTT 25.9, CMP wnl, Cr 0.7, Urine: 3+ blood and ___ RBCs
in the urine, BCx pending
Imaging: CTA chest: no PE, extensive nodular GGOs and airspace
disease bilaterally
CT abd/pelvis: small nonobstructing R renal calculus
Interventions: meropenem ___ at 19:00), vancomycin ___ at
16:00), 3L NS, acetaminophen 1 gram IV
___ ED course:
VS: Tmax 98.4, HR ___, BP 100s-130s/40s-60s, RR ___, SpO2
98-99% on supplemental O2 (L not recorded)
Labs: WBC 9.8, H/H 7.8/28.7, Plt 298
UA: mod blood, 30 protein, RBC 75, WBC 7, few bacteria
Imaging: None
Interventions: prednisone 40 mg, azathioprine 50 mg, atovaquone
750 mg, ondasetron 4 mg IV
Past Medical History:
- GERD
- Obesity
- Hypothyroidism
- Panic disorder
- Anxiety
- PTSD
- ADHD
- Dyslexia
- Depression
- Tonsillectomy (in early ___)
Social History:
___
Family History:
Not aware of any family history of cardiac or pulmonary disease
or blood clotting disorders.
Physical Exam:
ADMISSION EXAM
98.6 PO 139 / 85 90 20 98 3l
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored. Speaking in complete
sentences.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted, mild right cheek redness
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
AVSS, on RA
pleasant, NAD
R IJ site removed, dressing c/d/i
RRR
CTAB
obese, sntnd
neg CVAT
wwp, neg edema
A&O grossly, EOMI, PERRL, no droop, MAEE
Pertinent Results:
ADMISSION LABS
___ 02:16AM BLOOD WBC-9.8 RBC-3.22* Hgb-7.8* Hct-28.7*
MCV-89 MCH-24.2* MCHC-27.2*# RDW-18.0* RDWSD-59.4* Plt ___
___ 03:35PM BLOOD Glucose-122* UreaN-9 Creat-0.5 Na-139
K-4.4 Cl-102 HCO3-22 AnGap-15
___ 03:35PM BLOOD ALT-16 AST-12 LD(LDH)-233 AlkPhos-90
TotBili-0.4
___ 03:35PM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.2 Mg-1.9
___ 06:04AM BLOOD calTIBC-250* Ferritn-37 TRF-192*
___ 05:20PM BLOOD HCG-<5
___ 05:20PM BLOOD ANCA-NEGATIVE B
___ 07:12PM BLOOD ANTI-GBM-Test
___ 05:37AM BLOOD ANTI-GBM-PND
INTERVAL IMAGING AND RESULTS
CT Chest (___):
IMPRESSION:
1. No pulmonary emboli identified.
2. Extensive nodular groundglass and airspace disease
bilaterally
nonspecific for hemorrhage, infection, or vasculitis.
CT Abdomen (___):
IMPRESSION:
1. Small amount of nonspecific free fluid in the pelvis.
2. There is a small nonobstructing right renal calculus.
CXR (___):
Comparison to ___. Stable extent and severity of
the pre-existing severe bilateral and diffuse parenchymal
opacities. No new opacities are noted. Borderline size of the
heart with retrocardiac atelectasis. No pneumothorax. The
hemodialysis catheter on the right is in stable position.
___ 05:37AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.1
___ 06:04AM BLOOD Iron-13*
___ 06:04AM BLOOD calTIBC-250* Ferritn-37 TRF-192*
___ 05:20PM BLOOD ANCA-NEGATIVE B
___ 05:20PM BLOOD HCG-<5
___ 05:37AM BLOOD ANTI-GBM-Test <1.0
___ 07:12PM BLOOD ANTI-GBM-Test 1.0
___ 04:23AM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:23AM URINE RBC-75* WBC-7* Bacteri-FEW* Yeast-NONE
Epi-27
DISCHARGE LABS:
___ 05:55AM BLOOD WBC-13.8* RBC-3.17* Hgb-7.5* Hct-25.1*
MCV-79* MCH-23.7* MCHC-29.9* RDW-17.4* RDWSD-50.2* Plt ___
___ 05:55AM BLOOD Glucose-92 UreaN-20 Creat-0.7 Na-144
K-4.3 Cl-105 HCO3-28 AnGap-11
___ 05:55AM BLOOD ALT-13 AST-8 AlkPhos-36 TotBili-0.3
___ 10:45AM URINE Blood-MOD* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR*
___ 10:45AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
___ UCx neg final
Brief Hospital Course:
Ms. ___ is a ___ female with Goodpasture syndrome,
previously known to only have pulmonary involvement, presenting
with flank pain, N/V, and microscopic hematuria alongside
worsening pulmonary symptoms concerning for progression of
Goodpasture, transferred from ___, then transferred to
the ___ for monitoring of hemoptysis where she was started on
plasmapheresis and immunosuppression with cyclophosphamide and
steroids.
======================
ACUTE/ACTIVE PROBLEMS:
======================
# Goodpasture syndrome
# Progressive hemoptysis, chest pain, shortness of breath
Her hemoptysis, chest pain, and shortness of breath have been
chronic for the past 4 months, aside from a brief several week
break after biopsy and diagnosis, but have worsened in the past
few days since she discontinued azathioprine (due to possible
side effect causing back/flank pain). CTA chest from ___
showed extensive groundglass opacities and airspace disease,
most likely due to diffuse alveolar hemorrhage. She has had no
fevers or sputum production to suggest infection. CTA was
negative for PE. EKG did not show evidence of ischemia. After
consultation with multiple services (rheum, pulmonary, renal),
the plan was made to initiate plasmapheresis given progression
in the face of steroids/azathioprine. She continued to be
somewhat tenuous and was therefore transferred to the ___ for
observation in case of need for emergent plasmapheresis.
Discontinued azathioprine and prednisone, switched to
methylprednisone and cyclophosphamide. Her Anti-GBM titers were
still weakly positive. She was followed by pulmonology,
rhematology and nephrology. She continued on plasmpheresis with
improvement in her symptoms. After two sessions of
plasmapheresis, her anti-GBM level was undetectable. She
completed four sessions sessions of plasmapheresis in total. Her
steroids were decreased to Prednisone 60mg (higher than home
dose). She will be discharged on cyclophosphamide, prednisone,
TMP-SMX, Vit D and Calcium, and a PPI for prophylaxis. She will
follow up with pulmonology in ___ weeks. She and her
friends/family members were given extensive verbal return
precautions regarding infection and avoiding sick contacts given
her immunosuppressed state.
# Bilateral flank pain
# Microscopic hematuria
# Non-obstructing R renal calculus
Her symptoms are concerning for possible new renal involvement
of her Goodpastures. Her creatinine is reassuringly normal.
Hematuria may be secondary to non-obstructing renal calculus.
Her urine culture did not reveal infection. She was followed by
renal who felt that this was not a manifestation of renal
Goodpastures and should be followed up as an outpatient. Her
repeat urinalysis on discharge showed no proteinuria and
significantly less hematuria. She was given extensive verbal
return precautions about her kidney including UTI sxs,
nephrolithiasis symptoms.
# Normocytic anemia
H/H 7.8/28.7 on admission from 9.6/31.8 in ___ on ___.
Likely blood loss anemia in the setting of hemoptysis.
Microscopic hematuria is unlikely to be contributing.
# Leukocytosis
Likely due to diffuse alveolar hemorrhage. CTA was negative for
PE. No localizing signs/symptoms of infection. She was treated
with meropenem and vancomycin at ___ prior to transfer. She
did not require antibiotics at ___.
#Steroid associated hyperglycemia
She was treated with insulin sliding scale; however, after
transitioning to oral steroids she no longer required insulin.
#Fertility
Given her treatment with cyclophosphamide, GYN performed a
telephone consult. She will follow up with gynecology as an
outpatient.
TRANSITIONAL ISSUES:
- Regarding fertility: It was recommended that she contact Dr.
___ at ___ IVF at ___. REI
specialists will then assess patient's fertility as well as
whether she is a good candidate for fertility preservation. PCP
to please arrange such follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 40 mg PO DAILY
2. Atovaquone Suspension 750 mg PO DAILY
3. AzaTHIOprine 50 mg PO DAILY
4. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
Discharge Medications:
1. Calcium Carbonate 1500 mg PO DAILY
2. CycloPHOSPHAMIDE 200 mg PO QAM
RX *cyclophosphamide 50 mg 4 capsule(s) by mouth QAM Disp #*120
Capsule Refills:*0
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
5. Vitamin D 1000 UNIT PO DAILY
6. PredniSONE 60 mg PO DAILY
7. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoptysis
Goodpasture's Syndrome
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 during your stay. You were
admitted for coughing up blood. This is related to your
Goodpasture's disease. You were treated with plasmapheresis and
medications. You should follow up with your pulmonologist,
rheumatologist, a nephrologist.
Followup Instructions:
___
|
10323890-DS-9 | 10,323,890 | 22,006,510 | DS | 9 | 2117-10-12 00:00:00 | 2117-10-12 18:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, hemoptysis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a ___ F with no past medical history who was
recently admitted from ___ for shortness of breath and
hemoptysis, s/p full course of antibiotics and steroids for
bilateral pneumonitis (infectious vs inflammatory), now
presenting a few days after finishing antibiotics with worsening
shortness of breath and recurrent hemoptysis. She initially
presented on ___ to ___ with hemoptysis which she
describes as bright red and of volume approx. similar to a
medicine cup. She was found to have bilateral pulmonary
infiltrates and was discharged after a one week hospitalization
on oral antibiotics. During that hospitalization, she underwent
extensive work-up including ___ (neg), blood cultures (no
growth), and bronchoalveolar lavage (two washings, both grew
pan-sensitive E. coli).
Over the next few weeks, she began to feel progressively better
though she did have persistent hemoptysis. By ___ she was no
longer having hemoptysis and felt close to her baseline so
returned to work. She took her last dose of oral abx on ___.
The next day, she began feeling increasingly short of breath and
had recurrence of hemoptysis. She also complained of severe
reflux and heartburn x2 days immediately after stopping the
antibiotics. She returned to her PCP ___ ___ and was given
additional oral steroids as well as Augmentin. However, she
continued to have worsening hemoptysis and dyspnea throughout
the following day and returned to ___ on ___.
She denies any fevers/chills, nausea/vomiting or bowel changes
including diarrhea. She endorses dizziness/lightheadedness
especially worsened by activity. She also complains of central
chest pain that worsens with deep inspiration. She denies any
recent travel (has not left ___ in ___ years), any sick
contacts, recent dental procedures, IV drug use, or other recent
illnesses.
In the ED, initial vitals: 97.8 120 / 74 102 28 92% 1L
- Exam notable for: Labored breathing, diffuse crackles on pulm
exam
- Labs notable for: WBC 10.9, UA trace protein/few bacteria
On the floor, she appeared somewhat anxious and breathing was
shallow, though she could speak in complete sentences. She was
complaining of sharp, central chest pain on inspiration as well
as lightheadedness with activity such as walking to the
restroom. Her O2 sat was 92% on RA, so she was kept on 1L NC for
comfort.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
- GERD
- Obesity
- Hypothyroidism
- Panic disorder
- Anxiety
- PTSD
- ADHD
- Dyslexia
- Depression
- Tonsillectomy (in early ___)
Social History:
___
Family History:
Not aware of any family history of cardiac or pulmonary disease
or blood clotting disorders.
Physical Exam:
==============
ADMISSION EXAM:
==============
VITALS: 97.7 F 122/70 103 20 95% 1L NC
GENERAL: Alert, oriented, appears anxious
HEENT: Sclerae anicteric, EOMI, PERRL, neck supple, JVP appeared
elevated though difficult to assess as pt using accessory
muscles respiration
CARDIOVASCULAR: Regular rhythm, tachycardic, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: Bibasilar crackles, diminished breath sounds throughout
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
EXTREMITIES: Warm, well perfused, 2+ pulses, no splinter
hemorrhages, ___ nodes, ___ lesions, mild edema of
the lower extremities bilaterally
NEURO: Face grossly symmetric. Moving all limbs with purpose
against gravity. Pupils equal and reactive, no dysarthria. Some
horizontal nystagmus in direction of gaze with abduction.
==============
DISCHARGE EXAM:
==============
Vitals: 97.9PO 113/71L Sitting 86 20 98% RA
General: Alert, oriented, NAD
HEENT: Sclera anicteric
Lungs: CTAB, no wheezes, rales, rhonchi
CV: NRRR, normal S1 + S2, no murmurs, rubs, gallops appreciated.
Abdomen: soft, non-tender, no rebound tenderness or guarding,
Skin: No rashes on face, trunk, or upper extremities
Pertinent Results:
==============
ADMISSION LABS:
==============
___ 03:17PM HIV Ab-NEG
___ 05:30AM GLUCOSE-145* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-19* ANION GAP-15
___ 05:30AM TSH-1.9
___ 05:30AM FREE T4-1.0
___ 05:30AM WBC-10.9* RBC-3.45* HGB-10.3* HCT-31.7*
MCV-92 MCH-29.9 MCHC-32.5 RDW-13.7 RDWSD-45.6
___ 05:30AM NEUTS-91.5* LYMPHS-6.4* MONOS-1.0* EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-9.97* AbsLymp-0.70* AbsMono-0.11*
AbsEos-0.02* AbsBaso-0.03
___ 05:30AM PLT COUNT-361
___ 05:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 05:20AM URINE RBC-1 WBC-<1 BACTERIA-FEW* YEAST-NONE
EPI-<1
==============
PERTINENT LABS:
==============
___ 03:50PM BLOOD Lupus-NEG
___ 06:50AM BLOOD ALT-15 AST-13 AlkPhos-86 TotBili-0.4
___ 03:50PM BLOOD cTropnT-<0.01 proBNP-37
___ 03:50PM BLOOD ANCA-NEGATIVE B
___ 03:50PM BLOOD b2micro-1.8 IgG-603* IgA-139 IgM-75
___ 07:30AM BLOOD HIV Ab-NEG
___ 03:50PM BLOOD tTG-IgA-6
==============
DISCHARGE LABS:
==============
___ 04:39AM BLOOD WBC-10.3* RBC-3.13* Hgb-9.2* Hct-28.8*
MCV-92 MCH-29.4 MCHC-31.9* RDW-13.2 RDWSD-44.5 Plt ___
___ 04:39AM BLOOD Plt ___
___ 04:39AM BLOOD Glucose-103* UreaN-15 Creat-0.6 Na-140
K-4.3 Cl-103 HCO3-24 AnGap-13
___ 04:39AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.0
=============
MICROBIOLOGY:
=============
HIV (___): Negative
RPR (___): Non-Reactive
Coccidiodes Ab (___): Pending
Galactomannan (___): Negative
Mycoplasma Pneumoniae Abs (___): IgG positive, IgM negative
Legionella Pneumophilia Ab (___): Pending
B-Glucan (___): 44 (negative)
Histoplasma Antigen (___): Pending
Blastomyces Antigen (___): Pending
S. pneumonia Antigen (___): Negative
Sputum Culture (___): Contaminated by upper respiratory
flora
Sputum Culture (___): Contaminated by upper respiratory
flora
Respiratory Viral Panel (___): Negative
Influenza A/B PCR (___): Negative
BAL Culture (___): E.coli
Blood Cultures (___): No growth
Urine Cultue (___): No growth
=======
IMAGING:
=======
EKG (___): HR 83, NSR, Normal Axis, QTc 429
CXR (___): Heart size and mediastinum are stable. Right
lung consolidation and left lung opacity are unchanged and most
likely represent a combination of hemoptysis and potentially
pulmonary edema. Infectious process is a possibility. There is
no pneumothorax or interval increase in pleural effusion.
CXR (___): Extensive bilateral central to peripheral
pulmonary consolidation spares the apices and lung bases. It
has increased substantially since ___. Heart size is
top-normal. There is no pleural effusion, although pulmonary
vasculature is engorged. Additional history provided by the
referring physician suggests ___ chronic or subacute condition
rather than acute infection, but in the absence of new
medication or volume overload or new hemoptysis, I am at a loss
to explain the rapid interval change. It is possible but very
unlikely that patient developed a concurrent atypical pneumonia.
CT Chest (___): There are bilateral nodular and confluent
groundglass opacities and areas of nodular consolidation. No
pulmonary emboli or pleural effusions. There is minimal
improvement since the prior study.
CT Chest (___): There is diffuse nodular and confluent
airspace opacification within both the upper and lower lobes. No
pulmonary emboli or pleural effusions. No prior CT scans for
comparison.
TTE (___): The left atrium is elongated. 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
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. The mitral valve appears structurally normal with
trivial mitral regurgitation. No masses or vegetations are seen
on the mitral 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.
Brief Hospital Course:
=======================
BRIEF SUMMARY
=======================
___ is a ___ woman, smoker, with history of hypothyroidism,
obesity, GERD and recent hospitalization ___ at
___ for bilateral pneumonia s/p 3 weeks abx and
steroids after 2 BALs notable for only E coli, who presented to
___ on ___ with dyspnea and submassive hemoptysis. The
etiology of her hemoptysis and dyspnea remains unclear. She had
an extensive workup for both infectious and
inflammatory/autoimmune causes which were unrevealing.
Pulmonology, Infectious Disease, Rhumatology, and Nephrology
teams were all consulted and involved in her care. She received
broad-spectrum IV antibiotics, cefepime and vancomycin for 4
days (___) and azithromycin for 3 days (___),
with no change. She was found to have anti-GBM elevated at 1.8,
and repeat Anti-GBM, ESR/CRP, C3/C4 are pending with follow up
planned with pulmonology.
========================
PROBLEM-BASED SUMMARY
========================
#Submassive Hemoptysis
#Dyspnea
Unclear etiology. Given the chronic nature of this illness, both
infectious and inflammatory etiologies were considered.
Infectious Disease, Pulmonology, Rheumatology and Nephrology
were consulted. Thoracic endometriosis syndrome cannot be ruled
out at this time; Bronchoscopy not pursued during this
hospitalization as sampling error is likely but recommend repeat
CT scan on ___.
>>Infectious Workup
Has had stable leukocytosis ~10. S/p full course of abx
(Augmentin) and steroids for b/l pneumonitis at ___.
Bronchoalveolar lavage in ___ at ___ was positive
for pan-sensitive E. coli, which is highly unusual as E. coli is
not classic oral flora. Fungal etiology was on differential as
pulmonary fungal infections have been associated with marijuana
smoking and she has potential mold exposure as a cleaner. TB is
unlikely, as she has no recent travel history, no contact with
the prison system or any former inmates, or to recent immigrant
to the ___. Infective endocarditis could cause chronic lung
infection although TTE negative (limited study) and without
physical exam findings or suggestive history (no recent dental
procedures or history of IVDU). Viral etiology is also possible
given the bilateral diffuse infiltrates though this would be
much more common in immunocompromised pts. In this young
otherwise healthy woman, immunocompromise was considered as an
underlying predisposition to infections and IgG was found to be
mildly low (603), HIV neg. Received broad-spectrum IV
antibiotics, cefepime and vancomycin for 4 days (___)
and azithromycin for 3 days (___), with no change.
Mycoplasma antibodies w/-IgM, +IgG suggesting resolved prior
Mycoplasma PNA.
- Negative studies: Legionella culture and urine antigen. HIV
Ab. RVP, Flu A/B, S. pneumo urine antigen. Sputum PCP. Babesia
and anaplasma (___), Aspergillus galactomannan. TTE
unremarkable (limited study), RPR.
- Pending studies: Urine Histoplasma + Blastomyces, Coccidioides
Ab, Beta-glucan, , Sputum culture (bacterial and fungal),
Pneumocystis smear, Legionella Ab, blood cultures
>>Autoimmune/Inflammatory Workup
Ddx: Anti-GBM disease, SLE, ANCA-associated vasculitis
Anti-GBM elevated at 1.8, raising suspicion for Goodpasture's
disease. Rheumatology consulted and felt that pt's relatively
stable symptom course with response to moderate dose steroids is
less suggestive of Goodpasture's which tends to be rapidly
progressive once symptomatic with typically high antibody
titers. Renal consulted and found no evidence of renal
impairment. Therefore, she does not meet criteria for
Goodpasture at this time kidney biopsy or steroids are not
recommended at this time.
- Negative studies: Cardiolipin Antibodies (IgG, IgM), ANCA,
___ ___, tTG-IgA, lupus anticoagulant.
- Pending studies: Repeat Anti-GBM, CRP/ESR, C3/C4 levels.
#Anxiety/depression/PTSD:
On no medications at home. Previously had treater at ___
___ and trial of Zoloft with no effect.
Provided with contact for outpatient therapists.
#Hypothyroidism
Has not taken synthroid in over ___ years per patient report.
TSH WNL. Encouraged to follow up with primary care physician.
#GERD: initially held home omeprazole due to concern for PNA and
received ranitidine 150mg PO BID. Resumed home omeprazole ___.
#SMOKING HISTORY
Understands dangers of smoking and effect on current symptoms.
Encouraged to quit and follow up with PCP for smoking cessation
resources. Has tried Chantix and nicotine patch in past w/o
success.
========================
TRANSITIONAL ISSUES:
========================
- Repeat CT chest scan needed, to be coordinated by ___
department
- Pulmonology follow up with Dr. ___ in ___. Dr. ___
___ will also arrange for outpatient sleep study.
- Follow up results of pending studies (listed above).
- Referred to family planning clinic for birth control
counseling both to prevent pregnancy and alleviate potential
pulmonary endometriosis (on differential, not confirmed).
Consider implanon.
- Given psychiatric history, would benefit from outpatient
therapy. Provided with list of therapists.
- Follow up with primary care doctor for help quitting smoking
and management of hypothyroidism and GERD.
- Given information for welfare services given that she cannot
work her physically demanding job at this time.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO BID
Discharge Medications:
1. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
==================
PRIMARY DIAGNOSIS
==================
Submassive Hemoptysis
Dyspnea
====================
SECONDARY DIAGNOSIS
====================
GERD
Depression
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of ___ at ___. Please see below
for information on your time in the hospital.
================================
WHY WAS I IN THE HOSPITAL?
================================
- ___ came to the hospital with shortness of breath and bloody
cough.
================================
WHAT HAPPENED IN THE HOSPITAL?
================================
- ___ were treated with antibiotics in case this was a bacterial
lung infection similar to the one ___ had recently.
- ___ had many imaging and blood tests done to try to identify
the cause of your symptoms.
- Your symptoms slowly improved and ___ were ready to go home
with follow up (as below) for continued workup
- We discussed that your diagnosis is still unclear but it is
safe to leave the hospital.
================================
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please have CT scan of your chest in the coming weeks, the
exact time/place/date will be coordinated by the pulmonary
doctors
- Please follow up with the ___ doctors. ___ should see
Dr. ___ in 2wks. Dr. ___ will also help ___
schedule an outpatient sleep study as ___ were found to have
some disorganized breathing when asleep.
- Please follow up with the family planning clinic to find the
best birth control option for ___.
- Please follow up with your primary care doctor for help
quitting smoking.
- Please make an appointment with your new therapist.
We wish ___ the best!
-Your Care Team at ___
Followup Instructions:
___
|
10323925-DS-10 | 10,323,925 | 28,916,493 | DS | 10 | 2128-06-14 00:00:00 | 2128-07-08 11:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall, Chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with prostate ca s/p robotic prostatectomy who presents
after a fall. Patient noted symptoms of URI over the weekend
which were improving today with some residual mild dyspnea. Upon
leaving an appointment from his therapist's office he was taking
a flight of ___ stairs and was soon after found at the foot of
the staircase. He remembers realizing he was falling, but then
apparently lost consciousness until EMS had arrived. When he
awoke he noted L chest and shoulder pain.
On my evaluation, patient has been treated for pain in the ED,
and reports that it is improved but still severe. He is able to
IS to 1250 with subsequent productive cough. He also has L
shoulder pain.
Past Medical History:
DEPRESSION
SEASONAL ALLERGIES
IRRITABLE BOWEL SYNDROME
MID-DERMAL ELASTOLYSIS
OSTEOARTHRITIS
VITAMIN D DEFICIENCY
PATELLA TENDINITIS
CHONDROMALACIA PATELLAE
HEARING LOSS
ERECTILE DYSFUNCTION
ELEVATED PSA, Prostate cancer
Social History:
___
Family History:
non-contributory.
Physical Exam:
Physical Exam:
Vitals: 98.7 112 130/82 20 93RA
GEN: A&O, NAD GCS 15
CV: RRR
PULM: non-labored on RA. Small ecchymosis at sternal manubrium
ABD: Soft, nondistended, nontender
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 97.8 PO 109 / 73 L Sitting ___ Ra
GEN: well appearing.
CV: RRR
PULM: Clear to auscultation bilaterally.
EXT: Warm and dry.
Pertinent Results:
Laboratory:
___ 02:56PM BLOOD WBC: 7.4 RBC: 4.58* Hgb: 13.6* Hct: 42.1
MCV: 92 MCH: 29.7 MCHC: 32.3 RDW: 13.6 RDWSD: 45.___
___ 02:56PM BLOOD Neuts: 67.7 Lymphs: 18.5* Monos: 7.3 Eos:
2.7 Baso: 0.7 Im ___: 3.1* AbsNeut: 4.99 AbsLymp: 1.36 AbsMono:
0.54 AbsEos: 0.20 AbsBaso: 0.05
___ 02:56PM BLOOD Plt Ct: 312
___ 02:56PM BLOOD Glucose: 105* UreaN: 12 Creat: 0.8 Na:
139
K: 4.8 Cl: 105 HCO3: 23 AnGap: 11
___ 02:56PM BLOOD ALT: 209* AST: 102* AlkPhos: 278*
TotBili:
0.3
___ 02:56PM BLOOD cTropnT: <0.01
___ 02:56PM BLOOD Albumin: 4.1
___ 03:09PM BLOOD Lactate: 1.5
Imaging:
CTA CHEST IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level.
2. Acute nondisplaced manubrial fracture with adjacent hematoma.
3. Nodular opacities within the left upper lobe, which may be
infectious or
inflammatory in etiology.
4. Focal areas of mucous plugging within the bilateral lower
lobes, with
subsequent subsegmental atelectasis.
5. No acute intra-abdominal abnormality.
6. Mild splenomegaly.
7. 7 mm sclerotic focus within the right scapula.
L Shoulder film
IMPRESSION:
No acute fracture or dislocation.
CT Head:
IMPRESSION:
1. Soft tissue swelling overlying the left posterior parietal
bone without
acute fracture.
2. No acute intracranial abnormality.
3. 1.7 cm calcified right frontal parasagittal lesion at the
vertex, likely a
meningioma.
4. Paranasal sinus disease.
CT C Spine:
IMPRESSION:
1. No acute cervical spine fracture or traumatic malalignment.
2. Moderate, multilevel degenerative changes, most prominent at
C5-C6.
___ 01:15AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 09:58PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 09:58PM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Brief Hospital Course:
Mr. ___ is a ___ yo M who presented to the Emergency
department via EMS after a fall down several stairs with
possible loss of consciousness. Upon EMS arrival, GCS 15. He
underwent CTA chest due to reports of chest pain and dyspnea. He
was found to have an acute nondisplaced manubrial fracture with
adjacent hematoma and no evidence of pulmonary embolism. To
evaluate for blunt cardiac injury he had an EKG that was
negative and Troponins were also negative. A flu swab was sent
due to recent history of upper respiratory infection which was
negative for flu. The patient was admitted to the trauma service
for pain control and EKG monitoring. Incidental lab findings
shows mild elevated in liver enzymes. Therefore workup with
liver ultrasound and hepatitis panel were initiated. Liver ultra
sound showed a normal appearing liver and gallbladder without
biliary dilatation. Hepatitis panel was negative for infection.
The patient was seen and evaluated by occupational therapy due
to loss of consciousness. A referral to outpatient physical
therapy was placed.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled on oral medications. The patient was discharged home
without services. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Venlafaxine XR 150 mg PO DAILY
BuPROPion XL (Once Daily) 450 mg PO DAILY
LORazepam 0.5 mg PO Q8H:PRN anxiety
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
3. lidocaine 4 % topical DAILY:PRN Duration: 14 Weeks
Available over the counter. See package for instructions
4. BuPROPion XL (Once Daily) 450 mg PO DAILY
5. Venlafaxine XR 225 mg PO DAILY
6.Outpatient Physical Therapy
Dx: Fall, Sternal manubrium fracture, Impaired mobility,
Impaired ADLs, Impaired balance
Px: Good
___: 3 months
Discharge Disposition:
Home
Discharge Diagnosis:
Non-displaced sternal manubrium fracture
Mild Transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
after a fall sustaining a sternal bone fracture (the bone in the
middle of your chest). Your heart rhythm was monitored on
telemetry and remained stable. You were given pain medication
and encouraged to continue to take deep breaths, cough, and
walk. Your fracture will continue to heal over time and does not
need surgery.
Your blood work showed a slight elevation in your liver enzymes.
You had an ultrasound of your liver that showed your liver was
overall normal. A Hepatitis panel was sent that and negative for
infection. You should continue to follow up with your Primary
Care Provider to monitor your liver function.
You are now ready to be discharged from the hospital to continue
your recovery. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10324042-DS-12 | 10,324,042 | 24,044,648 | DS | 12 | 2128-09-12 00:00:00 | 2128-09-12 15:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Transfer for RP bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of aortic aneurysm repair, CAD s/p CABG, AF on
PPM and CHF presents from ___ with right hip pain, found
to have an RP bleed in the setting of elevated INR.
The patient has a history of a remote R femur fracture and has
noted progressive R hip pain over the last two weeks but
otherwise has been in his usual state of health without changes
in his medications or diet.
On the morning of presentation, he awoke with severe R hip pain
for which he sought evaluation at the ___. There he
was
found to have an INR of 4. Plain films of the femur showed no
acute fracture. A CT abd/pelvis was obtained which demonstrated
an RP bleed for which he was transferred to ___ for further
evaluation.
Of note, the patient was seen one year ago by interventional
pulmonology at ___ for evaluation of a R hilar mass in the
setting of prior asbestos exposure. He underwent a EBUS which
demonstrated reactive LAD thought to be secondary to recent CAP.
CT imaging showed no malignancy, but did demonstrate pleural
plaque related to prior asbestos exposure. He underwent a PET/CT
which showed FDG avidity at the GE junction. EGD demonstrated
esophagitis which was confirmed on biopsy.
He is without fevers/chills. He denies chest pain and states his
dyspnea is at his baseline. He does not endorse coughing. He has
no n/v/d or abd pain.
___
Na 139 K 5.0 Cl 95 HCO3 32
BUN 38 Cr 1.4
WBC 10.0 Hgb 8.4 Plt 408
___ 46 INR 4
XR Femur
No acute pelvic or hip fracture or dislocation. Internally
Stabilized well-healed right hip fracture as detailed.
CT abd/pelvis
___ right-sided iliopsoas mixed density hematoma that extends
from the level of the midpole the right kidney distally to the
muscle insertion on the lesser trochanter of the proximal right
femur. In the pelvis, hematoma measures 10 cm transverse by 8.5
cm AP. No hemorrhage in the dependent pelvis.
1. ___ right iliopsoas (retroperitoneal) hematoma as detailed.
2. No acute hip or pelvic bone fracture.
3. Bilateral pleural effusions, left >right, peribronchial
thickening
and nonspecific airspace disease at both lung bases. Calcified
pleural
plaques compatible with prior asbestos exposure.
4. Bilateral L5 spondylolysis with associated grade 1
spondylolisthesis at L5-S1.
In the ___, initial VS were:
T 97.6 HR 60 BP 157/74 R 18 SpO2 98% RA
EKG: V Paced at 60 BPM
___ showed:
___: 35.6 PTT: 35.9 INR: 3.3 -> 1.3 after Kcentra
7.1
10.9>----<371
24.1
138|97|37
----------<154
5.5|26|1.4
Repeat K 5.0
Consults: Surgery was consulted who stated there was no acute
surgical issues and recommended reversing the patient's INR and
to trend H/H.
Patient received:
___ 16:11 IV Kcentra ___ Units
___ 20:20 PO/NG Atorvastatin 40 mg
1u pRBC
On arrival to the floor, patient reports improvement of his R
hip
pain.
Past Medical History:
1. HTN
2. HLD
3. T2DM
4. CAD s/p CABG
5. CHF
6. AVR with aortic arch replacement
7. afib s/p PPM
8. Glaucoma
9. Patellofemoral arthritis (R)
10. Carpal tunnel syndrome
11. Bells Palsy ___ years ago s/p Bells palsy surgery x2
___. Left shoulder surgery
___. Tonsillectomy
Social History:
___
Family History:
No history of bleeding disorders
Son: ___ cancer
Sister: Lung cancer- smoker
Father: Lung operation in childhood
Brother: ESRD - on HD, narcolepsy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 88.6 BP 120/64 HR 60 R 18 ___
GEN: NAD
HEENT: L sided facial droop, moist mucous membranes
___: Regular, II/VI SEM
RESP: No increased work of breathing, diffuse rhonchi R>L
ABD: Mild TTP with distention, no rebound or guarding
EXT: Warm with pitting edema to mid shin b/l. 1+ DP pulse b/l.
Small well healing ulcer on ventral surface of L great toe
NEURO: Moving all 4 extremities with purpose. L facial droop
DISCHARGE PHYSICAL EXAM:
VITALS: 97.7 100/43 60 17 92% RA
GEN: NAD
HEENT: L sided facial droop (h/o Bell's palsy), moist mucous
membranes
___: Regular, II/VI SEM
RESP: No increased work of breathing, bilateral crackles in
lower
bases
ABD: soft, nontender, nondistended, no rebound or guarding. R
flank with ___, non tender, healing ecchymosis
EXT: Bruising along underside of RLE, 1+ pitting edema behind
knees bilaterally. 1+ DP pulse b/l. Small well healing ulcer on
ventral surface of L great toe. Extensive ecchymoses of
bilateral
proximal and distal UEs.
NEURO: L facial droop, ___ strength in RLE hip flexion,
otherwise
___ in rest of RLE, ___ in LLE, ___ BUE
Pertinent Results:
ADMISSION ___:
===========================
___ 02:00PM BLOOD WBC-10.9* RBC-2.86* Hgb-7.1* Hct-24.1*
MCV-84# MCH-24.8* MCHC-29.5* RDW-17.3* RDWSD-52.8* Plt ___
___ 02:00PM BLOOD Neuts-87.5* Lymphs-3.2* Monos-8.6
Eos-0.0* Baso-0.3 Im ___ AbsNeut-9.52* AbsLymp-0.35*
AbsMono-0.94* AbsEos-0.00* AbsBaso-0.03
___ 02:00PM BLOOD ___ PTT-35.9 ___
___ 02:00PM BLOOD Glucose-154* UreaN-37* Creat-1.4* Na-138
K-5.5* Cl-97 HCO3-26 AnGap-15
___ 06:00AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.9*
___ 03:20PM BLOOD K-5.0
MICRO:
===========================
NONE POSITIVE
STUDIES:
============================
CHEST (PORTABLE AP) Study Date of ___ 12:35 AM
Lungs are low volume with evidence of calcified and noncalcified
bilateral
pleural plaques. Cardiomediastinal silhouette is stable.
Evaluation for
underlying nodules is limited. Round atelectasis in both lower
lobes is
unchanged. No pneumothorax is seen
CT AT ___ right-sided iliopsoas mixed density hematoma that extends
from
the level of the midpole the right kidney distally to the muscle
insertion on the lesser trochanter of the proximal right femur.
In the
pelvis, hematoma measures 10 cm transverse by 8.5 cm AP. No
hemorrhage
in the dependent pelvis. Bone windows demonstrate no acute hip
or
pelvic bone fracture. Bilateral L5 spondylolysis with associated
grade
1 spondylolisthesis at L5-S1. No compression fracture the
visualized
spine.
Cardiomegaly, bilateral pleural effusions, left >right and
bilateral
lower lobe peribronchial thickening and nonspecific patchy
airspace
disease at the lung bases. Calcified pleural plaques compatible
with
prior asbestos exposure.
Liver, spleen, pancreas and adrenal glands are unremarkable.
Gallbladder gravel and/or small calculi. Gallbladder otherwise
unremarkable. Bile ducts are not grossly dilated. No
hydronephrosis on
either side. Aorta and iliac arteries are densely calcified. No
AAA.
No gross retroperitoneal lymphadenopathy.
No evaluation of bowel limited secondary lack of contrast media.
No
bowel obstruction or obvious inflammation. Unopacified urinary
bladder
grossly unremarkable. Tiny umbilical hernia containing not:
Nonobstructed small bowel.
IMPRESSION:
1. ___ right iliopsoas (retroperitoneal) hematoma as detailed.
2. No acute hip or pelvic bone fracture.
3. Bilateral pleural effusions, left >right, peribronchial
thickening
and nonspecific airspace disease at both lung bases. Calcified
pleural plaques compatible with prior asbestos exposure.
4. Bilateral L5 spondylolysis with associated grade 1
spondylolisthesis at L5-S1.
PELVIS XR AT ___ pelvis and AP and lateral views of the right femur without
comparison films demonstrate a compression screw and short stem
intramedullary rod stabilizing an old, well-healed right hip
fracture.
No acute pelvic or hip fracture or dislocation. No significant
hip or
SI joint arthropathy. Extensive vascular calcifications.
CONCLUSION: No acute pelvic or hip fracture or dislocation.
Internally
stabilized well-healed right hip fracture as detailed.
DISCHARGE ___:
===============
___ 06:00AM BLOOD WBC-8.4 RBC-3.00* Hgb-7.9* Hct-26.5*
MCV-88 MCH-26.3 MCHC-29.8* RDW-18.7* RDWSD-55.5* Plt ___
___ 06:00AM BLOOD ___ PTT-27.1 ___
___ 06:00AM BLOOD Glucose-146* UreaN-39* Creat-1.2 Na-138
K-3.9 Cl-94* HCO3-32 AnGap-12
___ 06:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
Brief Hospital Course:
Mr. ___ is an ___ with history of aortic aneurysm repair, CAD
s/p CABG, AF on PPM and warfarin, and CHF, who presented as a
transfer from ___ after work up for R hip pain
demonstrated a retroperitoneal hematoma in the setting of an
supratherapeutic INR.
ACUTE ISSUES:
===============================
#Retroperitoneal Hematoma
#Acute blood loss anemia ___ hematoma
No history of trauma, INR 4 on admission. Reversed with Kcentra
in ___. R hip pain was likely referred pain given negative XR of
femur. Patient remained hemodynamically stable. Received 2U prbc
in total during hospitalization with appropriate rise in
hemoglobin. No medication changes or diet changes to explain
increase in INR. No surgical indication. At the time of
discharge, his hemoglobin had been stable for several days
without transfusion requirement. His anticoagulation was held at
the time of discharge given the nature of his soft tissue bleed.
Risks of holding anticoagulation including thrombosis and stroke
(in the setting of afib) were reviewed with the patient, plan is
for him to follow with PCP to determine when to resume a/c and
which agent to resume.
#Right leg weakness
The patient complained of new right lower extremity weakness on
admission, likely ___ hematoma. Evaluated by neuro given concern
for nerve impingement, no other symptoms of cord compression as
no urinary incontinence, stool incontinence, sensation loss. No
need for imaging per neuro. Pacer not MRI compatible, so no
further imaging was obtained.
#Acute on Chronic Kidney disease
Baseline Cr 1.2, 1.4 on admission, likely due to hypovolemia in
the setting of acute blood loss anemia. Returned to baseline
with volume resuscitation.
#Acute on Chronic Diastolic Heart Failure
Volume overloaded on exam. Diuresis initially held iso ___, then
actively diuresed until euvolemic. Resumed on home regimen of
diuretics upon discharge. Of note he uses nocturnal oxygen and
throughout the day was in the low 90's off oxygen. ___ require
supplemental o2 going forward if his o2 levels remain low,
however no clear indication to continue around the clock O2.
Needs follow up with cardiology to ensure diuretic regimen
stable and monitor o2 sats.
#Atrial fibrillation
s/p PPM ___ Mobitz type I AV block, anticoagulated with warfarin
prior to admission. INR supratherapeutic as above. Unclear
precipitant for INR rise (no medication or diet changes).
Warfarin held iso bleed, with plans to restart approximately 1
week after discharge, or when felt to be clinically stable.
#Coronary artery disease
#Aortic Valve replacement
#Aortic Aneurysm repair
S/p 3v CABG on ___ with LIMA to LAD and SVG to OM and PAD
with bioprosthetic AVR replacement and concurrent ascending
aorta and hemiarch replacement with a 32-mm Gelweave graft.
Continued ASA, atorvastatin.
#COPD: The patient is on 2L NC O2 at night at baseline. He
required 2L NC around the clock intermittently while inpatient,
likely in the setting of volume overload after volume
resuscitation for his RP bleed (and his more tenuous volume
status given his known diastolic heart failure). His oxygenation
improved with diuresis, but he was still intermittently on O2
during the day at the time of discharge. He was continued on his
home albuterol and tiotropium. His o2 sat was 92% on RA before
discharge. Needs outpatient pulmonary follow up.
#HLD: continued home atorvastatin
#DM2: on metformin at home, held while inpatient and ISS given.
#GERD: Continued home PPI
#BPH: continued home tamsulosin
#Glaucoma: continued home dorzolamide and erythromycin ointment
TRANSITIONAL ISSUES:
=======================================
[ ] The patient's hemoglobin was stable at 7.9 in the days
leading up to discharge, but please check a repeat CBC in ___
days to ensure ongoing stability.
- DISCHARGE HGB: 7.9
[ ] The patient's warfarin was held on this admission in the
setting of (presumably spontaneous) retroperitoneal bleed.
Anticoagulation should be resumed approximately 1 week after
discharge. A discussion was initiated with the patient and his
family regarding the risks and benefits of warfarin vs NOAC
while the inpatient. Please continue this conversation as an
outpatient to determine appropriate anticoagulant to be used
given his increased bleeding risk.
[ ] The patient was discharged on furosemide 60mg PO daily for
maintenance of his volume status. Please obtain daily standing
weights, and if he gains 3 or more pounds from his discharge
weight, please increase furosemide dose accordingly.
- DISCHARGE WEIGHT: 82.7kg (182.32lbs)
- DISCHARGE CREATININE: 1.2
[ ] Please recheck the patient's Chem10 within 7 days given his
ongoing diuresis.
- DISCHARGE CREATININE: 1.2
[ ] The patient required 2L NC O2 intermittently during the day
during this admission (SpO2 90-93% on RA), but at baseline has
required it only at night. Please continue ___ and encourage
regular activity while at rehab, and reassess his need ongoing
need for O2 periodically (goal saturation 92%). ___ qualify for
home o2 around the clock going forward and should follow up with
PCP, pulmonary and cardiology closely.
[ ] Atrius PCP to arrange for close follow up with Atrius
cardiology for his chronic HFpEF and with pulmonology for his
COPD.
[ ] Note: Pacemaker is not MRI compatible.
Pacemaker Info:
Manufacturer: ___
Model: ___
S/N: ___
Date of implant: ___ in ___, ___
Type: VVI
#CODE: Full (presumed)
#CONTACT:
Name of health care proxy: ___
Relationship: daughter
Phone number: ___
Time spent coordinating the discharge of this patient: 50
minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Warfarin 5 mg PO DAILY16
3. Tamsulosin 0.4 mg PO QHS
4. Omeprazole 20 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Metolazone 2.5 mg PO DAILY:PRN If weight >184 lb
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN asthma symptoms
8. Tiotropium Bromide 1 CAP IH DAILY
9. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
10. Aspirin 81 mg PO DAILY
11. Cyanocobalamin 500 mcg PO DAILY
12. Calcium Carbonate Dose is Unknown PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID
2. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
3. Calcium Carbonate unknown PO DAILY
4. Furosemide 60 mg PO DAILY
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN asthma symptoms
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Cyanocobalamin 500 mcg PO DAILY
9. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
10. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE BID
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. Tiotropium Bromide 1 CAP IH DAILY
15. HELD- Metolazone 2.5 mg PO DAILY:PRN If weight >184 lb This
medication was held. Do not restart Metolazone until told by
your doctor to restart
16. HELD- Warfarin 5 mg PO DAILY16 This medication was held. Do
not restart Warfarin until told by your doctor to restart
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Spontaneous retroperitoneal hemorrhage
Acute blood loss anemia
Atrial fibrillation
Acute on chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear
It was a pleasure taking care of you during your stay at ___.
WHY WAS I HERE?
- You had pain in your right hip, and you were found to have
bleeding in the deep tissue of your back called a
retroperitoneal bleed.
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- Your warfarin (blood thinner) was stopped.
- You received some blood.
- The bleeding stopped, and your blood counts stabilized.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- We recommend that you spend some time at rehab to rebuild your
strength.
- Please continue to take your medications as prescribed.
- Please go to all of your scheduled doctor's appointments.
- Weigh yourself every morning, call MD if your weight goes up
more than 3 lbs.
Be well!
Your ___ Care Team
Followup Instructions:
___
|
10324394-DS-10 | 10,324,394 | 25,817,969 | DS | 10 | 2144-02-01 00:00:00 | 2144-02-03 11:59:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Cough, dyspnea, chills
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms ___ is ___ year old female with type 1 diabetes c/b
neuropathy who complains of cough, dyspnea and chills.
Over the past ___ days Ms ___ a new cough with
initially clear and then yellow sputum, a the onset the cough
was accompanied by a sore throat and sneezing. She's been having
some chills and a temperature at 99.9. Additionally, over the
last 2 days she developed dyspnea and global chest tightness
associated with wheezing. Her appetite is down and she has not
been eating but noticed her fingersticks to be in the 300 so
decided to call EMS.
Of note she recently had a UTI that was initially treated with 7
days of cefpodoxime without improvement and was switched to
ciprofloxacin which she took until yesterday. Of note she's also
been on permethrin likely for pubic scabiosis.
Her ED course was significant for:
-Initial vitals: 98.3 74 102/59 14 95% RA
-CBC: 8.5>9.8/28.4<237
-Chem: HypoNa 128, Cr 1.2 (b/l 0.8), gluc 515, pH 7.45
-CXR: RML and RLL PNA
-Pt received: nebs, prednisone 60, morphine sulfate 5mg iv,
humalog 8U SC, IV levofloxacint 750mg
-Vitals on tx 98.1 83 97/60 20 96% RA
On the floor, 97.9 127/74 80 18 99%RA. Patient complained of
full body pain.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
-DM 1 (uncontrolled)
-Chronic pain on chronic narcotics
-Hypertension
-Hyperlipidemia
-Asthma
-Depression with prior suicide attempt
-s/p C-section
-Left foot debridement ___
-Left foot debridement and left first toe amputation ___
-Debridement of skin, subcutaneous tissues and bone, left
forefoot ___
-Completion left transmetatarsal amputation, all toes,
___
-C section
-Right first toe amp ___
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL:
=======================
Vitals - 97.9 127/74 80 18 99%RA
GENERAL: Chronically ill appearing, moaning with pain
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, diffuse wheezes. No rales, rhonchi, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose. Multiple ulcers in both feet.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Decreased sensation in toes.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL:
=======================
Vital Signs: T 98, BP 124/81, P 70, RR 18, O2 100/RA
General: ___ speaking. Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezing,
non-labored breathing
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema. R
great toe amputation. All L toes amputated.
Skin: Ulcers on foot pads bilaterally. R heel ulcer.
Pertinent Results:
ADMISSION LABS:
===================
___ 08:30PM BLOOD WBC-8.5 RBC-3.29* Hgb-9.8* Hct-28.4*
MCV-87 MCH-29.9# MCHC-34.6# RDW-13.7 Plt ___
___ 08:30PM BLOOD Neuts-72.7* ___ Monos-3.7 Eos-0.9
Baso-0.2
___ 08:30PM BLOOD Glucose-515* UreaN-13 Creat-1.3* Na-128*
K-3.9 Cl-89* HCO3-25 AnGap-18
___ 07:41AM BLOOD ALT-12 AST-15 LD(LDH)-222 AlkPhos-93
TotBili-0.3
___ 07:41AM BLOOD Albumin-3.9 Calcium-9.6 Phos-4.0 Mg-2.0
Iron-17*
___ 08:41PM BLOOD Lactate-1.2
DISCHARGE LABS:
===================
___ 07:00AM BLOOD WBC-7.2 RBC-3.46* Hgb-9.9* Hct-30.5*
MCV-88 MCH-28.5 MCHC-32.4 RDW-13.2 Plt ___
___ 07:00AM BLOOD Glucose-313* UreaN-22* Creat-0.9 Na-135
K-4.0 Cl-97 HCO3-26 AnGap-16
MICROBIOLOGY:
===================
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
BLOOD CULTURES: NGTD
STUDIES:
===================
CXR (___):
FINDINGS:
PA and lateral views of the chest provided. Airspace
consolidation is seen within the right middle lobe compatible
with pneumonia. There may also be a smaller The
cardiomediastinal silhouette is normal. Imaged osseous
structures are intact. No free air below the right
hemidiaphragm is seen.
IMPRESSION:
Findings concerning for right middle and lower lobe pneumonia.
Brief Hospital Course:
___ with uncontrolled DM1 c/b diabetic feet + neuropathy, HTN,
asthma, chronic back pain on narcotics presents with 11 days of
URI symptoms, productive cough, and hyperglycemia. Pt. was
discharged against medical advice.
#PNEUMONIA: Patient with 11 days of symptoms, now with worsening
productive cough and CXR infiltrates likely representing a
post-viral CAP. Tmax at home was 99.9 and afebrile here. Flu
swab negative (though son recently had flu).
-Levofloxacin 750mg PO qd x 7d, to finish on ___.
-Sputum culture, patient left prior to results.
-Urinary legionella negative
#ASTHMA: Questionable wheezing and chest tightness. Not severe
since not requiring O2, not tachypneic. Holding off steroids
(did receive prednisone 60 mg x1 in ED) given poorly controled
diabetes.
-Albuterol nebs PRN
-Continued home advair discus
#HYPERGLYCEMIA / T1DM: Decompensation in setting of acute
infection. Normal bicarb, no urine ketones, no change in MS.
___ hyperglycemic while in the hospital. Patient chose to
leave against medical advice before glycemic control could be
achieved.
-Continued glargine 38U.
-Humalog SSI while in house.
#Foot ulcers: Patient with bilateral foot ulcers and a R heel
ulcer, likely ___ diabetic neuropathy. No signs of infection.
-Wound care consulted and patient was provided with wound care
education. Podiatry information was provided to patient for
follow up.
#CHRONIC PAIN / PSYCH ISSUES: Patient is on high doses of
opioids and gabapentin for back pain and neuropathy. Home pain
regimen confirmed with PCP and pharmacy.
-Continued home regimen equivalent: Ms contin 100mg TID,
percocet ___ q4h PNR (changed to oxycodone ___ mg Q4H PRN
and standing APAP). By record, on tramadol 100 mg Q8H PRN but
patient reports not taking this at home, so it was discontinued.
As the patient is stable on this regimen, no changes were made
prior to discharge but we are concerned she has an aspect of
opioid induce hyperalgesia contributing to her chronic pain.
Consider weaning narcotics as an outpatient.
___: Likely volume down due to poor PO intake in setting of
acute illness and osmotic diuresis. Received fluids in ED.
Resolved prior to discharge.
#HYPONATREMIA: Likely hypovolemic, resolved with IVF.
#Otherwise home medications were continued without alteration.
TRANSITIONAL ISSUES:
[ ] patient will need close follow up of blood glucose levels
and insulin management
[ ] continue PO levofloxacin 750 mg daily until ___
[ ] consider weaning high dose narcotic medications as patient
may have a component of hyperalgesia contributing to her chronic
pain
# Code: Full
# Emergency Contact: ___ (boyfriend) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Ointment 1 Appl TP Q4H:PRN burning
2. ClonazePAM 1 mg PO BID:PRN Anxiety
3. Percocet (oxyCODONE-acetaminophen) ___ mg oral Q4H:PRN
pain
4. TraMADOL (Ultram) 100 mg PO Q8H:PRN pain
5. Morphine SR (MS ___ 100 mg PO Q8H
6. Sertraline 100 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Gabapentin 300 mg PO TID
10. Glargine 38 Units Breakfast
Insulin SC Sliding Scale using novolog Insulin
11. Lisinopril 5 mg PO DAILY
12. permethrin 5 % topical DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
15. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Aspirin 81 mg PO DAILY
3. ClonazePAM 1 mg PO BID:PRN Anxiety
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Gabapentin 300 mg PO TID
6. Glargine 38 Units Breakfast
Humalog 2 Units Breakfast
Humalog 3 Units Lunch
Humalog 5 Units Dinner
7. Lidocaine 5% Ointment 1 Appl TP Q4H:PRN burning
8. Lisinopril 5 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Morphine SR (MS ___ 100 mg PO Q8H
11. Sertraline 100 mg PO DAILY
12. Levofloxacin 750 mg PO DAILY Duration: 5 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth each evening Disp
#*5 Tablet Refills:*0
13. Montelukast 10 mg PO DAILY
14. Percocet (oxyCODONE-acetaminophen) ___ mg oral Q4H:PRN
pain
15. permethrin 5 % topical DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: suspected bacterial pneumonia, hyperglycemia
SECONDARY: chronic back pain, type I diabetes on insulin, asthma
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 a pneumonia and high blood
sugars. We started an antibiotic (called levofloxacin) for your
pneumonia. You should continue to take this to complete a 7-day
course. Your last day is ___.
We also were working to control your blood sugar with insulin.
We think your blood sugars were high because you have an
infection, but the antibiotic can also alter your blood sugars.
Our recommendation for your own medical safety was that you stay
in the hospital until your blood sugars were stable. We
discussed this at length and explained the risks of leaving with
unstable blood sugars. You understood these risks and decided to
go home. As such, you are leaving the hospital against medical
advice. You should continue to check your blood sugars
regularly and return to the hospital if they are either too high
or too low.
We also discussed your pain medications. We believe that your
pain is actually WORSE because you are on high doses of pain
medicine, especially morphine and Percocet. We recommend that
you discuss decreasing the doses of these medications with your
primary care provider.
All of your medication changes and new medications are detailed
in your discharge medication list. You should review this list
carefully and bring it with you to any upcoming appointments.
It was a pleasure taking care of you.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10324632-DS-21 | 10,324,632 | 25,835,058 | DS | 21 | 2176-12-01 00:00:00 | 2176-12-01 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with DM2, dementia, depression, previous falls, now p/w
fall.
On evaluation in the ___, she states that has been falling
repeatedly but is unsure why. Cannot state any preceding events.
Per ___ conversation with patient's daughter, she is incontinent
of urine/stool at baseline.
In the ___, initial vitals were:
96.5 95 148/67 16 99% RA
- Exam notable for Guaiac negative stool, frail appearing
patient, dry mouth, FAST negative.
- Labs notable for:
Lactate 3.6->3.1
WBC 13.3->8
Hgb 10.7->9.5
Plt 289->247
UA with few bacteria, 2 WBCs, Mod leuks
Na 131, Cl 90, Cr 0.5
LFTs, lipase unremarkable
___ normal
CT C/A/P with contrast showed large stool burden and concern for
sterocoral colitis. Gastroenterology recommended repeated
enemas, and no immediate disimpaction but may require
disimpaction subsequently if enemas not effective.
She passed a small amount of soft stool after soap suds enema.
Given continued stool burden, she was admitted for serial enemas
and physical therapy evaluation.
- Patient was given:
___ 15:50 IVF NS 500 mL
___ 18:14 IVF NS ( 1000 mL ordered)
___ 20:20 IV Ciprofloxacin 400 mg
___ 23:07 IV MetRONIDAZOLE (FLagyl) 500 mg
Upon arrival to the floor, patient reports no pain including no
chest or abdominal pain. She has itching with urination which
she reports is not new. No fevers/chills. No cough or sputum.
She is not able to remember how she got to the hospital or why
she came, and is also not able to remember the circumstances of
the fall.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Recurrent hospitalizations for UTI, last at ___
___ ___
DIABETES TYPE II
HYPERTENSION
DIABETIC NEUROPATHY
DEPRESSION
DEMENTIA
FALLS
STAGE 2 SACRAL DECUBITUS
Social History:
___
Family History:
Mother ___ ___
Father ___ ___
Sister Living ALZHEIMER'S DISEASE
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 98.6 184/75 76 18 97RA
General: Alert, oriented, no acute distress. Very thin
appearing.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. ___ SEM over RUSB.
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. Adult diaper in place.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moves all extremities to command. Gait
deferred.
Remembers self, name of daughter. Year is ___. Does not know
where she is currently. Frequently answers "I don't remember"
during the interview.
DISCHARGE PHYSICAL EXAM
=======================
VS: Afebrile BP 150s-170s/70s-90s HR ___ RR 16 SaO2 94%Ra
General: Alert, oriented, no acute distress. Very thin
appearing.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. ___ SEM over RUSB.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly tender epigastrim, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
GU: No foley. Adult diaper in place.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No lesions on left buttock and mild TTP superior gluteus
Neuro: CNII-XII intact, moves all extremities to command. Gait
deferred. A+Ox1, (thinks she's in ___, year is ___,
dowb ___.
Skin: Known healing stage 2 sacral decubitus ulcer
Pertinent Results:
LABS ON ADMISSION
=================
___ 01:20PM BLOOD WBC-13.3* RBC-3.43* Hgb-10.7* Hct-32.6*
MCV-95 MCH-31.2 MCHC-32.8 RDW-13.3 RDWSD-46.4* Plt ___
___ 01:20PM BLOOD Neuts-81.5* Lymphs-14.7* Monos-2.6*
Eos-0.5* Baso-0.2 Im ___ AbsNeut-10.83* AbsLymp-1.96
AbsMono-0.34 AbsEos-0.07 AbsBaso-0.03
___ 01:20PM BLOOD ___ PTT-35.1 ___
___ 01:20PM BLOOD Glucose-186* UreaN-17 Creat-0.5 Na-131*
K-5.1 Cl-90* HCO3-26 AnGap-20
___ 01:20PM BLOOD Albumin-4.0 Calcium-9.2
NOTABLE LABS
============
___ 01:20PM BLOOD TSH-1.3
___ 01:20PM BLOOD T4-7.4
___ 06:25AM BLOOD CRP-35.7*
___ 01:28PM BLOOD Lactate-3.6*
___ 08:52PM BLOOD Lactate-3.1*
___ 06:30AM BLOOD Lactate-2.1*
IMAGING
=======
CT A/P ___. Large amount of stool burden seen in the rectal vault with
increased rectal
wall enhancement and mild haziness of the posterior adjacent
perirectal fat,
which can be seen in early stercoral colitis.
2. Incidental note is made of a 4-5 mm pulmonary nodule in the
right lower
lobe.
CT C SPINE ___. No evidence of fracture or traumatic malalignment.
2. Mild-to-moderate degenerative changes in the cervical spine
with multilevel
vertebral canal narrowing, most prominent at the C5-C6 and C6-C7
levels, as
described above.
3. Additional findings as described above
CTH ___. No evidence of acute intracranial abnormality on noncontrast
head CT.
Specifically no large territory infarct or intracranial
hemorrhage.
2. Chronic microangiopathy and age related global atrophy.
XR LUMBAR SPINE ___
Comparison is performed with an abdomen film from ___. Mild
rightward rotation of the spine. The disc spaces are preserved.
The
alignment of the vertebral bodies is unremarkable. There is no
evidence of
vertebral compression fracture. Mild degenerative changes at
the level of the
intervertebral joints.
DISCHARGE LABS:
===============
___ 07:06AM BLOOD WBC-8.9# RBC-3.15* Hgb-9.9* Hct-30.1*
MCV-96 MCH-31.4 MCHC-32.9 RDW-13.4 RDWSD-47.1* Plt ___
___ 07:06AM BLOOD Glucose-140* UreaN-16 Creat-0.4 Na-138
K-4.2 Cl-99 HCO3-27 AnGap-16
___ 07:06AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.7
Brief Hospital Course:
Ms. ___ is a ___ with DM2, dementia, depression, previous falls
who presented after a fall and was found to have significant
stercoral colitis. During the course of her hospital stay, the
following issues were addressed:
#Stercoral colitis. Patient with severe constipation and CT A/P
___ btained as part of her trauma eval showing stool burden seen
in the rectal vault with increased rectal wall enhancement and
mild haziness of the posterior adjacent perirectal fat,
which can be seen in early stercoral colitis. She was treated
with Standing senna/Colace, miralax, bisacodyl PR and warm water
enemas with improvement. Abdominal exam was benign for entirety
of stay. TSH normal. She will go to her facility with senna,
miralax, bisacodyl with instructions to do water enema if there
aren't daily BMs.
#Falls:
She has history of recurrent falls in the setting of frailty,
dementia and overall medical decompensation. Per daughter,
patient's presenting fall was mechanical: patient was witnessed
trying to get out of her wheelchair because she forgets that she
isn't able to support her own weight and fell. Low suspicion for
syncope, seizure. She was started on vitamin D 1,000 IU per day.
#Bacteruria:
She does have history in the past of recurrent UTIs. Given lack
of pyuria and normalized WBC prior to antibiotics in the ___,
___ defer on further antibiotics for UTI unless symptomatic.
#Weight loss:
#Severe malnutrition:
Outpatient workup ongoing. Negative mammogram in ___. No recent
colonoscopy. No overt malignancy on imaging obtained in the ___.
ESR 113, CRP was 158 in ___ c/w systemic inflammatory process
repeat in-house showed CRP 35.7, ESR 22. Consider discussion
with PCP ___ workup as inpatient vs outpatient for
malignancy (such as MM) or autoimmune disease.
#Hypertension: Continued lisinopril 10 mg qd
#T2DM: Continued home lantus 9u QAM, ISS. Held home metformin 1
g BID initially, but will restart at 500 mg BID upon discharge.
#Chronic pain:
- Continued Tylenol 1g TID, Gabapentin 300 mg PO QHS, Lidocaine
5% Patch 1 PTCH TD QAM, TraMADol 50 mg PO BID
#Depression: Continued DULoxetine 30 mg PO QHS, Sertraline 100
mg PO DAILY
TRANSITIONAL ISSUES:
====================
-Had stercoral colitis: Please give miralax BID, senna BID,
bisacodyl PR PRN. If no BM, then recommend water enemas q2h
until stool.
-Her hbA1c is ~6.7% so we cut her metformin in half to 500 mg
BID.
-Depression: Her FTT could be related to her depression and
recommend intensifying her anti-depressant regimen. Consider
adding mirtazapine for depression and weight loss.
-Has a stage 2 healing sacral decubitus ulcer.
-Please consider osteoporosis work up as an outpatient
-CRP 35.7 from 150 as an outpatient. Please continue work up as
clinically indicated
Radiology Follow Up:
Incidental note is made of a 4-5 mm pulmonary nodule in the
right lower
lobe. In the case of nodule size >4 - 6 mm: For low risk
patients, follow-up at 12
months and if no change, no further imaging needed. For high
risk patients,
initial follow-up CT at ___ months and then at ___ months if
no change
-Code status: DNR/DNI
-Contact: ___ (Daughter) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO TID
2. Lisinopril 10 mg PO DAILY
3. Gabapentin 300 mg PO QHS
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Fenofibrate 48 mg PO DAILY
8. Glargine 9 Units Breakfast
9. Multivitamins W/minerals 1 TAB PO DAILY
10. TraMADol 50 mg PO BID
11. diclofenac sodium 1 % topical BID
12. Zinc Sulfate 220 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. DULoxetine 30 mg PO QHS
15. Sertraline 100 mg PO DAILY
16. Capsaicin 0.025% 1 Appl TP DAILY
17. Ascorbic Acid ___ mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
=======
Stercoral colitis
Fall
Bacteruria
Secondary:
Failure to thrive
Severe malnutrition
Depression
Diabetes type 2
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:
Ms. ___,
It was a pleasure caring for you at ___
___. You came to us after sustaining a fall. You were
found to have a significant amount of stool in your colon with
associated inflammation (stercoral colitis). We used stool
softeners and enemas and you passed stool well. We started you
on constipation medications (senna, miralax, and bisacodyl) and
decreased your metformin in half (see below).
Please take all of your medications as described in this
discharge summary. If you experience any of the danger signs
below please contact your primary care doctor or come to the
emergency department immediately.
Best Wishes,
Your ___ Care Team
Followup Instructions:
___
|
10324638-DS-20 | 10,324,638 | 26,609,321 | DS | 20 | 2135-11-27 00:00:00 | 2135-11-27 17:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dislodged dobhoff
Major Surgical or Invasive Procedure:
___ Exchange of the existing 8 ___ percutaneous
transhepatic biliary drainage catheters with new bilateral 10
___ PTBD catheters.
___ Diagnostic laparoscopy with peritoneal biopsy.
___: Three Wall stents and anchor drains placed, Doboff
repositioned and bridled
___: Anchor drains removed
History of Present Illness:
___ with cholangioCA s/p ERCP and internal stent now s/p R/L
ext/internal PTBD on ___. Additionally, pt had PP feeding tube
placed by ___ at the same time. Discharged on ___ and seen by Dr.
___ in clinic shortly afterwards. During this clinic visit it
was discovered that his PTBDs were clogged.
.
Patient was sent home and was doing well until ___ when his
dobhoff clogged. Seen at ___ ED where it was replaced
(pre-pylorus). Started on his usual tube feeds to goal without
problems. Today feeding tube dislodged and patient sent over to
ED for replacement.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Prostate cancer, stage III (T3, N0, M0), s/p Lupron and
radiation. Presented with ___ grade 8, PSA of 11.5.
"He underwent a routine screening PSA in ___, which
was elevated at 11.5. He had no urinary difficulties at that
time. He had evidence of nodularity throughout the left mid
portion of the prostate, but disease appeared confined to the
prostate with no signs of extension. As a result of his
elevated PSA and abnormal digital rectal exam, he underwent
transrectal ultrasound-guided biopsy, which demonstrated ___
8 adenocarcinoma of the prostate in ___ cores. There was a
second focus on the left side ___ 6 cancer. He underwent
a bone scan and a CT of the abdomen and pelvis, which were
reportedly negative.
The patient underwent an endorectal MRI of the prostate
on ___, which showed two foci of gland confined to the
right base medially and to the mid-gland laterally. On the left
lobe, there was a large mass from the mid gland to apex that
invades the capsule and appears to infiltrate the left
neurovascular bundle. The seminal vesicles are not involved.
He began hormonal therapy on ___ with lupron and casodex
and radiation therapy."
PMH:
Prostate cancer, as above
History of GERD
PSH:
none
Social History:
___
Family History:
No family history of malignancies or tumors.
Physical Exam:
ADMISSION:
PE: ___ 18 100%
NAD AOX3
No jaundice noted
RRR
CTAB
Soft, NT/ND
Right PTBD capped with some bilious drainage around the tube,
flushes easily without resistance
Left PTBD capped without problems
.
Discharge:
VS: 99.4, 100, 126/68, 20, 99% RA
General: NAD, A+Ox3
Card: RRR
Resp: CTA bilaterally
ABD: Soft, non-distended, all drains removed, incision C/D/I
Extr: No C/C/E
Pertinent Results:
On Admission: ___
WBC-13.9* RBC-3.28* Hgb-10.4* Hct-32.1* MCV-98 MCH-31.9
MCHC-32.5 RDW-14.2 Plt ___ PTT-30.7 ___
Glucose-136* UreaN-27* Creat-0.9 Na-131* K-4.3 Cl-93* HCO3-28
AnGap-14
ALT-71* AST-45* AlkPhos-169* TotBili-2.4*
Albumin-3.4* Calcium-8.6 Phos-3.4 Mg-2.3
.
___ WBC-6.6 RBC-2.95* Hgb-9.5* Hct-28.9* MCV-98 MCH-32.2*
MCHC-32.9 RDW-13.5 Plt ___
Glucose-126* UreaN-12 Creat-0.7 Na-137 K-3.5 Cl-102 HCO3-27
AnGap-12
ALT-27 AST-29 AlkPhos-182* TotBili-1.1
.
Labs at Discharge: ___
WBC-5.8 RBC-2.80* Hgb-9.4* Hct-27.4* MCV-98 MCH-33.6* MCHC-34.3
RDW-13.9 Plt ___ PTT-30.5 ___
Glucose-141* UreaN-17 Creat-0.7 Na-134 K-3.1* Cl-98 HCO3-29
AnGap-10
ALT-61* AST-44* AlkPhos-135* TotBili-1.3
Albumin-2.7* Calcium-7.7* Phos-2.0* Mg-2.1
.
___ ABDOMEN (SUPINE ONLY)
IMPRESSION: Dobbhoff tube in the distal stomach.
.
___ BILIARY CATH REPLACE
IMPRESSION:
1. Successful exchange of existing percutaneous transhepatic
biliary drainage catheters with new bilateral 10 ___
percutaneous transhepatic biliary drainage) catheters.
2. Successful advancement of Dobbhoff tube into post pyloric
position.
.
___ ___ TUBE PL
IMPRESSION: Successful placement of a nasointestinal tube in a
post pyloric position.
Brief Hospital Course:
___ with cholangioCA s/p int/ext PTBD (R/L)was admitted capped
with bilious drainage around R PTBD and dislodged dobhoff.
Biliary drains were placed to gravity drainage. Dobhoff was
replaced at bedside, reglan was administered and a KUB was done
to check position. KUB showed the tube in the stomach. Tube
feeds were started then held the next day for cholangiogram.
On ___, cholangiogram through existing bilateral percutaneous
transhepatic biliary drainage catheter was done with exchange of
the existing 8 ___ percutaneous transhepatic biliary drainage
catheters with new bilateral 10 ___ PTBD catheters and the
Dobbhoff tube was advanced into a post pyloric position, third
portion of the duodenum. LFTs improved. He remained afebrile and
IV Unasyn was continue. On ___, biliary drains were capped.
Labs remained stable and he continued to be afebrile while
receiving tube feedings pending planned OR on ___ for
laparoscopy with possible bile duct excision and roux en y.
On ___, he underwent diagnostic laparoscopy with peritoneal
biopsy only as he was found to be unresectable. Surgeon was Dr.
___. At the time of surgery, the diagnostic
laparoscopy showed he was noted to have extensive, hard, white
deposits, 2-5 mm in size over the peritoneal surfaces, mainly on
the right side, but also in the lower abdomen and some areas of
mesentery. Biopsy was consistent with a fairly
well-differentiated adenocarcinoma.
Please refer to operative note for further details. Postop, he
was informed of findings. Oncologist, Dr. ___ was consulted
and will follow. Epidural was removed.
Vital signs remained stable. Pain was controlled and diet
resumed. On ___, an ERCP was performed to remove the previously
placed plastic stent. Biliary drains were kept to gravity
drainage. Unasyn continued. On ___, he underwent placement of 3
metal stents with anchor drains which were capped. A feeding
tube was placed post pylorus and bridled. Tube feeds were
resumed. LFTs improved. He did have some intermittent nausea and
epigastric pain.
On ___, he felt better. LFTs were lower and the anchor drains
were removed. It was determined he did not require further
antibiotic coverage now that the anchor drains were removed.
___ and Home Solutions have been engaged to assist with
tube feeds at home.
Following extensive discussion with the patient and his wife, at
this time no outpatient oncology follow up has been scheduled.
He returns to Dr ___ in ten days, and has been
provided with Dr ___ information.
Medications on Admission:
1. Cipro (ciprofloxacin) 500 mg/5 mL oral BID
2. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Tube Feeds
Tubefeeding: Jevity 1.5 Full strength via ___ tube
Goal rate: 65 ml/hr
Flush w/ 30 ml water q6h
.
Pump and supplies
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*4
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*10 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
No driving if taking this medicaiton
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q8H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
cholangio ca
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Home Solution and ___ Visiting Nurse services have been
arranged to provide your tube feeding supplies and assist with
management.
You should continue to eat as well as you can with the tube feed
*****please flush your feeding tube with 30 cc of water every
time your disconnect your feeding no matter how long the tube
will be disconnected******
Please call Dr. ___ office at ___ for any of the
following:
fever of 101, chills, nausea, vomiting, feeding tube clogs,
diarrhea, constipation, increased abdominal pain, pain not
controlled by your pain medication, swelling of the abdomen or
ankles, increased yellowing of the skin or eyes, inability to
tolerate food, fluids or medications, drain sites appear red,
have drainage or bleeding, or feeding tube clogs
You may shower. Pat the drain sites dry, do not apply lotion or
powder to the area.
No driving if taking narcotic pain medication
No need to continue Cipro now that drains are removed
Followup Instructions:
___
|
10324715-DS-13 | 10,324,715 | 22,658,087 | DS | 13 | 2124-07-13 00:00:00 | 2124-07-13 15:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
DVT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of metastatic colon cancer (to liver, lung)
undergoing radiation treatment at ___ at ___,
DM2, ?Parkinsons, DVT/PE s/p IVC filter ___, NPH s/p VP shunt,
dementia, A. fib previously on Coumadin (anticoagulation on hold
in setting of GI bleed) presenting with acute onset LLE pain and
newly diagnosed DVT.
Based on review of records, pt underwent colonoscopy on ___
after he presented with Hb 5.4 and fatigue. Colonoscopy revealed
a 3-4 cm friable and ulcerated mass on the ileocecal valve.
Biopsies apparently revealed invasive adenocarcinoma carcinoma,
moderately differentiated, without loss of nuclear expression of
MMR protein. Subsequent imaging revealed metastatic disease to
the liver and lungs. Family opted to pursue radiation treatment
alone, as patient had previously expressed a desire to avoid any
further surgeries. Of note, family has made a unified decision
not to share diagnosis of metastatic cancer with the patient,
given their certainty that he would "give up" if he knew. They
have pursued treatments that prioritizes comfort and avoidance
of suffering. On the day of admission, he completed the first
treatment in his fifth week of radiation, with plans for a total
of 5 weeks of radiation therapy.
Recent history is obtained from pt's family at bedside, and
review of limited Partners records, accessed through Physician
___. Pt's wife reports that pt was brought for radiation
treatment at 2:30 pm, finished at 3 pm. In the car, patient
reported mild nausea. Family offered lunch or ice cream, at
which point he began to report terrible L thigh pain. Wife
examined his leg, at which time his L thigh was firm but normal
color. By the time they arrived at the ___ ED 5 minutes
later, the color of his LLE had changed to red. He has had two
previous DVTs, one in RLE, second in LLE. He denied chest pain,
SOB. He did not report palpitations, but his wife could tell
from the way that he was breathing that he was in rapid afib. In
the ED, he was diaphoretic and clammy. He was transferred to the
___ ED to ___ ED for evaluation of thrombectomy and in
setting of multiple comorbidities. Pt has IVC filter in place
since time of RLE DVT, which occurred in ___. Wife reports
that, although ordinarily IVC filter would be removed, "for some
reason, his should stay in." IVC filter was placed at ___; they
were transferred to ___ ED ___ apparent bed shortage at ___.
Pt reportedly developed nausea, weakness, fatigue, and
diaphoresis on ___, which improved with rest, without Tylenol
or treatment for nausea.
With respect to bleeding history, wife notes that, while they
were staying in ___ earlier in ___, he had progressive
weakness. Around the time of ___, he was found to be anemic
requiring 4u PRBCs. She cannot recall the numbers, but believes
Hb was "5. something." At that time, she believes that he was
continued on blood thinners. He underwent a colonoscopy, which
was apparently a poor prep. He was brought back to ___, then
underwent a repeat colonoscopy, which apparently confirmed that
colonic mass was hemorrhaging. Per pt's wife, tumor is "right
where the large intestine meets the small intestine." Providers
recommended radiation without resection given prohibitively
elevated risk of surgery; family apparently declined
chemotherapy given high priority of comfort and avoidance of
suffering.
In the ___ ED:
VS 97.9, 94->129->98, ___, 94% RA
Exam notable for "Left leg generally swollen, no erythema. Mild
pain to palpation over lateral thigh. Able to wiggle toes,
dorsiflex and plantarflex ankle, and lift leg off of bed. DP 1+
bilaterally. Good cap refill."
Labs notable for WBC 9.7, Hb 9.3, Plt 172, INR 1.2
BUN 36, Cr 1.5, UA with pyuria without bacteria
Imaging:
Case reviewed with ___ - plan to assess in am for thrombectomy
Received:
Metoprolol tartrate 25 mg PO
Diltiazem 10 mg IV
Tylenol ___ mg PO
IVF
On arrival to the floor, patient endorses 4 out of 10 pain,
denies shortness of breath, chest pain.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
Colon cancer metastatic to liver and lung
NPH s/p VP shunt - Dr. ___ in ___. Subsequently, seen
at ___ by Dr. ___, apparently removed VP shunt
and replaced with programmable shunt, with course complicated by
infection (P acnes from CSF), requiring prolonged
hospitalization at ___ in ___ - now has ___ Strata II
valve
Cognitive impairment
Hiatal hernia - managed by Dr. ___ at ___
BPH s/p TURP
Afib
DVT/PE - Bard Eclipse IVC filter that was placed at ___ on
___, placed shortly after neurosurgical procedure,
which was contraindication to anticoagulation
Social History:
___
Family History:
Reviewed and found to be not relevant to this
hospitalization/illness
Physical Exam:
Physical Exam On Admission
VS: ___ 0242 Temp: 97.7 PO BP: 100/69 HR: 89 RR: 16 O2 sat:
96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GEN: elderly male, alert and interactive, comfortable, no acute
distress
HEENT: slight anisocoria with R pupil >L pupil, bilateral
reactive to light and accommodation, anicteric, conjunctiva
pink, oropharynx without lesion or exudate, dry mucus membranes,
ears without lesions or apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Irregularly irregular without m/r/g
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended with normal active bowel
sounds, no hepatomegaly, liver margin palpated at costal margin
EXTREMITIES: LLE with compression wrap, firm but nontender at
lateral L thigh, no palpable cords. L hip flexion limited by
pain. Bilateral DPs are dopplerable but not palpable.
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: Alert and oriented to person, not to place or date,
cranial nerves II-XII intact, strength is ___ in bilateral UEs.
R hip flexor ___, L hip flexor limited by pain. Able to move
distal bilateral LEs.
PSYCH: normal mood and affect
ON DISCHARGE
VS Temp: 98.4 PO BP: 100/64 HR: 81 RR: 18 O2 sat: 94% O2
delivery: RA FSBG: 146
Guaiac negative
Abdomen benign, S, NT, ND, BS+
Lungs breathing entirely unlabored, comfortable, satting on RA
Ext upper equal WWP, lower RLE WWP with minimal edema, LLE
wrapped but foot warm with intermittently palpable DP (has
always been dopplerable), 2+ edema overall slowly improving from
admission
Mental status alert but oriented only to person and place
Pertinent Results:
ADMISSION
___ 08:15PM BLOOD WBC-9.7 RBC-4.43* Hgb-9.3* Hct-33.2*
MCV-75* MCH-21.0* MCHC-28.0* RDW-20.4* RDWSD-54.0* Plt ___
___ 08:15PM BLOOD ___ PTT-26.0 ___
___ 08:15PM BLOOD Glucose-149* UreaN-36* Creat-1.5* Na-143
K-5.3 Cl-106 HCO3-21* AnGap-16
DISCHARGE
___ 06:40AM BLOOD WBC-5.5 RBC-3.39* Hgb-7.3* Hct-26.0*
MCV-77* MCH-21.5* MCHC-28.1* RDW-20.3* RDWSD-55.7* Plt ___
___ 05:01AM BLOOD ___ PTT-74.7* ___
___ 05:01AM BLOOD Glucose-140* UreaN-43* Creat-1.3* Na-141
K-4.2 Cl-105 HCO3-24 AnGap-12
___ 05:01AM BLOOD Calcium-9.8 Phos-4.0 Mg-2.4 Iron-22*
___ 05:01AM BLOOD calTIBC-399 Ferritn-34 TRF-307
IMAGING AND OTHER STUDIES
CT abdomen/pelvis with contrast: 2.3 cm lesion in the posterior
medial aspect of the left lung base. This could represent a
primary or metastatic lesion. Clinical correlation is
suggested. A CT scan of the chest may be considered. 2 lesions
in the liver are again noted and without change. These are
concerning for possible metastatic lesions. Clinical
correlation is suggested. 2 small hypodense lesions in the
spleen without change. 2.2 cm hypodense lesion in the left
kidney without change.
No high-grade bowel obstruction, free air or free fluid in the
abdomen. The ileocecal valve appears irregular. Moderate hiatal
hernia.
Head CT: No acute intracranial abnormality. Enlargement of the
lateral and third ventricles, likely obstructive hydrocephalus
status post left ventriculostomy. No extra-axial collection.
Moderate sized white matter hypodensity likely scoliosis at left
occipital parietal region.
EKG: afib at 93 bpm, normal axis, normal intervals, TWI in III,
no ST segment changes, no pathologic Q waves, no priors for
comparison
LENIS:
1. Extensive occlusive deep vein thrombosis in the left lower
extremity, extending from the left common femoral, femoral,
popliteal, and left posterior tibial and peroneal veins.
2. Nonocclusive thrombus at the right common femoral/greater
saphenous
junction, and occlusive deep vein thrombosis in the right
proximal and mid
posterior tibial veins.
Brief Hospital Course:
BRIEF SUMMARY:
This is an ___ with metastatic colon cancer (to liver, lung)
undergoing radiation treatment at ___ at ___ ___,
DM2, ?Parkinsons, DVT/PE s/p IVC filter ___, NPH s/p VP shunt,
dementia, A. fib previously on Coumadin (anticoagulation on hold
in setting of GI bleed) who presented with acute onset LLE pain
and newly diagnosed DVT. Found to have bilateral L>R
DETAILED SUMMARY:
# Recurrent VTE: Extensive LLE DVT with some RLE DVT as well.
Seen by ___ and vascular surgery who recommended wraps,
anticoagulation, no procedures at this time as the risk benefit
ratio is unfavorable given his risk of bleeding. With
anticoagulation and wraps he has been improving and leg seems
better, less swollen, warmer, better perfusion.
- Continue Lovenox; ideally this would be lifelong but I would
do Lovenox for at least 1 month and then consider transition to
Xarelto or Eliquis thereafter as family has significant cost
concerns with Lovenox
- Continue bilateral ACE wraps for lower extremities from ankle
to mid-thighs; continue leg elevation
- Tylenol, oxycodone, home Neurontin for analgesia
# Chronic iron deficiency anemia
# GIB
# Stage IV colon cancer: History of GI bleed with hemoglobin
down to 5.4 in ___, which seems to have resolved with
cessation of anticoagulation and radiation treatment. As above,
discussed at some length with patient's family and, at this
time, potential benefits of anticoagulation outweigh the risks.
With respect to his stage IV colon cancer, which is the cause of
his prior GI bleed, patient's wife and daughter clearly
articulate the rationale for not sharing his cancer diagnosis
with him. All in agreement that comfort is a top priority for
Mr. ___, and that radiation treatment has been pursued as a
means of palliation. He was maintained on heparin gtt and CBC
was trended and he was monitored for bleeding; there were no
signs of bleeding and CBC was fairly stable. He was found to
have iron deficiency and so was given 2 doses of IV iron.
- DO NOT SHARE DIAGNOSIS WITH PATIENT - HE DOES NOT KNOW OF
CANCER DIAGNOSIS
- Monitor iron stores monthly and give iron infusions for
treatment as needed
- Monitor CBC weekly while on anticoagulation
# Afib with RVR: Had rapid rates in ED but subsequently rate
controlled after metoprolol and diltiazem in ED. Suspect trigger
was pain associated with acute DVT, possibly missing diagnoses.
Given filter in place, without hypoxia, tachypnea, or chest
pain, suspicion for acute PE is low and treatment is same.
- Continue metop 25 BID; if BPs running low can reduce to 12.5mg
BID
- Anticoagulation as above
# Chronic constipation: He has been on Miralax at home and this
was continued here. - Continue bowel regimen to goal 1BM daily
# ___ given Cr 1.5: Cr downtrended subsequently.
Likely mild hypovolemia/ prerenal state.
# Cognitive impairment
# History of NPH: VP shunt in place. He remained stable here.
Minimal agitation.
# NIDDM2: Stable. Resumed metformin after brief hold. Did not
require any significant correctional insulin while here.
# BPH: Stable. Substituted tamsulosin for home alfuzosin while
here, resumed alfuzosin at discharge.
>30 MINUTES SPENT COORDINATING DISCHARGE TO REHAB
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 150 mg PO DAILY
2. Metoprolol Tartrate 12.5 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. alfuzosin 10 mg oral QHS
5. Gabapentin 300 mg PO QHS
6. Pantoprazole 40 mg PO Q24H
7. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Take standing for 2 weeks then PRN
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Enoxaparin Sodium 130 mg SC DAILY
Monitor blood counts closely while on this medication
4. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours Disp #*10 Tablet Refills:*0
5. Senna 17.2 mg PO BID
6. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours Disp #*15 Tablet Refills:*0
7. Metoprolol Tartrate 25 mg PO BID
8. Polyethylene Glycol 17 g PO BID
9. alfuzosin 10 mg oral QHS
10. Gabapentin 300 mg PO QHS
11. MetFORMIN (Glucophage) 500 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Sertraline 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral ___ DVT, L worse than R
Status post radiation to colon
Prior GI bleeding
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a new blood clot in your left leg. You
were seen by the vascular surgery and interventional radiology
teams and it was recommended you be treated with
anticoagulation. You were started on anticoagulation and you
tolerated this fairly well without any signs of bleeding. You
were anemic likely due to slow blood loss in your intestines and
you were given some intravenous iron.
You are being discharged with daily Lovenox for treatment of
your blood clot.
You will need to have your laboratory studies monitored for
signs of worsening anemia. You should also have your iron
studies monitored as you will likely need more iron infusions as
an outpatient to bring up your blood counts. You received 2
doses of iron infusion here.
Followup Instructions:
___
|
10324973-DS-8 | 10,324,973 | 25,404,910 | DS | 8 | 2162-10-04 00:00:00 | 2162-10-06 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion and slurred
speech.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is an ___ year old man with a history of afib on
warfarin, HFpEF, dementia with baseline mild confusion (not
oriented to year or month but generally is oriented to self,
situation, and family members), ___ (baseline Cr 1.4) and remote
clear cell carcinoma s/p nephrectomy, prostate cancer s/p
radiation who presents with episode of confusion and slurred
speech.
On my evaluation, patient is alone in the ED. He is unable to
tell me why we are in the ED, has no recollection of what
happened today. I attempted to call his wife, but she did not
answer (it was 1:30 in the morning). Spoke to the ED, who had
received collateral information from wife; earlier this evening
wife was at bedside and felt patient was at baseline. She did
warn the ED that he sundowns.
Per ED report: "Noticed upon awakening from nap earlier today.
Noted to have slurred and incoherent speech. Resolved
spontaneously and without other neuro deficits. Moving all four
extremities and without facial weakness. Recommended coming in
to
ED. ___ 88. He appears at baseline per wife at bedside. Further
collaterol obtained from son via telephone, who noted pt was at
baseline this AM and confirmed the above history. Patient with
nonproductive cough. Otherwise denies HA, nausea, CP, SOB, abd
pain. Of note, recently admitted for pneumonia, discharged on
10d
course of augmentin (end date ___
Past Medical History:
- afib on Coumadin
- HFpEF
- HTN
- dementia with baseline confusion
- ___
- h/o renal carcinoma s/p resection
- h/o prostate ca s/p radiation
- Arthritis: S/p b/l knee replacement
Social History:
___
Family History:
His mother had ___ diagnosed in her
early ___, died in her ___. His father lived into his ___.
Physical Exam:
Physical Exam:
Vitals: T: 97.8 HR 88 BP 143/83
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self. Says we are at a
___
graduation, cannot tell me the year or month. He has a hard time
understanding the command to repeat a sentence (he is also
fairly
hard of hearing) and when I ask him to repeat a sentence he says
"well I'm not sure if it is a nice fall day in ___ or not!"
Normal prosody. He calls a pen a pencil. Pt. was able to name
both high and some low frequency objects (feather, desert plant,
chair, and could not think of the word for hammock). Speech was
not dysarthric. Able to follow simple midline and appendicular
commands. There was no evidence of apraxia or neglect.
CN
I: not tested
II,III: blinks to threat in all quadrants, pupils 4mm->2mm
bilaterally
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone, paratonia noted bilaterally; no
asterixis or myoclonus. No pronator drift.
Difficult to perform formal confrontational testing due to
attention, but he is full in the deltoids, biceps, triceps
bilaterally. IP, quad and ham full in the lower extremities
bilaterally.
-Sensory: No deficits to light touch throughout upper and lower
extremities.
-Coordination: He touches both fingers to his nose with no
ataxia. No intention tremor noted.
-Gait: Unsteady with standing. Patient is very tall and I was
worried he would fall and I wouldn't be able to catch him so we
did not try to walk further.
Pertinent Results:
___ 06:52PM BLOOD WBC-8.4 RBC-3.52* Hgb-10.7* Hct-34.6*
MCV-98 MCH-30.4 MCHC-30.9* RDW-13.1 RDWSD-46.8* Plt ___
___ 06:52PM BLOOD Neuts-82.6* Lymphs-7.6* Monos-7.5 Eos-1.1
Baso-0.2 Im ___ AbsNeut-6.95* AbsLymp-0.64* AbsMono-0.63
AbsEos-0.09 AbsBaso-0.02
___ 06:52PM BLOOD ___ PTT-42.0* ___
___ 06:52PM BLOOD Glucose-82 UreaN-23* Creat-1.2 Na-142
K-4.4 Cl-99 HCO3-32 AnGap-11
___ 06:52PM BLOOD ALT-10 AST-20 AlkPhos-83 TotBili-0.3
___ 06:52PM BLOOD cTropnT-0.02*
___ 03:45AM BLOOD cTropnT-0.01
___ 06:52PM BLOOD Albumin-3.6 Calcium-9.3 Phos-3.3 Mg-2.0
___ 11:56PM BLOOD %HbA1c-5.7 eAG-117
___ 06:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ Imaging CTA HEAD AND CTA NECK
-No acute intracranial abnormality.
-Patent circle of ___ without evidence of
stenosis,occlusion,or aneurysm.
-Patent bilateral cervical carotid and vertebral arteries
without evidence of
stenosis, occlusion, or dissection.
-18 mm outpouching from the right lateral aspect of the
esophagus, just
inferior to the level of the larynx, likely representing an
esophageal
diverticulum.
Brief Hospital Course:
___ with a-fib (on warfarin), HFpEF, dementia, ___ (baseline Cr
1.4) and remote clear cell carcinoma s/p nephrectomy, prostate
cancer s/p radiation who presents with episode of confusion and
slurred speech.
This episode occurred in the setting of waking up from a nap. On
examination, his mental status appears to back to his baseline.
He has no focal neurologic deficits. A CTA was performed and
showed patent vessels with only moderate calcification at the
bilateral carotid bulb and bilateral ICA siphons. Given that his
exam was back to baseline and the fact that the patient is
already anticoagulated with warfarin (in therapeutic range) for
atrial fibrillation, we decided not to pursue MRI, as the
pretest probability is low and it would not change management.
TRANSITIONAL ISSUES
- If the patient has recurrent episodes or develops more clear
focal neurologic deficits, then one could consider an MRI to
fully exclude the possibility of stroke.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. QUEtiapine Fumarate 25 mg PO QHS
2. Torsemide 10 mg PO DAILY
3. Warfarin 3 mg PO DAILY16
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
5. Metoprolol Tartrate 25 mg PO BID
6. rivastigmine tartrate 1.5 mg oral BID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 2 Days
2. Metoprolol Tartrate 25 mg PO BID
3. QUEtiapine Fumarate 25 mg PO QHS
4. rivastigmine tartrate 1.5 mg oral BID
5. Torsemide 10 mg PO DAILY
6. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Transient confusional state
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came into the hospital because you had an episode of
confusion and slurred speech. Initially there was some concern
that this may represent a stroke. However, we do not believe you
had a stroke. Since you are already on a good medication to
prevent strokes (ie warfarin), we did not obtain an MRI to fully
exclude the possibility of a stroke.
When you leave the hospital, you should:
- Continue to take all of your medications as prescribed.
- Attend all of your scheduled clinic appointments.
It was a pleasure taking care of you,
Your ___ care team
Followup Instructions:
___
|
10325255-DS-19 | 10,325,255 | 24,449,325 | DS | 19 | 2152-01-03 00:00:00 | 2152-01-04 16:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, fever, vision change
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Mr. ___ is a ___ M w/ DM who presents to ED with sudden onset
headache after 1 day of fever prompting concern for meningitis.
Patient reported having recent blurry vision, suddent onset
occipital headache, neck pain, nausea and vomiting all for one
day. Patient notes myalgias and fevers which also started on day
of admission. Denied abdominal pain, chest pain, cough, diarrhea
rash or dyspnea.
Baseline headaches are usually ___, but this headache was
___ located mostly in occipital region. Denies any sick
contacts.
ED Course
- Initial vitals: pain ___ HR 87 128/82 15 100%
- ED neuro exam: No meningismus. Pupils 5mm, equal reactive.
EOMI. Strength ___ in ___.
- LP performed by ___, after attempts by ED
- CSF not particularly concerning for bacterial meningitis
- Ceftriaxone 2g x1 @ 1300 ___
- Vancomycin 1g x1
- Morphine x1
- Zofran x1
On arrival to floor, reports continued ___ headache and also
having back pain at site of multiple LP attempts.
ROS: Full 10 pt review of systems negative except for above. Of
note, Denied abdominal pain, chest pain, cough, diarrhea,
numbness, rash or dyspnea.
Past Medical History:
- Diabetes Mellitus, type II: on oral meds, poorly controlled
- Hyperlipidemia
- Obesity
- Balanitis
- microalbuminuira
- Episode of meningitis at age ___ in ___ accompanied by
severe nose bleed and prolonged hospital stay, per sister's
report.
Social History:
___
Family History:
Mother, Father, MGM - hypertension; PGF- died of prostate cancer
Physical Exam:
VS: 98.3 133/59 75 18 99 RA
Gen: NAD, pleasant
HEENT: clear OP, no LAD
CV: NR, no murmur
Pulm: CTAB, nonlabored
Abd: soft, NT, ND
GU: no Foley,
Ext: no edema
Skin: no rash
Neuro: AOx3, CN II-XII intact, moving all extremities.
Pertinent Results:
___ 10:55AM BLOOD WBC-11.5*# RBC-4.82 Hgb-15.0 Hct-41.0
MCV-85 MCH-31.1 MCHC-36.5* RDW-11.9 Plt ___
.
___ 01:45PM BLOOD WBC-7.9 RBC-4.36* Hgb-12.7* Hct-37.2*
MCV-86 MCH-29.1 MCHC-34.1 RDW-12.4 Plt ___
.
___ 08:15AM BLOOD WBC-5.4 RBC-4.56* Hgb-13.7* Hct-39.5*
MCV-87 MCH-30.1 MCHC-34.8 RDW-12.3 Plt ___
.
___ 08:15AM BLOOD Glucose-198* UreaN-8 Creat-0.8 Na-139
K-4.6 Cl-104 HCO3-25 AnGap-15
.
___ 06:21PM BLOOD Lactate-1.7
.
___ 04:15PM CEREBROSPINAL FLUID (CSF) TotProt-20
Glucose-111
.
___ 04:15PM CEREBROSPINAL FLUID (CSF) WBC-50 RBC-2875*
Polys-59 ___ Monos-1
.
___ 04:15PM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-430*
Polys-37 ___ Monos-1
.
Head CT w/o contrast ___
FINDINGS: There is no hemorrhage, edema, mass effect
or acute vascular territorial infarct. Ventricles and
sulci are normal in size and configuration for age.
The basal cisterns are patent and there is preservation
of gray-white matter differentiation. No fracture is
identified. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear. The globes
are intact.
IMPRESSION: No acute intracranial abnormality.
Brief Hospital Course:
___ M w/ DM2 who presented with sudden onset headache, blurry
vision, neck pain, nausea and vomiting following 1 day of fever
prompting concern for meningitis.
# Viral Illness Vs Aseptic Meningitis: Patient had LP which was
traumatic and showed 50WBC on tube 1 and 5WBC on tube 5. He
also had CT head which did not show any acute bleed. He received
IV Ceftriaxone and vancomycin x 1 empirically in the ED which
was discontinued on the floor following LP results. He was also
started on empiric treatment with acyclovir which was also
discontinued given rapid improvement in clinical status and low
suspicion for HSV meningitis. His CSF culture remained
negative. He was observed off of antibiotics for more than 24
hours and he remained afebrile with no symptom recurrence. He
most likely had aseptic meningitis vs self limited viral
illness. He will follow up with PCP for ___.
.
# Diabetes Mellitus, type II: Poorly controlled with
microalbuminuria. Last HgbA1c 9.6% in ___. Lisinopril and
Humalog SS was given in house. Home oral metformin and glipizide
were held in house but restarted at time of discharge.
.
Transitional Issues:
- ___ with PCP for management of poorly controlled diabetes
(could consider initiation of insulin given poor control)
- ___ with PCP for ___ of symptoms
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 10 mg PO BID
2. Lisinopril 10 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Pravastatin 80 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Pravastatin 80 mg PO DAILY
3. GlipiZIDE 10 mg PO BID
4. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
1. Aseptic Meningitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted with fever, headache, vision
changes concerning for meningitis. A CT scan of your head
showed no acute process that could be causing your symptoms. A
spinal tap was done that suggested you likely do not have
meningitis, and if so it is due to a virus that will improve
over time. On the day of discharge you did not have any further
fevers and your neck pain and headaches were improving.
Followup Instructions:
___
|
10325532-DS-8 | 10,325,532 | 21,761,990 | DS | 8 | 2174-03-21 00:00:00 | 2174-03-23 13:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache, brain mass
Major Surgical or Invasive Procedure:
___ brain biopsy, Dr. ___
___ of Present Illness:
HPI: ___ yo G2P1 at 33w1d with HA onset ___ morning,
described as throbbing right sided pain unchanged with
conservative measures at home (Tylenol). Was in town visiting
family for the weekend, went to ___ where HA was
unresponsive to reglan, IVF, Benadryl and responsive only to
morphine. MR showed ___ new brain lesion in the frontal lobe and
she was transferred to ___ for neurosurgery evaluation. ___
labs were negative per ED records including normal LFTs,
negative
urine protein and normal BPs. She has mild photophobia but
denies
weakness, numbness or tingling.
Denies ctx, VB, LOF. +FM. Denies N/V, CP, SOB, fevers, chills,
constipation. Multiple BMs daily due to known Crohn's disease.
Past Medical History:
PNC: (prenatal records not yet available ,PNC per patient
report)
- ___ ___ vs ___ by first trimester ultrasound per patient
- Labs Rh /Abs /Rub /RPR /HBsAg /HIV /GBS
- Screening LR NIPT, girl
- FFS normal
- GTT elevated 1hr, normal 3hr
- U/S at 33w 4#13oz
- Issues
*) h/o c/s: planning repeat section with GI surgery on standby
given Crohn's and prior surgeries
*) Crohn's: troublesome this pregnancy, not on meds. Has been
seen for IVF during pregnancy
*) possible h/o portal vein thrombosis: on prophylactic lovenox
during this pregnancy
OBHx:
- G1 pLTCS due to crohn's and prior abdominal surgeries,
recommended by her GI MD, uncomplicated pregnancy, 7#5oz boy
- G2 current, planning repeat section
GynHx:
- h/o abnormal Pap, s/p cryo with normal since per patient
- denies fibroids, STIs
- endometriosis per patient, no prior surgeries but reports
"chocolate cysts"
- irregular menses
PMH:
- Crohn's disease - s/p total colectomy now with J pouch, has
had
issues with pouchitis
- possible portal vein thrombosis - equivocal diagnosis
following
her total colectomy, s/p 3 months of anticoagulation and was
maintained on prophylactic anticoagulation during her previous
pregnancy (not continued postpartum). Was taking lovenox during
this pregnancy as well.
PSH:
- total colectomy with ostomy
- ostomy takedown and creation of J pouch
- c/s x1
Social History:
___
Family History:
NC
Physical Exam:
AdmittingPhysical Exam
VS: T 99.6, 97.9 HR 116 -> 84 BP 118/73 RR 16 SpO2 96%RA
Gen: A&O, comfortable
Neuro: CNII-XII grossly intact, grossly normal strength and
sensation throughout
CV: RRR
PULM: normal work of breathing, CTAB
Abd: soft, gravid, nontender, palpable fetal movement
Ext: no calf tenderness
SVE: deferred
Discharge Physical Exam
Gen: A&O
Neuro: CNII-XII grossly intact; scalp sutures in place
PULM: normal work of breathing
Abd: soft, gravid, nontender, palpable fetal movement
Ext: no calf tenderness
Pertinent Results:
___ 06:00PM estGFR-Using this
___ 06:00PM GLUCOSE-92 UREA N-4* CREAT-0.5 SODIUM-136
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-18* ANION GAP-19
___ 06:00PM estGFR-Using this
___ 06:00PM NEUTS-78.8* LYMPHS-12.0* MONOS-5.7 EOS-1.6
BASOS-0.2 IM ___ AbsNeut-13.77* AbsLymp-2.10 AbsMono-0.99*
AbsEos-0.28 AbsBaso-0.04
___ 06:00PM PLT COUNT-217
Brief Hospital Course:
Ms. ___ was admitted on ___ for the expedited work-up of a
brain mass, which was detected on MRI when she presented for a
headache.
The patient was evaluated by our neurosurgery team, and had a
MRI spectroscopy on ___. She then underwent a CT-guided
stereotactic brain biopsy on ___. The patient had intraoperative
fetal monitoring. She had a post-operative CT scan which did not
show evidence of large intracranial hemorrhage. She was
transferred to the antepartum floor, where she was observed
until POD#1. The patient's pain was controlled with oxycodone
5mg q4-6 hrs and acetaminophen with good effect. She was also
started on Keppra 500mg BID as recommended by the neurosurgical
team for seizure prophylaxis given her brain mass.
For fetal monitoring, she had daily reassuring NSTs.
Betamethasone was deferred, as there was no concern for
immediate need for delivery, and the Neurosurgery team was
concerned that it may affect the brain biopsy results.
For her history of portal vein thrombosis, she was taken off of
the lovenox prior to the brain biopsy. Per the patient, the
diagnosis of portal vein thrombosis was never confirmed. Her
anticoagulation was not restarted given her recent brain biopsy
and a questionable history of thrombosis.
On ___, the patient was discharged home with planned
follow-up with her regular OB in ___ and with the
Neurosurgery team at ___. All records and image discs were
provided to her.
Medications on Admission:
PNV
Lovenox
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
don't take more than 4000mg in 24hrs
RX *acetaminophen 325 mg ___ capsule(s) by mouth every 6 hrs
Disp #*100 Capsule Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth every 12 hrs
Disp #*60 Capsule Refills:*0
3. LevETIRAcetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth every 12
hrs Disp #*60 Tablet Refills:*1
4. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every 12 hrs Disp
#*40 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
take this only if Tylenol is not enough
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hrs Disp #*15
Tablet Refills:*0
6. FoLIC Acid 1 mg PO DAILY
7. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Brain mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Dear. Ms. ___,
You were admitted to the hospital for the work-up of your brain
mass. You had your brain biopsy on ___, and you were observed
for pain control until today.
All of your fetal testing have been reassuring. We think it is
now safe for you to go home but please follow-up with your OB
(or the OB you wish to transfer care to) within the week. All of
your records have been provided to you (images and notes)
Please follow the instructions below:
- Attend all appointments with your obstetrician and all fetal
scans
- Monitor for the following danger signs:
- headache that is not responsive to medication
- abdominal pain
- increased swelling in your legs
- vision changes
- Worsening, painful or regular contractions
- Vaginal bleeding
- Leakage of water or concern that your water broke
- Nausea/vomiting
- Fever, chills
- Decreased fetal movement
- Other concerns
From the neurosurgery team, the instructions are as follows
· You underwent a biopsy. A sample of tissue from the lesion
in your brain was sent to pathology for testing.
· Please keep your incision dry until your sutures are
removed.
· You may shower at this time but keep your incision dry.
· It is best to keep your incision open to air but it is ok
to cover it when outside.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· ***Please do NOT take any blood thinning medication
(Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the
neurosurgeon.
· You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
· You may use Acetaminophen (Tylenol) for minor discomfort
if you are not otherwise restricted from taking this medication.
Followup Instructions:
___
|
10325643-DS-13 | 10,325,643 | 23,396,652 | DS | 13 | 2164-06-09 00:00:00 | 2164-06-09 17:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness, headache.
Major Surgical or Invasive Procedure:
___: Diagnostic angiogram.
History of Present Illness:
Mr. ___ is an ___ year old male with a known fusiform aneurysmal
dilation of the left intracranial paraclinoid/supraclinoid ICA.
The patient has been followed at ___ for this
aneurysm since he was ___ years old
as it was found on an incidental finding. The patient has had
repeat imaging which has showed a stable size in the fusiform
aneurysmal dilation. The patient reports that he has had
increased dizziness, difficulty focusing and left sided pressure
in head and neck. He has been to the ED 3 times in the past
month
with worsening symptoms and reports at times he "blacks out" and
has had near syncopal events. The patient also reports left
sided chest pain and occasional shortness of breath. On ROS he
denies diplopia, fevers or chills.
Past Medical History:
fusiform aneurysmal dilation of the left intracranial
paraclinoid/supraclinoid ICA.
Social History:
___
Family History:
No history of aneurysms.
Physical Exam:
=============
ON DISCHARGE
=============
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally. EOMs intact throughout.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally.
Groin site: clean, dry and intact. No hematoma.
Pertinent Results:
============
IMAGING
============
___ CAROTID/CEREBRAL UNILAT
1. A long-standing fusiform dilation of the distal left internal
carotid
artery. This appears to be stable based on previous reports
from ___. No aneurysmal abnormalities
identified.
___ FEMORAL ULTRASOUND
No evidence of hematoma or pseudoaneurysm in the right groin.
Brief Hospital Course:
On ___, the patient presented to the ED with complaints of
increased dizziness, difficulty focusion and left sided headache
and neck pain and syncopal/near-syncopal episodes. He has had
multiple ED visits for similar complaints.
On ___, Given his history of left intracranial
paraclinoid/supraclinoid ICA aneurysm, he was taken for
diagnostic angiogram which did not reveal an aneurysm, but a
normal ICA variant. Neurology and medicine were consulted for
evaluation of his headaches and syncopal episodes. Overnight,
he experienced groin pain and a femoral ultrasound was ordered
which was negative for hematoma or pseudoaneurysm in the right
groin.
On ___, the patient remained neurologically intact. He was
ambulating independently, tolerating a diet, and voiding without
difficulty. His pain was well-controlled. It was determined he
would be discharged to home with instructions to follow-up with
his primary care physician ___ 5-days. The medicine consult
team was consulted and stated that at this time no further
inpatient testing is required and would recommend outpatient
follow-up with PCP for evaluation of panic
disorder versus cardiac monitoring.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Do not exceed greater than 4g Acetaminophen in a 24-hour period.
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Headache.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a diagnostic cerebral angiogram on ___. You found to
have a normal variant of the ICA.
Activity:
You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ to avoid
bleeding from your groin.
Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
You make take a shower.
Medications
Resume your normal medications and begin new medications as
directed.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
Care of the Puncture Site:
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
Soreness in your arms from the intravenous lines.
Mild to moderate headaches that last several days to a few
weeks.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the puncture
site.
Fever greater than 101.5 degrees Fahrenheit.
Constipation.
Blood in your stool or urine.
Nausea and/or vomiting.
Extreme sleepiness and not being able to stay awake.
Severe headaches not relieved by pain relievers.
Seizures.
Any new problems with your vision or ability to speak.
Weakness or changes in sensation in your face, arms, or leg.
Followup Instructions:
___
|
10325716-DS-22 | 10,325,716 | 29,579,720 | DS | 22 | 2156-12-15 00:00:00 | 2156-12-15 15:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zyban / Celexa / Codeine / Doxycycline / Nsaids
Attending: ___.
Chief Complaint:
Headache with concern for papilledema
Major Surgical or Invasive Procedure:
Lumbar Puncture
___ Placement
History of Present Illness:
Patient is ___ year old left handed woman with PMH migraine
headaches/headaches, anxiety/depression, and hyperlipidemia
evaluated in neurology clinic ___ for headaches with concern
for papilledema presenting to ED for expedited ophthalmologic
workup with concern for increased intracranial pressure.
Patient has been having headaches for the last three months.
Patient localizes them to the frontal top portion of the head,
but sometimes bilateral temporal region and back of head.
Headache characterized as pounding and throbbing. Patient
feels
that her head is going to burst when having headaches. Patient
reports that since onset three months ago that they are
increasing in frequency and are becoming more severe. Patient
is
currently having 20 to 30 each day, each lasting 10 to 15
minutes. Headaches are rapid in onset and rapid in offset.
Patient wakes up every morning with a headache, but gets them
throughout the day. Patient is never awoken because of pain
from
headaches. Patient denies that bending or straining brings on
the headache, but if she has a headache it makes them worse.
Patient reports that laying down or sitting sometimes makes the
headache worse. Patient endorses some nausea with headaches,
but
no vomiting. Patient denies that she has blurry vision, except
for sometimes after a long period of reading. Patient denies
autonomic symptoms. Patient denies weakness or change in
sensation with headache.
Patient reports that she has always had poor vision in her left
eye and it improved somewhat after she had cataract surgery of
both eyes. Patient does not feel that her vision has changed
acutely over the last three months.
Ophthalmology evaluated patient in the ED and reports that
intraocular pressures are normal in both eyes, but cannot
definetly rule out early papilledema. This is because of
patient's anatomy. Patient is very myopic and has peripapillary
atophy likely secondary to staphyloma. This can look like
papilledema and can obscure early evidence of papilledema.
Dr. ___ was called and he wanted patient to have MRV and
lumbar
puncture with opening pressure if there was evidence of
papilledema on examination. Patient was given two options, 1)
inpatient observation admission for expedited workup or 2)
studies as an oupatient. Patient has elected for inpatient
admission.
Past Medical History:
Headaches
HLD
Anxiety
Depression
Breast ca s/p b/l mastectomy in ___
Cataract (OS)
Vitreous detachment (OS)
Cervical radiculitis
Lumbar stenosis
Social History:
___
Family History:
1. Two sisters with breast cancer, one at age ___, one age
_____.
2. Mom with breast cancer in her ___.
3. Maternal aunt with breast cancer in her ___.
4. Maternal cousin with breast cancer in her ___.
5. Maternal great aunt with breast cancer in ___.
6. Maternal great cousin with breast cancer in ___.
7. Dad with skin cancer.
8. Maternal uncle with prostate cancer in his ___.
Physical Exam:
Vital signs:
Temperature: 97.6
Pulse: 79
Respiratory rate: 16
Blood pressure: 128/81
Oxygen saturation: 99%
General examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Fundoscopic examination:
Performed with ophthalmology resident with eyes dilated. Optic
disks of normal color. The margins on both sides are irregular.
There is no disk edema. Peripapillary atophy bilaterally .
Visual acuity: right eye ___, left eye ___. No RAPD.
Mental status:
Patient pleasant. Patient oriented to name, location, month,
and
year. Patient can provide current president and two presidents
before current. Patient can perform months of the year
backwards
quickly without mistake. Patient can name all items on the
stroke care. Patient can repeat phrase longer than 10 words
without error. Left, right differentiation intact.
Calculations
intact. No evidence of apraxia. No errors in speech or the
production of language.
Cranial nerves:
No visual field cut. PERRL. EOMI intact, smooth pursuit.
Normal saccades. Facial sensation normal. Face symmetric.
Hearing intact. Palate elevates symmetrically. Uvula midline.
Tongue protrudes to midline. Shoulders elevate symmetrically.
Motor:
Normal bulk, tone throughout. No pronator drift. No orbiting.
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
Sensory:
No deficits to light touch, proprioception throughout.
No extinction to DSS.
Reflexes:
Bilateral pectoral reflexes
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally, but very strong
withdrawal secondary to feeling tickled
Coordination:
No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
Gait:
Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
==============
DISCHARGE
24 HR Data (last updated ___ @ 856)
Temp: 98.1 (Tm 98.4), BP: 108/70 (100-118/64-74), HR: 62
(60-69), RR: 18 (___), O2 sat: 97% (94-97), O2 delivery: RA
General: NAD, well appearing
HEENT: Oropharynx clear, MMM, no scleral icterus
CV: RRR no murmurs heard
PULM: Clear to auscultation bilaterally
ABD: Bowel sounds present. Soft, nontender, nondistended
LIMBS: No peripheral edema, WWP
SKIN: No rashes seen over torso
NEURO:
- AO x 3 ___ ___
- Recites days of week backward crisply
- CN: PERRL, EOMI (complains of headache and clutches right
forehead when looks in either direction laterally or upward),
facial sensation equal bilaterally, resists eye opening ___,
hearing intact to finger rub bilaterally, palate elevates
symmetrically, tongue midline, shoulder shrug ___
- ___ deltoid, bicep, tricep, hip flexion, knee flex/ext,
plantar/dorsiflex
- Sensation equal to light touch throughout
Pertinent Results:
___ 09:15AM BLOOD WBC-5.0 RBC-3.79* Hgb-12.9 Hct-37.9
MCV-100* MCH-34.0* MCHC-34.0 RDW-12.3 RDWSD-44.7 Plt ___
___ 09:15AM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-142
K-4.6 Cl-105 HCO3-25 AnGap-12
___ 09:15AM BLOOD Calcium-9.7 Phos-3.9 Mg-2.2
___ 02:24PM CEREBROSPINAL FLUID (CSF) TNC-43* RBC-2 Polys-0
___ Monos-7 Other-35
___ 02:24PM CEREBROSPINAL FLUID (CSF) TotProt-53*
Glucose-50
MRI HEAD ___
FINDINGS: A 1.7 x 1.3 x 1.2 cm dural-based extra-axial enhancing
mass with a slightly bilobed configuration overlying the left
lateral central sulcus with restricted diffusion and minimal
associated susceptibility artifact is unchanged since 3 weeks
prior and results in minimal mass effect on the adjacent
precentral and postcentral gyri at the level of the upper
frontoparietal operculum.. No associated cerebral edema.
Findings most consistent with meningioma. Metastasis is
unlikely. Normal underlying bone. No evidence of intracranial
hemorrhage or infarction. Minimal periventricular and
subcortical white matter T2/FLAIR hyperintensities are
nonspecific but likely sequelae of chronic small vessel ischemic
disease. The ventricles and sulci are normal in caliber and
configuration. A small sphenoid sinus mucous retention cyst is
unchanged. Nonspecific partial opacification of the bilateral
mastoid air cells is unchanged decreased flow void left
vertebral artery, stable since prior, consistent with slow flow,
vessel opacifies on post gadolinium images.
IMPRESSION:
1. No dural venous sinus thrombosis. No acute findings.
2. Findings most consistent with meningioma overlying lateral
left central sulcus.
CT chest/abdomen/pelvis ___
IMPRESSION:
1. New left internal mammary lymph nodes measuring 6-7 mm,
suspicious for recurrence. A PET-CT can be considered for
further evaluation.
2. Scattered right pulmonary nodules ranging in size from 2-5
mm, which are nonspecific but should be followed to ensure
stability.
3. Lobular left ovarian soft tissue lesion measuring 2.7 x 2.5
cm, for which further evaluation with a dedicated pelvic
ultrasound is recommended.
4. Two subcentimeter hepatic hypodensities, too small to
characterize.
5. Lobular left thyroid lobe contour with hyperenhancement
measuring up to 1.8 cm, which may be due to an underlying
nodule.
DISCHARGE LABS:
===============
___ 07:35AM BLOOD WBC-5.8 RBC-3.27* Hgb-11.2 Hct-34.2
MCV-105* MCH-34.3* MCHC-32.7 RDW-13.1 RDWSD-49.5* Plt ___
___ 07:35AM BLOOD Plt ___
___ 07:35AM BLOOD Glucose-89 UreaN-18 Creat-0.8 Na-150*
K-4.9 Cl-115* HCO3-24 AnGap-11
___ 07:52AM BLOOD Glucose-85 UreaN-12 Creat-0.8 Na-147
K-4.6 Cl-110* HCO3-26 AnGap-11
___ 07:52AM BLOOD ALT-25 AST-25 AlkPhos-66 TotBili-0.3
___ 07:35AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.2
Brief Hospital Course:
Patient is a ___ year old left handed woman with a PMHx of breast
ca s/p bilateral mastectomy, radiation and chemotherapy,
headaches, left sided cataracts and vitreous detachment,
anxiety/depression, who presented from neurology clinic for
headaches and was found to have leptomeningeal metastasis. She
underwent placement of Ommaya reservoir prior to discharge.
#Leptomeningeal Carcinomatosis
Patient initially presented to neurology with symptoms
concerning for elevated ICP, including whooshing sound, they
were worse with laying down and concern for papilledema. LP
opening pressure, however, was 21. Per ophthalmology, the
blurred disc margins are more
consistent with peripapillary atrophy, which can be seen in
severely myopic patients. Her CSF showed lymphocytic pleocytosis
with elevated protein. Coupled with her history of breast
cancer, this was concerning for leptomeningeal spread, which was
confirmed on cytology. MRI additionally showed a small frontal
left frontal enhancing lesion, most consistent with meningioma.
MRV negative for SVT. Patient decided to pursue IT and systemic
chemotherapy with Dr. ___ Dr. ___ underwent placement
of an Ommaya reservoir without complications. Headache pain was
controlled with MS ___ 30 BID, moprhine ___ 15mg q4 and
topiramate.
#H/o Breast Ca
The patient was diagnosed in ___ with triple-negative
left sided pleomorphic infiltrative lobular breast cancer s/p
bilateral mastectomies in ___. She had five positive lymph
nodes seen on MRI prior to neoadjuvant chemotherapy. The largest
1.5 cm and was positive on cytology with FNA. She was treated
with neoadjuvant dose-dense Cytoxan, Adriamycin and Taxol. All
10 lymph nodes removed during mastectomy were negative and had
treatment effect, meaning that she had responded that well to
the chemotherapy. She then had postmastectomy radiation on the
left with Dr ___.
She has an extremely strong family history of breast cancer with
her mother having had breast cancer in her ___, her sister at
___, another sister at age ___. ___ panel was negative, and
no other inherited gene mutation has been identified to explain
her
or her family's breast cancer.
In addition to leptomeningeal spread noted above, some findings
were otherwise noted including 6-7mm left internal mammary LN,
ovarion soft tissue lesion 2.7x2.5cm, thyroid lobe lobularity
with hyperenhancement and subcentimeter hepatic hypodensities.
Transitional Issues:
- ___ with Dr. ___
- ___ with Dr. ___
- ___ with primary care
- Consider contrast enhanced pelvic MRI to evaluate ovarian mass
- Sutures to be removed through ___ clinic ___ days
post-discharge
- Please monitor bowel movements and prescribe additional
laxatives as needed
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. Vitamin D ___ UNIT PO DAILY
2. Cyanocobalamin 500 mcg PO DAILY
3. FLUoxetine 20 mg PO DAILY
4. LORazepam 0.5 mg PO BID:PRN anxiety
5. Nabumetone 500 mg PO DAILY:PRN pain
6. Pantoprazole 40 mg PO QHS
7. Simvastatin 20 mg PO DAILY
8. Topiramate (Topamax) 50 mg PO QHS
9. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*360 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY
RX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
3. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine 30 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*60 Tablet Refills:*0
4. Morphine Sulfate ___ 15 mg PO Q8H:PRN BREAKTHROUGH PAIN
RX *morphine 15 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Cyanocobalamin 500 mcg PO DAILY
7. FLUoxetine 20 mg PO DAILY
8. LORazepam 0.5 mg PO BID:PRN anxiety
9. Nabumetone 500 mg PO DAILY:PRN pain
10. Pantoprazole 40 mg PO QHS
11. Simvastatin 20 mg PO DAILY
12. Topiramate (Topamax) 50 mg PO QHS
13. TraZODone 25 mg PO QHS:PRN insomnia
14. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Leptomeningeal Carcinomatosis
Triple Negative Breast Cancer
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 ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for headaches that have been ongoing for
about 2-months time.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, you had a test of your spinal
fluid which showed cancerous cells.
- You were seen by our neuro-oncologist Dr. ___. A plan was
determined by Dr. ___ your primary oncologist Dr. ___.
- You had an Ommaya reservoir placed by our neurosurgeons to
prepare you for your treatment.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the ___!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10325780-DS-7 | 10,325,780 | 28,237,649 | DS | 7 | 2163-04-01 00:00:00 | 2163-04-01 14:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Right Chest Tube
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ male with metastatic
pancreatic cancer receiving palliative AbGn-107 on DF/HCC ___
who presents with chest pain.
On ___ morning patient had routine CT torso for staging. He
then went home and while he was bending over to pick up laundry
he had sudden onset sharp central chest pain and associated
cough
and shortness of breath. His symptoms improve when in upright
position. He called his outpatient Oncology team who recommended
further evaluation.
On arrival to the ED, initial vitals were 97.1 65 122/70 16 97%
RA. Exam was notable for decreased breath sounds at right base.
Labs were notable for WBC 3.0, H/H 10.8/33.4, Plt 140, INR 1.2,
Na 134, K 3.5, BUN/Cr ___, BNP 35, and Trop-T < 0.01. CTA
chest showed worsening of right pleural effusion. IP was
consulted and placed right chest tube with removal of 1700 ml.
Pleural fluid studies were sent. CXR showed decrease in pleural
effusion and no pneumothorax. Patient was given creon, ursodiol,
Tylenol, ibuprofen, and 500cc NS. Prior to transfer vitals were
98.7 69 112/71 16 96% RA.
On arrival to the floor, patient reports his breathing and pain
has improved. He also notes feeling more itchy recently. He
denies fevers/chills, night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbness, hemoptysis,
palpitations, abdominal pain, nausea/vomiting, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST MEDICAL HISTORY:
- Benign tumor (glomangioma) removed from left hand in ___
- Back pain since ___
- Left elbow pain since ___ r/t lifting injury
- Nephrolithiasis ___
- Tinnitus ___
- Pneumonia x3 (once as a child, once in ___, once in ___
- Colon polyps at age ___
- ACL tear in 1990s, occasional left knee pain
Social History:
___
Family History:
Father with lung cancer. Sister with breast
cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.0, BP 123/78, HR 61, RR 20, O2 sat 97% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, decreased breath
sounds at right base, right chest tube in place.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 02:00AM BLOOD WBC-3.0* RBC-3.67* Hgb-10.8* Hct-33.4*
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.0 RDWSD-45.5 Plt ___
___ 02:00AM BLOOD Neuts-52.2 ___ Monos-10.1 Eos-5.4
Baso-1.3* AbsNeut-1.55* AbsLymp-0.92* AbsMono-0.30 AbsEos-0.16
AbsBaso-0.04
___ 02:00AM BLOOD ___ PTT-96.3* ___
___ 02:00AM BLOOD Glucose-128* UreaN-17 Creat-0.9 Na-134*
K-9.8* Cl-102 HCO3-25 AnGap-7*
___ 02:00AM BLOOD ALT-27 AST-62* LD(LDH)-912* AlkPhos-146*
TotBili-1.7*
___ 02:00AM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD proBNP-35
___ 02:00AM BLOOD TotProt-7.0 Albumin-3.9 Globuln-3.1
Cholest-121
___ 03:56AM BLOOD K-3.5
___ 03:19PM PLEURAL TNC-335* RBC-669* Polys-4* Lymphs-30*
Monos-46* Macro-19* Other-1*
___ 03:19PM PLEURAL TotProt-1.2 Glucose-121 LD(LDH)-59
Amylase-7 Albumin-0.7 Cholest-15 Triglyc-230 proBNP-46
==================
IMAGING AND STUDIES
==================
___ MRCP
IMPRESSION:
1. Mild intrahepatic biliary ductal dilatation to the level of
the hepaticojejunostomy is unchanged from ___.
2. Redemonstration of soft tissue in the pancreatectomy bed that
includes the SMV and encases and narrows the SMA, which appears
slightly increased compared to MRI from ___, but is
similar compared to more recent CTs.
3. Moderate right pleural effusion, slightly decreased from ___.
4. Probable small left upper pole renal infarct. Continued
attention on follow-up is recommended.
5. Otherwise expected post treatment changes following Whipple
procedure and right hepatic ablation.
___ CXR
IMPRESSION:
In comparison with the study of ___, there has been no
reaccumulation of right pleural effusion with the chest tube in
place. Small pneumothorax is again seen.
The cardiac silhouette is within normal limits and there is no
vascular congestion or acute focal pneumonia.
___ TTE normal without elevated PASP
___ RUQ US with dopplers: Limited study due to acoustic
shadowing from overlying bowel gas demonstrate possible
bidirectional flow of the proximal main portal vein. The
splenic
vein and SMV are not visualized and thrombosis involving these
vessel cannot
be excluded.
CXR ___: New small pleural effusion since ___ with right
basal pigtail in place. Slightly increased right apical
pneumothorax.
Ascites flow study with nuc med ___: Positive study showing flow
of activity from the site of injection in the right lower
quadrant ascites into the right pleural effusion.
==============
DISCHARGE LABS:
==============
Brief Hospital Course:
Mr. ___ is a ___ male with metastatic
pancreatic cancer receiving palliative AbGn-107 on DF/HCC ___
who presents with chest pain and shortness of breath and was
found to have a right pleural effusion
# Right Pleural Effusion:
# Chest Pain:
# Chylothorax:
# Abdominal ascites
Symptoms due to new right pleural effusion, concerning for a
chylothorax given pleural fluid with triglyceride level of 230.
Per light's criteria, the effusion was TRANSUDATIVE. The patient
underwent a nuclear medicine flow study which showed the pleural
effusion was likely due to ascitic fluid CROSSING A DEFECT in
the diaphragm. Ongoing drainage from the pleural catheter over
several days showed clear yellow fluid more consistent with
ABDOMINAL ASICTES CROSSING THROUGH A DIAPHRAGMATIC DEFECT given
high SAAG and low triglycerides on repeat studies.
He was started on furosemide and spironolactone with decreased
chest tube output and chest tube was removed ___. TTE did not
show elevated PASP. NO EVIDENCE OF CIRRHOSIS based on imaging
and labs and pancreatic mets to liver not numerous enough to
generally cause portal hypertension. He underwent portal
pressure measurements and liver biopsy which showed NO EVIDENCE
OF PORTAL HYPERTENSION and preliminary pathology results showed
NO EVIDENCE OF CIRRHOSIS. Discharged home on the following
diuretic doses to try to keep the effusion from reaccumulating:
80 MG furosemide BID and 50 mg spironolactone daily. He had
outpatient oncology and interventional pulmonology follow-up
scheduled ___. Note: If the results of the liver biopsy
later come back normal, the spironolactone should be stopped.
# Metastatic Pancreatic Cancer
# Secondary Neoplasm of Liver
# Secondary Neoplasm of Lung
Continued on home creon and ursodiol. Dr. ___ Dr.
___ of the admission. Study drug held on admission.
Patient will follow-up with his outpatient oncology on ___.
# ___ Syndrome:
Patient reported history of ___ syndrome which would
account for the slightly elevated bilirubin of 1.6. Bilirubin
remained stable this admission.
# Leukopenia:
# Anemia:
# Thrombocytopenia: Remained baseline.
OUTSTANDING ISSUES
[ ] If the results of the liver biopsy later come back normal,
the spironolactone should be stopped.
[ ] Ensure pt follow up with IP and heme onc
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon ___ CAP PO TID W/MEALS
2. Ursodiol 600 mg PO BID
3. Vitamin D ___ UNIT PO 1X/WEEK (___)
4. turmeric 400 mg oral DAILY
5. paricalcitol 1 mcg oral DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Zinc Sulfate 220 mg PO DAILY
Discharge Medications:
1. Furosemide 80 mg PO 8AM AND 2PM
RX *furosemide 80 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
3. Creon ___ CAP PO TID W/MEALS
4. paricalcitol 1 mcg oral DAILY
5. turmeric 400 mg oral DAILY
6. Ursodiol 600 mg PO BID
7. Vitamin D ___ UNIT PO 1X/WEEK (___)
8. Vitamin D ___ UNIT PO DAILY
9. Zinc Sulfate 220 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with shortness of breath and
chest pain and found to have a pleural effusion (fluid around
your lung).
You had a chest tube placed to drain the fluid with improvement
in your symptoms. You had a studies to evaluate where the fluid
was coming from which showed communication between your abdomen
and chest. It was not clear why this happened, especial a number
of tests. Your cancer appears stable and your liver functioning
appears normal.
We think you are safe to go home now. You were discharged on
diuretic medications to make you pee and reduce the potential
for fluid to refill the right pleural space.
You have appointments next week with both oncology and
interventional pulmonology .
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10326078-DS-2 | 10,326,078 | 23,912,064 | DS | 2 | 2111-09-20 00:00:00 | 2111-09-20 23:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
___ DCCV/TEE
___ dual chamber ICD extraction w/ RIJ temporary screw-in lead
insertion connected to an external pacemaker
___ PPM reimplant
PICC placement
History of Present Illness:
Ms. ___ is a ___ year-old woman with a PMH of myotonic
dystrophy, atrial fibrillation, mobitz II AVB s/p PPM/primary
prevention ICD who presented to an OSH after a fall hitting R
side of face w/ R zygomatic and lateral orbital wall fractures
as
well as L side lac that was sutured. Transferred to ___ for
plastics evaluation. Plastics evaluated, no need for surgical
intervention, recommended soft diet and ice to the area for ___
weeks. Seen by ophthalmology w/ no globe trauma and no recs from
team. Cardiology was consulted for troponin elevation 0.06, who
recommended 6 hour repeat given no chest pain and obtaining an
echocardiogram. Became symptomatically hypotensive to SBP 60's
while ambulating, and a random desat to 85% on RA
In the ED, initial vitals were: T 98, HR 88, BP 85/62, RR 18,
O2
95% RA
- Exam notable for: not documented
- Labs notable for: CBC 8.2>15.2<166, chem panel unremarkable,
d-dimer 737, troponin 0.06
- Imaging was notable for: CTA w/ scattered bilateral GGO, 1.9
cm
R thyroid lobe nodule
- Patient was given: Acetaminophen 650mg, ASA 324 mg, 2L NS,
azithromycin 500mg, ceftriaxone 1 gm
Upon arrival to the floor, she reports that she fell due to not
holding onto her walker properly. Denies other recent falls at
home. Currently not having any pain but frustrated that she felt
surgery did not communicate plan well to her. Otherwise was
feeling well at home with no fevers/chills, chest pain,
shortness
of breath, dizziness, lightheadedness, abdominal pain, n/v.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
-Myotonic dystrophy
-Atrial fibrillation not on anticoagulation
-Mobitz type II AVB s/p PPM/primary prevention ICD
Social History:
___
Family History:
Father died of stroke, brother of cancer, five out of six
siblings have myotonic dystrophy
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: T 98.4, RR 73, BP 104/71, RR 18, O2 94% RA
GENERAL: Lying in bed, NAD
HEENT: Sutures near L eye covered in steri strips, ecchymosis
surrounding L eye but able to open. No apparent bony
abnormalities of face/skull. Able to open jaw wide w/o pain, MMM
NECK: JVP not elevated
CARDIAC: ___, S1, S2, no m/r/g
LUNGS: CTAB
ABDOMEN: Soft, nt, nd
EXTREMITIES: Wwp, no ___ edema
NEUROLOGIC: A&O x3
SKIN: Ecchymosis as noted above
DISCHARGE PHSYCIAL EXAM:
========================
PHYSICAL EXAM: 97.9 PO 91/59 71 18 93 2L
GENERAL: sitting up in bed, NAD
HEENT: ecchymosis resolving around R eye and right jaw, MMM
NECK: JVP 10cm
CARDIAC: irregular rhythm, no m/r/g
LUNGS: posterior crackles right base and left base ext to
midlung
ABDOMEN: Soft, nt, nd
EXTREMITIES: Wwp, no ___ edema
NEURO: AOx4, hypotonic, ___l, sensation
intact
PSYCH: flat affect
Pertinent Results:
ADMISSION LABS:
===============
___ 05:41PM cTropnT-0.05*
___ 11:35AM GLUCOSE-80 UREA N-14 CREAT-0.8 SODIUM-143
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-29 ANION GAP-14
___ 11:35AM cTropnT-0.06*
___ 11:35AM D-DIMER-737*
___ 11:35AM WBC-8.2 RBC-5.28* HGB-15.2 HCT-48.2* MCV-91
MCH-28.8 MCHC-31.5* RDW-14.0 RDWSD-47.1*
___ 11:35AM NEUTS-62.0 ___ MONOS-8.2 EOS-0.6*
BASOS-0.4 IM ___ AbsNeut-5.07 AbsLymp-2.35 AbsMono-0.67
AbsEos-0.05 AbsBaso-0.03
___ 11:35AM PLT COUNT-166
___ 11:48PM COMMENTS-GREEN TOP
___ 11:48PM LACTATE-1.6
___ 11:45PM GLUCOSE-96 UREA N-15 CREAT-0.9 SODIUM-144
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-18
___ 11:45PM estGFR-Using this
___ 11:45PM CALCIUM-10.2 PHOSPHATE-2.2* MAGNESIUM-2.2
___ 11:45PM WBC-12.3* RBC-5.74* HGB-16.4* HCT-52.2*
MCV-91 MCH-28.6 MCHC-31.4* RDW-14.2 RDWSD-46.6*
___ 11:45PM WBC-12.3* RBC-5.74* HGB-16.4* HCT-52.2*
MCV-91 MCH-28.6 MCHC-31.4* RDW-14.2 RDWSD-46.6*
___ 11:45PM NEUTS-73.4* LYMPHS-18.5* MONOS-7.5 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-9.06* AbsLymp-2.28 AbsMono-0.92*
AbsEos-0.02* AbsBaso-0.03
___ 11:45PM PLT COUNT-202
___ 11:45PM ___ PTT-26.4 ___
IMAGING & STUDIES:
=================
**CARDIAC IMAGING**
+ ECG: Atrial fibrillation w/ controlled ventricular response,
TWI in V1-V6 which is new compared to prior ECG.
+ TTE ___:
The left atrium is normal in size. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with focal
dyskinesis of the mid inferolateral wall (clip 46; second beat
of clip 66) . The remaining segments contract normally (biplane
LVEF = 48 %. The estimated cardiac index is normal
(>=2.5L/min/m2). There is no ventricular septal defect. with
normal free wall contractility.The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild to moderate
(___) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction in an atypical distribution most suggestive
of Takotsubo cardiomyopathy rather than coronary artery disease.
Mild-moderate mitral regurgitation most likely due to papillary
muscle dysfunction
+ TTE ___
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. There is a 1.4 x 0.9 cm fusiform
mass associated with the right atrial aspect of the right
ventricular lead that is minimally mobile (best visualized in
Clip #23). No masses were observed on the rest of the
ventricular lead or atrial lead. Overall left ventricular
systolic function is normal (LVEF>55%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen. No
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. No mitral valve abscess
is seen. Mild (1+) mitral regurgitation is seen. There is no
abscess of the tricuspid valve. [Due to acoustic shadowing, the
severity of tricuspid regurgitation may be significantly
UNDERestimated.] The pulmonary artery systolic pressure could
not be determined. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
IMPRESSION: Large fusiform mass attached to the right atrial
aspect of the right ventricular lead, most c/w thrombus or
vegetation. No left atrial or left atrial appendage thrombus
identified. Normal biventricular systolic function. Mild mitral
regurgitation.
**ADVANCED IMAGING**
___ CT SINUS/MANDIBLE/MAXIL IMPRESSION:
1. Right zygomatic maxillary complex fracture, including
fractures of the right lateral orbital wall, right zygomatic
arch, and the lateral wall of the right maxillary sinus, as
detailed above.
2. No evidence for right extraconal hematoma or right lateral
rectus muscle edema. Right preseptal periorbital edema.
3. Left anterior ethmoid sinus disease, as detailed above. 4 x
2 mm soft tissue density in the left nasal cavity near the
ostium of the left sphenoid sinus may represent a polyp.
4. Periapical lucency ___ 29. Please correlate clinically
whether active dental inflammation may be present.
___ CTA CHEST
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Scattered bilateral ground-glass opacities are nonspecific,
possibly suggestive of atypical infection or inflammation.
3. Diffuse airway wall thickening suggestive of chronic airways
disease.
4. 1.9 cm right thyroid lobe nodule. Per ACR guidelines on
incidentally discovered thyroid nodules, recommend nonemergent
dedicated thyroid ultrasound for further evaluation with
consideration of fine needle aspiration.
**CHEST X-RAYS**
+ ___ CXR (MOST RECENT PRIOR TO DISCHARGE)
IMPRESSION: No significant interval change compared to ___.
+ ___ CXR:
FINDINGS/ IMPRESSION: Right-sided PICC line is likely in the
right atrium. There is stable position of the left chest wall
pacemaker with leads terminating in the right atrium and right
ventricle. Chronic elevation of the left hemidiaphragm as seen
on recent chest CT is again noted. There is slightly increased
left basilar atelectasis. Right basilar atelectasis stable.
Cardiomediastinal silhouette is largely obscured, but appears
stable. Slight interval increase in left basilar atelectasis.
+ ___ CXR:
IMPRESSION: Left lower lobe consolidation improved, subsequently
stable, but small to moderate left pleural effusion has
increased. Right basal atelectasis is mild.
+ ___ CXR:
IMPRESSION: No pneumothorax. Cardiac silhouette is enlarged,
shifted to the left.
+ ___ CXR:
IMPRESSION: Left mediastinal shift is similar but left basal
consolidation appears to be progressing concerning for
progression of infectious process. The pacemaker lead
terminates most likely in the right ventricle. No pneumothorax
appreciated. No interval increase in pleural effusion
demonstrated.
+ ___ (ADMISSION) CXR:
IMPRESSION: Assessment of left lung base is difficult due to
overlying pacemaker, but is probably grossly unchanged compared
with ___ if If there is ongoing concern for subtle
and for a new left base opacity, then a lateral view may help
for further assessment. Otherwise, no acute pulmonary process
identified.
MICRO:
======
___ 4:30 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS CAPITIS. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CLINDAMYCIN : sensitivity testing confirmed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS CAPITIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
VANCOMYCIN------------ <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ON ___,
13:16.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
___ 4:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS CAPITIS. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
CLINDAMYCIN : sensitivity testing confirmed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS CAPITIS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
VANCOMYCIN------------ <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) ON
___, 15:36.
DISCHARGE LABS:
================
___ 05:26AM BLOOD WBC-6.3 RBC-3.67* Hgb-10.4* Hct-35.3
MCV-96 MCH-28.3 MCHC-29.5* RDW-15.9* RDWSD-55.4* Plt ___
___ 05:04AM BLOOD Glucose-95 UreaN-5* Creat-0.6 Na-142
K-4.1 Cl-101 HCO3-35* AnGap-10
Brief Hospital Course:
Ms. ___ is a ___ year-old woman with a PMH of myotonic
dystrophy, atrial fibrillation, mobitz II AVB s/p PPM/primary
prevention ICD who presented following a mechanical fall with
stable zygomatic and orbital wall fractures w/ hospital course
c/b staph capitus bacteremia with possible RV lead seeding. PPM
was removed and screw-in pacemaker was placed with planned
discharge to rehab and PPM placement at the end of the month.
However, her course was complicated by monomorphic VT, which
prompted CCU transfer and expedited PPM/ICD re-placement.
#STAPH CAPITUS BACTEREMIA
#INFECTION OF IMPLANTED CARDIAC PACEMAKER
She initially presented after reported mechanical fall and blood
cultures were obtained due to hypotension. She had positive
blood cultures growing staph capititus. Had TEE showing possible
vegetation vs. thrombus of RV lead. She was started on
vancomycin (___) w/ PPM explant on ___ and RIJ temp pacer
placed. Plan for vancomycin will be 2 weeks from PPM explant (___). ID followed throughout her course and recommended
follow-up ID follow up. This appointment has been scheduled.
#ATRIAL FIBRILLATION:
#MOBITZ TYPE II, s/p dual chamber ICD.
Her ICD interrogation ___ showed appropriate functioning ICD but
she was in atrial fibrillation. As an outpatient, there was a
plan to ultimately undergo DCCV, and since she was going to et a
TEE, DCCV was planned for the same time. She was started on
Xarelto 20 mg daily for atrial fibrillation and underwent
DCCV/TEE on ___ w/ conversion to sinus rhythm, but ultimately
reverted back to atrial fibrillation. Ultimately, due to
vegetation seen on ICD lead, she had the ICD explanted ___ with
plan to place permanent ICD on ___ to allow for full recovery
from infection. Howver, given monomorphic VT (discussed below),
explantation and ICD placement was expedited and done on ___.
This was discussed with ID, who felt that this time frame was
appropriate, given that it was 72 hours after negative blood
cultures. She had ICD site pain which was managed with standing
acetaminophen, lidocaine ointment on shoulder and a short course
of tramadol.
#MONOMORPHIC VTACH: On ___ approximately 00:25, went into
monomorphic v tach while moving to the commode. Lasted
approximately 50 seconds at which time patient was unresponsive
per patient (per patient, she denies loss of consciousness) but
she was normotensive with SBPs in the 120s. Self resolved and
mentation returned to baseline. Patient was subsequently
transferred to the CCU for observation. She was started on
metoprolol. Her V-tach may have been secondary to her myotonic
dystrophy, her temp wire, or takotsubo's cardiomyopathy, and was
unlikely ___ ischemia given no chest pain or EKG changes. She
had PPM and ICD placement on ___ with no complications. She
will have ongoing PPM interrogation. If she continues to have
vtach, could consider metoprolol vs. amlodipine; although blood
pressure would not tolerate a beta blocker during her
hospitalization.
#TAKOTSUBO CARDIOMYOPATHY
#TWI, TROPONINEMIA
Her admission ECG showed new TWI V1-V6 compared to prior ECG and
troponin 0.06 on admission. TTE with findings c/w stress CPM
with no LVOT and EF 48%. Etiology could be fall and
catecholamine surge. Expect to be transient and resolve within
___ weeks. Other etiologies of trop elevation and TWI could be
demand ischemia in the setting of fall, bacteria or CMP from
myotonic dysphrophy. Follow-up on TEE on ___ w/ normal EF which
could represent recovered of EF. She was not started on a beta
blocker or ACEi because of her SBP in ___ at times. She will
have cardiology follow-up as outpatient.
#ACUTE ON CHRONIC HYERCARBIC RESPIRATORY FAILURE
#HYPOXEMIC RESPIRATORY FAILURE
#LEFT LOBE ATELECTASIS
She had intermittent 2L O2 requirement on admission and then
primarily at night. She had CTA which showed no PE, but did show
GGOs. However, she was afebrile, w/o leukocytosis and sx c/f
infection. We initially suspected atelectasis vs. OSA (in the
setting of myotonic dystrophy) w/ possible component of stress
CPM. She then developed increase O2 requirement (3L) post PPM
placement. Her VBG was significant for CO2 ~70s which remained
stable on serial monitoring. This was thought to be acute on
chronic worsening in the setting of her myotonic dystrophy and
left lobe atelectasis (seen on CXR). She was encouraged to use
ICS/Acapella, work with ___ and mobilize. We did do a one day
trial of Lasix 20 mg IV, to which she had significant UOP;
however, there was no appreciable change in her respiratory
status. We have scheduled an appointment with pulmonology as an
outpatient as she could be evaluated for CPAP and long-term
prognosis re her respiratory status.
#FALL
#FACIAL FRACTURES
Mechanical fall due to not using walker properly, history not
concerning for syncope, no lightheadness, dizziness, chest pain
or other prodromal sx and she remembers falling and did not lose
consciousness. She had stable right zygomatic and orbital
fractures. Seen by plastics and optho in the ED with no acute
concerns. These services recommended soft diet and ice packs to
face for 2 weeks and then her diet was advanced to regular.
Sutures from face were removed. Pain was well controlled
acetaminophen.
#HYPERNATREMIA : She had intermittent hypernatremia mostly in
the setting of being NPO for various procedures and poor PO
intake. She was intermittently given D5W which resolved her
hypernatremia.
#MYOTONIC DYSTROPHY: Five out of six of her siblings have
myotonic dystrophy. She had genetic testing which showed
expansion mutation in the classic range of the myotonin protein
kinase gene, 956 repeats one chromosome, and 11 (normal range)
on the other. There are two main types: type 1 (DM1) due to
mutations in the DMPK gene and type 2 (DM2) due to mutations in
the CNBP gene. She likely has DM1. Of note, these patient's
often have respiratory complicates from pharyngoesophageal
weakness and myotonia of muscles of respiration. They are
especially susceptible to decompensation w/ general anesthesia,
sedatives and NM blockade.
#HYPOTENSION: Her baseline sbp throughout her hospital course
was sbp 80-100s. She is always asymptomatic with sbp in the ___.
Avoid blood pressure lowering medications.
TRANSITIONAL ISSUES:
TRANSITIONAL ISSUES:
====================
# MEDICATIONS: Please see discharge worksheet for medication
details.
[] Please continue respiratory hygiene- incentive spirometry and
Acapella daily.
[] Please do not take NSAIDs while you are on apixiban because
of the increased risk of bleeding.
[] 1.9 cm right thyroid lobe nodule. Per ACR guidelines on
incidentally discovered thyroid nodules, recommend nonemergent
dedicated thyroid ultrasound for further evaluation with
consideration of fine needle aspiration. She reports this is
chronic and she sees outpatient endocrinologist
[] She will need pulmonology, PFT followup as outpatient to
discuss restrictive process and also prognosis of her
respiratory status w/ underlying myotonic dystrophy
[] Vancomycin planned for 2 week course from ICD explant
(explant ___, end date= ___.
[] PCP to be scheduled by rehab
[] She has DM1 which affects the heart in the form of
arrhythmias and endocrinology including hypogonadism and
diabetes. Respiratory insufficiency and cataracts are other
features which can develop.
[] Please continue to work with SW regarding long term coping
with her diagnosis and resources.
[] FYI: Respiratory studies done while in hospital- ___ -21, ___
501 ml
[] Please remove PICC once vancomycin course is completed.
# FULL CODE
# CONTACT: ___ (brother) ___
Medications 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
2. Lidocaine 5% Ointment 1 Appl TP Q24H left shoulder
3. Miconazole Powder 2% 1 Appl TP QID:PRN rash
4. Rivaroxaban 20 mg PO DINNER
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth Q6H:PRN Disp #*12 Tablet
Refills:*0
6. Vancomycin 500 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Mechanical fall
Orbital and zygomatic arch fractures
Staph Capitus Bacteremia
Stress cardiomyopathy
Acute on chronic hypercarbic respiratory failure
Myotonic dystrophy
Hypernatremia
Monomorphic VT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You had a fall and fractured the bones of your face
-You were having low oxygen levels and low blood pressure
WHAT HAPPENED IN THE HOSPITAL?
-You were found to have bacteria growing in your blood
-You were treated with an antibiotic, "vancomycyin" to kill the
bacteria
-You had an "echo" of your heart which showed possible infection
of your pacemaker
-Your permanent pacemaker was removed and replaced with a new
pacemaker on ___
-You were started on a blood thinner called "apixiban" to treat
your risk of blood clots and strokes (due to your irregular
heart rate)
WHAT SHOULD YOU DO NOW THAT YOU ARE LEAVING THE HOSPITAL?
- You will go to a rehab facility where you will continue to get
strong
- Please take your medicine exactly as prescribed.
- Do not take NSAIDs while on apixiban, as this increases your
risk of bleeding.
- Please follow-up with your doctors as listed in this
paperwork.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10326312-DS-24 | 10,326,312 | 20,556,172 | DS | 24 | 2155-10-16 00:00:00 | 2155-10-16 15:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex / Clindamycin Hcl / Nsaids / Aspirin
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with history of mood disorder, anxiety disorder,
bipolar disorder, and chronic lower back ___ who presents from
outpatient CT for somnolence. He saw Dr ___ on ___nd new horizontal double vision. He
was scheduled for an outpatient CT head today. During the scan
he was noted to be somnolent, and afterward was found wandering
around, falling and walking into walls. The patient reportedly
disclosed that he took total of 450 mg PO morphine and 5mg PO
ativan prior to arrival.
.
In the ED initial VS were 98.4, 91, 130/64, 14, 98%RA. Patient
was intermittently somnolent, however agitated when aroused,
A&Ox3. Exam also notable for erythema of ___ suspicious for
cellulitis so he was given 1g vancomycin. Tox screen pos for
opiates, labs otherwise unremarkable. CT head neg for acute
process. ___ was ordered but patient refused. Psychiatry
was consulted who felt that the patient lacks capacity at this
time due to delerium, and cannot refuse necessary testing or
leave AMA. VS prior to transfer were afebrile, 58, 16, 102/56,
100%1L.
.
Upon arrival to the floor the patient was sobbing, begging for
___ medication. During the interview he repeatedly falls asleep
and is unable to provide a coherant history. He does state that
he has been taking 30mg MSIR, ___ tabs Q3h, though denies taking
any more than this. He states that he is directed to take this
dose by his ___ physician ___ at ___.
.
ROS: Reports chronic lower back ___ "above my S1" secondary to
h/o arachnoiditis and multiple prior back surgeries. Denies any
change in the ___ or other ___. No fevers. Cannot relay
history regarding the redness over his right leg. Cannot give
details regarding his prior falls though states that the details
are "esoteric." Unable to obtain a more detailed ROS.
Past Medical History:
CARDIAC RISK FACTORS: +Hyperlipidemia
CARDIAC HISTORY:
-Prior hospitalization ___ for deconditioning and HR ___
without clear etiology
OTHER MEDICAL HISTORY:
- non-Hodgkin's B-cell follicular lymphoma diagnosed in ___,
treated with excision and radiation therapy, recurrence in ___
s/p R-CHOP (last dose ___
- arachnoiditis-secondary to spinal cord involvement of XRT
field
- DVT X 2 as child,
- Pulmonary Embolism in ___
- Chronic low back ___ s/p hemilaminectomy X 2 (___) and s/p
spine procedure in ___ with Dr. ___ at ___
- Bipolar disorder
- Hypothyroidism
- High cholesterol
- BPH
- Low testosterone
- History of migraines
Social History:
___
Family History:
Father-non ___ lymphoma
Brother- melanoma
mGM- heart disease
Physical Exam:
VITALS: 98.2, 110/73, 61, 18, 100%RA
GENERAL: Intermittently somnolent and agitated.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___. JVP not elevated.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND
BACK: No spinal tenderness on palpation.
EXTREMITIES: Trace-1+ non-pitting edema in both calves though
symmetric. Mild erythema over anterior right calf. Poorly
groomed toenails but no definitive site of entry.
NEURO: A&Ox3, somnolent and falling asleep during interview,
though will wake up and start screaming for ___ medications.
CNs grossly intact. Patient does not cooperate with further
neuro exam though moving all 4 extremities and no focal deficits
noted.
Prior to discharge, AOx3, alert, interactive, coherent.
Pertinent Results:
Admission labs:
___ 02:00PM BLOOD WBC-10.1 RBC-3.55* Hgb-11.3* Hct-35.8*
MCV-101* MCH-31.9 MCHC-31.6 RDW-12.5 Plt ___
___ 02:00PM BLOOD Neuts-77.2* Lymphs-16.5* Monos-3.6
Eos-2.2 Baso-0.5
___ 02:00PM BLOOD ___ PTT-30.8 ___
___ 02:00PM BLOOD Glucose-110* UreaN-10 Creat-0.9 Na-141
K-3.4 Cl-103 HCO3-30 AnGap-11
___ 02:00PM BLOOD Calcium-9.9 Phos-3.0 Mg-2.0
___ 02:00PM BLOOD VitB12-316 Folate-17.3
___ 02:00PM BLOOD TSH-2.3
___ 02:00PM BLOOD Lithium-0.5
___ 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:04PM BLOOD Lactate-1.1
CT head without contrast ___
FINDINGS: There is no intra- or extra-axial hemorrhage, edema,
mass effect, or shift of midline structures. The ventricles and
sulci are normal in size and configuration. Gray-white matter
differentiation is preserved. Atherosclerotic calcifications in
the bilateral carotid siphons and distal vertebral arteries are
again noted. There is no fracture. The visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION: No acute intracranial process.
Brief Hospital Course:
___ year old gentleman with history of mood disorder, anxiety
disorder, bipolar disorder, and chronic lower back ___ who
presented from outpatient CT for somnolence and altered mental
status, most likely secondary to medication overdose, discharged
in stable condition, has follow up with ___ clinic.
# AMS: Likely secondary to over-medication with morphine and
ativan. Unclear what patient's home dose should be, though the
patient reports that he has been taking 30mg MSIR, ___ tablets
every 3 hour while Dr ___ physician at ___
reachable at ___ reported his home regimen to be 30mg
MSIR ___ tablets every 6 hour. He does have mild erythema and
warmth over his right lower extremity which could be a
cellulitis, however patient is afebrile with normal WBC and no
other infectious focus on exam. The primary care physician
noticed this slight erythema during an earlier clinic visit
___ and noted to be slightly more erythematous at this
admission. CT head earlier on day of admission wa negative for
acute process. His morphine, trazodone lorazepam and other
sedating medications were initially held then morphine was
restarted at half of his home regimen. Psychiatry team was
consulted after he refused ___ and concluded that at that
time he didn't have capacity to take decisions and 1:1 sitter
was started. Lithium level, TSH, B12, folate, RPR, Ca,Mg and Ph
were all normal. Subsequently, his mental status cleared.
Psychiatry re-evaluated the patient to ensure having capacity
prior to discharge. He was instructed to follow MSIR 30mg ___
tablets every 6 hour regimen. UA was normal. Urine toxicology
was positive only for opiates. He is discharged with ___ for
medication reconciliation.
# ?Cellulitis: Right anterior shin with mild erythema and
warmth. Has history of bilateral lower extremity pitting edema
per prior notes and primary care physician. The physical exam
was not convincing of cellulitis. He received 1 dose of IV
vancomycin in the ED. Patient is listed as having allergies to
penicillins, cephalosporins, and clindamycin. He is instructed
to contact his primary care physician if erythema gets worse or
develops ___ or fever.
# Chronic back ___: Midline, over L5-S1 area. Reportedly
secondary to history of arachnoiditis and multiple prior back
surgeries. Patient states that his ___ is unchanged. No fevers
so low suspicion for abscess. Tylenol and lidocaine patch were
provided while morphine was initially not given. He subsequently
received half of his home regimen of morphine once he was clear
and awake.
# Depression/Anxiety/Bipolar: We continued lithium and
duloxetine at home dose.
# Hypothyroidism: We continued levothyroxine. TSH was normal.
# Hyperlipidemia: We continued home simvastatin.
# H/o DVT/PE: Per Dr. ___, the DVT occured when he
was a ___ and the PE was over a decade ago. The warfarin
was discontinued on ___ due to history of falls. ED staff
were concerned for recurrent DVT given ___ swelling so ordered a
___ which patient refused. His legs appear fairly symmetric.
___ weren not pursued further.
Medications on Admission:
MEDICATIONS: (confirmed)
DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.) - 2
Capsule(s) by mouth once a day
FINASTERIDE - 5 mg Tablet - TAKE 1 TABLET BY MOUTH ONCE A DAY
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays in each
nostril
as needed
LEVOTHYROXINE - 125 mcg Tablet - TAKE 1 TABLET BY MOUTH EVERY
DAY
LITHIUM CARBONATE [LITHOBID] - 300 mg Tablet Extended Release -
1
Tablet(s) by mouth twice a day
LORAZEPAM - 1 mg Tablet - ___ Tablet(s) by mouth every six (6)
hours as needed for anxiety
MORPHINE - (Prescribed by Other Provider: Dr. ___ - Per Dr
___ 90-120mg every 6 hour
PROCHLORPERAZINE MALEATE - 5 mg Tablet - 1 Tablet(s) q6 as
needed
for nausea
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth qpm
TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - TAKE 1 CAPSULE
BY MOUTH DAILY
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth once a day
ACETAMINOPHEN [TYLENOL] - (OTC) - Dosage uncertain
CETIRIZINE - (OTC) - 10 mg Tablet - 2 Tablet(s) by mouth once a
day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (Prescribed by Other
Provider) - Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider; ___--patient
states he is taking this) - Dosage uncertain
Discharge Medications:
1. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO once a day.
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
spray Nasal once a day as needed for allergy symptoms.
4. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lithium carbonate 300 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
6. lorazepam 1 mg Tablet Sig: 1 - 1.5 Tablet PO every six (6)
hours as needed for anxiety.
7. morphine 30 mg Tablet Sig: ___ Tablets PO every six (6)
hours.
8. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. acetaminophen Oral
13. cetirizine 10 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for allergy symptoms.
14. Vitamin D3 4,000 unit Capsule Sig: One (1) Capsule PO once a
day.
15. multivitamin Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Altered mental status
Arachnoiditis
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
It was a great pleasure taking care of you as your doctor. As
you know you were admitted to ___
___ because you were drowsy that was noticed after the head
CT scan you had. We were concerned of medication side effect
(combination of morphine and ativan). Your CT head did not show
acute process. Your kidney function, B12, folate, thyroid
function test and lithium levels were normal.
We discussed with your ___ doctor Dr ___ at ___ who stated
that your oral morphine immediate release (___) regimen is 30 mg
tablet ___ tablets (90-120mg total at each time) every 6 hours
as needed. Please adhere to this regimen for now to avoid over
sedation.
We did not make changes in your medication list. Please continue
taking the rest of your home medications as you were taking them
prior to admission.
Please contact your Primary care physician Dr ___ needed
earlier than your upcoming appointment as he instructed you to
do so.
If the redness in your right lower leg gets worse, please
contact your primary care physician.
Followup Instructions:
___
|
10326429-DS-22 | 10,326,429 | 21,206,205 | DS | 22 | 2159-07-24 00:00:00 | 2159-07-25 21:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol / Benadryl Decongestant / Penicillins / Sulfa
(Sulfonamide Antibiotics) / Baby Powder / Atrovent / Effexor /
Dilaudid / ibuprofen / Keflex
Attending: ___.
Chief Complaint:
pyelonephritis, headache, back pain
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
___ morbidly obese female with PMH a-fib, asthma/COPD on 3.5 L NC
at baseline, hypothyroid, bipolar disorder presenting to ___
___ with flank pain and headache with recent diagnosis of
UTI/pyelonephritis. Pt. reports that on ___ prior to arrival
she was seen by ___ and diagnosed with UTI and started on
ciprofloxacin. Symptoms were dysuria and inability to empty
bladder completely, no frequency or urgency. She then developed
low back pain and presented to ___, diagnosed with
pyelonephritis and dishcarged on cipro. On ___ she
represented to ___ with continued back pain, headache and
feeling out of it. At ___ she was found to have pH 7.27,
pCO2 75, pO2 60, HCO3 35.7. Trop 0.02, WBC 9, BUN 5, cr 0.72,
LFTs WNL. Urine culture from ___ reportedly growing >100K of
something sensitive to augmentin and cipro. CTA head and neck
no acute intracranial abnormality. EKG sinus rhythm 94 BPM
normal axis incomplete LBBB , PVC present, no ischemic changes
similar to prior.
In the ED, initial vs were: 100.5 92 120/76 14 96% RA. pH 7.31
pCO2
75 pO2 192 HCO3 40. Patient started on BiPAP satting comfortably
in mid 90's. Patient given Sumatriptan 50 mg PO x2,
metoclopramide 10mg IV, dilaudid 1 mg IV. Vitals prior to
transfer 100.7 122 118/78 24 92% vent.
On arrival 98.8, 125, 149/89, 21, 40% ___ mask. Patient c/o
back pain bilateral R>L. Headache, occipital, throbbing,
photophonophobia, blurry vision. She also c/o sweats and chills
but afebrile at home. Also c/o n/v of slighty bloody vomitus.
Denies diarrhea. She denies feeling short of breath or having
increased cough, this does not feel like an exacerbation, which
she typically has 10/ year and last had prednisone one month
ago.
Past Medical History:
Atrial fibrillation on diltiazem and ASA
GERD
Asthma
Bipolar d/o
DM
OSA, not on CPAP because company went out of business that
provided it
Hypothyroidism
Migraine
Fibromyalgia
PCOS
COPD
Restless leg syndrome
Social History:
___
Family History:
Asthma (father), DM (multiple relatives), CAD/MI(Mother in ___,
father in ___), AML
Physical Exam:
ADMISSION:
Vitals: 98.8, 125, 149/89, 21, 40% ___ mask.
General: Alert, oriented, obese female, no apparent distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
poor dentition
Neck: supple, unable to assess JVP, no LAD,
Lungs: Mild end expiratory wheezing and otherwise clear, no
crackles
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, obese, with panus that has chronic
scaling bowel sounds present, no rebound tenderness or guarding,
no organomegaly
GU: no foley
Ext: warm, well perfused, trace pulses, no clubbing, no edema,
chronic venous changes anterior legs
Neuro: CN II to XII intact, normal sensation, normal strength
Discharge:
Vitals: 97.9 124/54 78 97% 5L (back to 3.5L at d/c)
General: Alert, oriented, no acute distress, morbidly obese
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi. TTP on left parasternal area
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, morbidly obese, NT, NABS. Pannus with diffuse
erythema and crusted exudate that is improved, within drawn
borders. Indurated nodules (per pt stable).
Ext: Warm, bilateral erythema consistent with longstanding
venous stasis
Skin: See above, PICC wnl
Neuro: A+0x3, CN II-XII intact, grossly nml
Pertinent Results:
================
ADMISSION LABS:
================
___ 06:20AM PLT COUNT-290
___ 06:20AM NEUTS-77.7* LYMPHS-13.3* MONOS-6.4 EOS-2.3
BASOS-0.4
___ 06:20AM WBC-7.5 RBC-3.86* HGB-11.2* HCT-35.8* MCV-93
MCH-29.0 MCHC-31.2 RDW-14.9
___ 06:20AM UREA N-6 CREAT-0.6
___ 06:37AM GLUCOSE-233* LACTATE-0.8 NA+-138 K+-3.9
CL--95*
___ 06:37AM TYPE-ART PO2-192* PCO2-75* PH-7.31* TOTAL
CO2-40* BASE XS-8
___ 06:46AM ___ PTT-32.0 ___
___ 01:54PM TYPE-ART PO2-75* PCO2-73* PH-7.34* TOTAL
CO2-41* BASE XS-9 INTUBATED-NOT INTUBA COMMENTS-NASAL ___
Discharge:
___ 05:06AM BLOOD WBC-5.4 RBC-3.92* Hgb-10.8* Hct-35.9*
MCV-92 MCH-27.6 MCHC-30.1* RDW-14.9 Plt ___
___ 05:06AM BLOOD Glucose-106* UreaN-6 Creat-0.6 Na-147*
K-3.5 Cl-98 HCO3-42* AnGap-11
___ 05:06AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.9
___ 07:40PM BLOOD TSH-9.2*
___ 06:50AM BLOOD T4-5.9
=========
IMAGING
=========
CXR ___:
IMPRESSION:
1. Interval placement of left subclavian PICC line, which has
its tip in the
proximal-to-mid SVC. Cardiac and mediastinal contours are
difficult to assess
due to marked patient rotation, but are likely unchanged. Lung
volumes appear
somewhat diminished. There is a possible increase in opacity at
the left
base, although this area is somewhat underpenetrated on the
current
examination but does raise concern for either partial lower lobe
atelectasis,
pneumonia or aspiration. Followup imaging would be advised. In
addition, the
mild interstitial edema persists.
Micro:
___ 6:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
___ yo morbidly obese female with PMH a-fib, asthma, hypothyroid,
bipolar disorder presenting to ___ with flank pain
and headache with recent diagnosis of UTI/pyelonephritis.
# Pyelonephritis: Pt. initially with dysuria and incomplete
emptying found to have UTI. Urine culture from ___ >100,000
colonies from OSH, Klebsiella with ESBL. She then developed
flank pain, nausea and vomiting, diagnosed with pyelonephritis
at OSH. Given that she was started on cipro several days ago and
continued to be symptomatic, considering this to be cipro
failure. Did not meet any SIRS criteria so not septic. Treated
with IV meropenem and then ertapenem for a 2 week course via
PICC. Pt will have ___ at home.
# Chronic Respiratory Acidosis: Pt. with history of asthma on
home oxygen 3.5L NC. She also has morbid obesity and likely
obesity hypoventilation. Increased CO2 likely chronic based on
pH. Had some nocturnal desaturations in the setting of anxiety,
but overall oxygenated well on her home settings without SOB.
CXR w/ ?mild pulmonary edema. Pt. did not endorse symptoms of
acute exacerbation (e.g. significant productive cough or
wheezing) and thus did not treat for COPD exacerbation.
Continued home 3.5 L NC 02. Gave home albuterol nebs PRN, home
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID, Fluticasone
Propionate.
# Pannus cellulitis: Per pt she recently 2 weeks ago received
clindamycin and diflucan for ?pannus cellitis (she was admitted
here with this dx in ___, treated with vanc). It did look
potentially infected now (especially the pendulous LLQ component
to her pannus). Given DM she is at risk for MRSA. No obvious
evidence of fluctuance but exam is limited by habitus. Given IV
vanc and saw improvement in erythema, and so was transitioned to
PO doxy for a ___t d/c given nystatin cream as
well.
# N/V: Likely ___ known pyelo. Could also consider gastritis
given scant blood seen, ___ tear from vomiting.
None here while admitted. No e/o active GIB. Passing stool/gas.
EKG c/w priors, trops neg x1 AM of admission. She was given an
empiric PO PPI, Maalox during this admission with improvement in
her symptoms.
# Headache: Pt. with history of migraines, pt reports that this
is not typical for her migraine which is usually frontal on the
right. These were bitemporal, felt to be most likely tension
type (possibly exacerbated by uncontrolled OSA). Not improved by
sumatriptan. CTA head and neck without any acute processes at
OSH (Pt noted hearing her heartbeat in her ears, but CTA was neg
excluding concerning vascular pathology such as dissection or
AVM). Neck was supple and she was afebrile without photophobia,
arguing against bacterial meningitis. Hesistant to use
ketoroloac given UGI sx as above (though this improved her sx
intially). Tramadol and Fioricet did not help. Headaches
improved with CPAP.
# RUQ tenderness: Pt with enlarged, tender liver on exam. Given
obvious e/o metabolic syndrome, most likely has a component of
NAFLD. LFTs wnl. Consider outpt RUQ-US, hepatology ___.
Chronic Issues:
# DM: Chronic. Intermittently hypoglycemic to the ___
(symptomatic, always knew when sugars were low) but pt did not
like food at the hospital and so ate little. Continued home
regimen as she will return to her previous diet after d/c. Her
insulin may need to be further titrated as an outpt.
# Bipolar: Continued home seroquel, Citalopram and clonazepam
# A-fib: Had some sinus tachycardia with repositioning but
otherwise NSR. Continued home diltiazem and aspirin.
# OSA: Pt. with diagnosis of OSA however not on CPAP because
company that made her equipment went out of business. Apparently
has not had a sleep study in ___ yrs. Resumed CPAP while
admitted and referred for pulmonary ___ and repeat sleep study,
whereupon a new CPAP unit can be arranged for.
# Hypothyroidism: TSH>9 but total T4 was nml. Consistent with
subclinical hypothyroidism. Continued home levothyroxine.
Transition issues:
- Discharged on a 2 week course of IV ertapenem (via PICC) for
ESBL Klebs pyelo (completes ___
- DIscharged on 10 day course of PO doxycycline for cellulitis
(completes ___
- Outpt PCP ___ (PCP is arranging this) within 1 week
- Outpt pulmonary ___ (PCP ___ arrange this)
- Outpt sleep study (per pt it has been more than ___ yrs since
she had one) (PCP ___ arrange this)
- Once sleep study is completed, needs arrangements made for new
CPAP machine
- Consider RUQ ultrasound as outpt to eval for possible NAFLD
(liver tender, enlarged on exam)
- TSH/Total T4 should be followed prospectively as an
outpatient, as doses may need to be adjusted if total T4 levels
start to fall.
- Consolidation on CXR should be evaluated for resolution within
the next ___ weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q ___ PRN dyspnea
2. Aspirin 325 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Fexofenadine 180 mg PO DAILY:PRN allergies
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Furosemide 40 mg PO DAILY
7. 70/30 75 Units Breakfast
70/30 60 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: on home med list
8. Levothyroxine Sodium 150 mcg PO DAILY
9. Pregabalin 150 mg PO HS
10. QUEtiapine Fumarate 600 mg PO QHS
11. Ropinirole 4 mg PO BID
12. Diltiazem Extended-Release 120 mg PO QPM
13. Diltiazem Extended-Release 240 mg PO QAM
14. Flovent HFA (fluticasone) 220 mcg/actuation Inhalation BID
15. ClonazePAM 0.5 mg PO BID:PRN anxiety
16. ClonazePAM 1 mg PO DAILY insomnia
17. Sumatriptan Succinate 50 mg PO MRX1:PRN headache
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. ClonazePAM 0.5 mg PO BID:PRN anxiety
4. Diltiazem Extended-Release 120 mg PO QPM
5. Diltiazem Extended-Release 240 mg PO QAM
6. Flovent HFA (fluticasone) 220 mcg/actuation Inhalation BID
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Levothyroxine Sodium 150 mcg PO DAILY
9. Pregabalin 150 mg PO HS
10. QUEtiapine Fumarate 600 mg PO QHS
11. Ropinirole 4 mg PO BID
12. Albuterol Inhaler 2 PUFF IH Q ___ PRN dyspnea
13. ClonazePAM 1 mg PO DAILY insomnia
14. Fexofenadine 180 mg PO DAILY:PRN allergies
15. Sumatriptan Succinate 50 mg PO MRX1:PRN headache
16. Furosemide 40 mg PO DAILY
17. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth q12 hr Disp
#*12 Capsule Refills:*0
18. ertapenem 1 gram injection Q24h Duration: 2 Weeks
RX *ertapenem [___] 1 gram 1 gram IV daily Disp #*10 Vial
Refills:*0
19. 70/30 75 Units Breakfast
70/30 60 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: on home med list
20. Nystatin Cream 1 Appl TP BID
RX *nystatin 100,000 unit/gram 1 application twice a day Disp
#*1 Tube Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses
Pyelonephritis
ESBL Klebsiella
Secondary diagnoses
OSA
Asthma
Migraines
Tension headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with a kidney infection and concern over your carbon dioxide
retention. You were treated with antibiotics. A PICC IV catheter
was placed so that you can complete this course in a 2 week
form. You also were given antibiotics for a likely skin
infection.
You were noted to have chronic high carbon dioxide levels based
on your blood work. Your breathing is depressed while you sleep
and you suffer from sleep apnea and COPD. We gave you a CPAP
machine while you were here and you were able to sleep better.
Your doctor ___ arrange for ___ follow up (lung doctors)
and a sleep study to get you a machine at home. Please continue
using your oxygen during the day and CPAP anytime you want to
sleep.
Thank you,
Followup Instructions:
___
|
10326457-DS-6 | 10,326,457 | 27,900,881 | DS | 6 | 2136-07-14 00:00:00 | 2136-07-14 19:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
___ EGD
A single 3 cm ulcer with a visible vessel was
found in the gastroesophageal junction, suspicious for ___ tear. This extended from 2cm above the GEJ to 1cm below
the
GEJ. 8 1 cc. Epinephrine ___ injections were applied for
hemostasis with success, applied above and below the GE
junction.
Four endoclips were successfully applied for the purpose of
hemostasis and ulcer defect closure. The first endoclip closed
the distal most portion of the ulcer below the GE junction. One
clip was deployed at the site of the visible vessel. Two
additional clips were deployed to close the proximal portion of
the defect above the GE junction.
___ EGD repeat due to another BRBPR event after initial EGD
treatment.
Mr. ___ is a ___ year old man with a history of alcohol
abuse who presents with one day history of hematemesis and
melena
found to have ___ tear with a large ulcer and visible
vessel now s/p epinephrine and endoclips x4 on ___ with
hemostasis.
History of Present Illness:
Mr. ___ is a ___ year old man with a history of alcohol
abuse who presents with one day history of hematemesis and
melena in the setting of ongoing alcohol use, now intubated and
on pressors.
The patient reports that he was drinking beer at a bar yesterday
when he started to feel unwell. He then took a break from
drinking briefly and switched from beer to Bloody Marys. He then
became so unwell that he ultimately left the bar and went home.
Once arriving home, he had one episode of dark, bloody,
non-bilious emesis, after which he "passed out" and has no
memory of what happened. He later awoke on the floor of his
bathroom and subsequently had several more episodes of bloody
emesis as well as melenic stool
Patient drinks ___ beers per day. Last drink was ___
around midnight. He denies a history of alcohol withdrawal
seizures or cirrhosis.
Past Medical History:
Hypertension
Alcohol Abuse
Tobacco Abuse
Asthma
Social History:
___
Family History:
Family history of alcoholism and hypertension in his father.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: ___, 112, 137/66, 16, 99% on 100% FiO2
GENERAL: alert, oriented, no acute distress, lying in bed,
intubated
HEENT: single 3-4cm laceration on the L cheek
NECK: supple
LUNGS: scattered wheezes in the lung fields bilaterally
CV: regular, no murmurs, rubs or gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: warm and well-perfused
SKIN: no appreciable rashes
NEURO: alert and oriented, interactive and appropriate, no focal
CN deficits, moving extremities with purpose
DISCHARGE PHYSICAL EXAM
VITALS: ___, 72, 128/77, 17, 100% on RA
GENERAL: alert, oriented, no acute distress, lying in bed
HEENT: single 3-4cm laceration on the L cheek
NECK: supple
LUNGS: scattered wheezes in the lung fields bilaterally
CV: regular, no murmurs, rubs or gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: warm and well-perfused
SKIN: no appreciable rashes
NEURO: alert and oriented, interactive and appropriate, no focal
CN deficits, moving extremities with purpose
Pertinent Results:
___ 04:00PM BLOOD WBC-16.1* RBC-3.54* Hgb-12.1* Hct-34.4*
MCV-97 MCH-34.2* MCHC-35.2 RDW-11.9 RDWSD-42.9 Plt ___
___ 04:10PM BLOOD ___ PTT-26.0 ___
___ 04:00PM BLOOD Glucose-146* UreaN-51* Creat-1.4* Na-138
K-5.5* Cl-87* HCO3-28 AnGap-23*
___ 04:00PM BLOOD Albumin-4.8 Calcium-9.9 Phos-5.6* Mg-2.2
___ 09:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:32AM BLOOD ___ pO2-40* pCO2-52* pH-7.33*
calTCO2-29 Base XS-0
___ 03:32AM BLOOD Lactate-1.8
___ EGD
Findings:
Esophagus:
Mucosa:Trachealization of the mucosa was noted in the whole
esophagus.
Excavated LesionsA single 3 cm ulcer with a visible vessel was
found in the gastroesophageal junction, suspicious for ___ tear. This extended from 2cm above the GEJ to 1cm below
the
GEJ. 8 1 cc.Epinephrine ___ injections were applied for
hemostasis with success, applied above and below the GE
junction.
Four endoclips were successfully applied for the purpose of
hemostasis and ulcer defect closure. The first endoclip closed
the distal most portion of the ulcer below the GE junction. One
clip was deployed at the site of the visible vessel. Two
additional clips were deployed to close the proximal portion of
the defect above the GE junction.
Stomach:
Contents:A large amount of clotted blood was seen in the
stomach. This was extensively irrigated and suctioned but could
not be removed. A ___ net was used to relocate the clot into
the
antrum for evaluation of the stomach body but was not
successful.
Duodenum:
Contents:Red blood was seen in the whole examined duodenum.
Impression:
Mr. ___ is a ___ year old man with a history of alcohol
abuse who presents with one day history of hematemesis and
melena
found to have ___ tear with a large ulcer and visible
vessel now s/p epinephrine and endoclips x4 on ___ with
hemostasis.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of alcohol
abuse who presented with ___ tear in the context of a
one day history of hematemesis and melena in the setting of
ongoing alcohol use, s/p esophageal endoclips and PRBC
transfusions.
ACUTE ISSUES
#GI Bleed
EGD by GI demonstrated ___ tear, requiring 4 endoclips
___. He was placed on BID PPI. He was transfused 3 units
throughout ___ and one further unit ___. He was felt to no
longer be acutely bleeding and was hemodynamically stable. GI
recommended that he start enteral feeding with 48 hours of
clears followed by 1 week of soft foods.
CHRONIC ISSUES
#Alcohol Use Disorder
He was started on withdrawal therapy with phenobarbital taper
after demonstrating myoclonic activity during his intubation
with etomidate. He has a history of drinking a 6 pack per day
and ___ beers per weekend.
TRANSITIONAL ISSUES
- Follow up hemoglobin (8.2 on day of discharge) to ensure
stability
- Patient discharged on protonix 40 BID
- Follow up alcohol use; this was discussed at length with
patient and parents together and emphasis was placed on complete
etOH cessation. Patient met with social work as well for
resources for etOH cessation
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Omeprazole 20 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
3. Lisinopril 20 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Hematemesis secondary to ___ tear
Acute anemia
Hemorrhagic shock
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHAT BROUGHT YOU INTO THE HOSPITAL?
- You were admitted for a bleed from your esophagus in your
throat that made you have a very low blood count.
WHAT WAS DONE FOR YOU WHILE IN THE HOSPITAL?
- A procedure was done to stop the bleeding in your throat with
clips.
- You were given blood to replace the blood you lost.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
-It is very important you follow up with your primary care
doctor after leaving the hospital so they can monitor your blood
levels to make sure you are not still bleeding.
-It is also important that you only eat soft foods until ___ to
prevent your throat from bleeding again.
- As we discussed, please abstain from alcohol entirely. Please
discuss with your PCP how to avoid alcohol going forward.
Followup Instructions:
___
|
10326564-DS-15 | 10,326,564 | 25,687,276 | DS | 15 | 2173-03-03 00:00:00 | 2173-03-04 17:09:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Epinephrine / Iodine / Optiray 350 / Aspirin / Egg /
Shellfish Derived / Lactose / Flu
Attending: ___.
Chief Complaint:
Multifocal pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of IDDM, PBC, asthma and previous pneumonias who
presented with sore throat, fevers, myalgias, arthralgias, and
cough productive of green-yellow sputum x 3days. She first noted
symptoms 3 days prior which started with a runny nose and sore
throat. Started feeling worse 2 days prior to admission with
fevers to ___ yesterday amd to ___ this AM. She took some
aleve which made her feel better but she spiked another temp of
___ this morning. She had some blood tinged sputum this morning
and an associated headache with photophobia. Notes pleuritic
chest pain and DOE. No recent travel or sick contacts. She
called her PCP and was told to come to ___ ED. Her last bout
of pneumonia ___ ___ years ago. She is unable to get the
pneumonia or influenza vaccine due to allergies.
.
In ED VS were 97.8 91 132/60 18 98%. Patient spiked a temp 101.
EKG: HR: 82, sinus, leftward axis, normal R wave progression,
no ST segment changes. Labs were remarkable for WBC 5.8 (86% N,
10%L), negative UA, platelets 101, glucose 220. CXR suggestive
for a multifocal PNA. Given levofloxacin 750mg PO x1 and tylenol
___ PO x1. Vitals on transfer were 100.1 72 18 97%RA 115/50.
.
On arrival to the floor, vitals were 99.5, 122/60, 77, 20,
98%RA. Patient still with pleuritic chest pain, worse on the
right. Denies SOB currently. Denies current fevers/chills. Has
headache with photophobia.
.
Review of systems:
(+) Per HPI.
(-) Denies recent weight loss or gain. Denied palpitations.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Past Medical History:
DIABETES MELLITUS
OSTEOARTHRITIS
OSTEOPOROSIS
PRIMARY BILIARY CIRRHOSIS
ASTHMA
HYPOTHYOIDISM
Social History:
___
Family History:
Positive for hypertension, heart disease, diabetes, breast and
cervical cancer. No other malignancies or stroke.
Physical Exam:
Admission Exam:
VS: 99.5, 122/60, 77, 20, 98%RA
GA: AOx3, NAD
HEENT: PERRLA. mild scleral icteris. MMM. no LAD. no JVD. neck
supple.
Cards: RRR S1/S2 nml. no murmurs/gallops/rubs.
Pulm: CTA on right, crackles at posterior lung base on left, no
wheezing or rhonchi
Abd: soft, NT, +BS. no g/rt. neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes, several bruises on stomach ___ insulin
injections
Neuro/Psych: CNs II-XII grossly intact. ___ strength in U/L
extremities. sensation intact to LT.
Discharge Exam:
VS 99.5 142/58, 71, 18, 98%RA ___ 112
GA: AOx3, NAD
HEENT: PERRLA. mild scleral icteris. MMM. no LAD. no JVD. neck
supple.
Cards: RRR S1/S2 nml. no murmurs/gallops/rubs.
Pulm: CTA on right, persistent crackles at posterior lung base
___ of the way up) on left, no wheezing or rhonchi
Abd: soft, NT, +BS. no g/rt. neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes, several bruises on stomach ___ insulin
injections
Neuro/Psych: CNs II-XII grossly intact. ___ strength in U/L
extremities. sensation intact to LT.
Pertinent Results:
Admission labs:
___ 01:00PM BLOOD WBC-5.8# RBC-3.98* Hgb-12.5 Hct-36.0
MCV-90 MCH-31.3 MCHC-34.7 RDW-13.2 Plt ___
___ 01:00PM BLOOD Neuts-86.1* Lymphs-10.2* Monos-2.9
Eos-0.4 Baso-0.3
___ 01:00PM BLOOD ___ PTT-35.4 ___
___ 01:00PM BLOOD Glucose-220* UreaN-14 Creat-0.8 Na-135
K-3.8 Cl-103 HCO3-23 AnGap-13
___ 01:04PM BLOOD Glucose-214* Lactate-1.4 K-3.9
Discharge Labs:
___ 06:20AM BLOOD WBC-4.9 RBC-3.70* Hgb-11.4* Hct-33.2*
MCV-90 MCH-30.7 MCHC-34.2 RDW-13.7 Plt ___
___ 06:20AM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-145
K-3.6 Cl-112* HCO3-23 AnGap-14
___ 06:20AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.2
Microbiology:
___ URINE negative
___ BLOOD CULTURE Pending
___ BLOOD CULTURE Pending
___ DFA negative
Imaging:
___ ECG: rate 82, Sinus rhythm. Low QRS voltage in the limb
leads. Non-specific inferior ST-T wave changes. Compared to the
previous tracing of ___ the findings are similar.
___ CXR: The heart size is within normal limits. The
mediastinal and hilar contours are unremarkable. There are new
bilateral lower lung opacities predominantly in the lower lobes,
more extensive on the left than right, suggesting pneumonia.
There is no pleural effusion or pneumothorax. IMPRESSION:
Findings suggesting multifocal pneumonia. Follow-up radiographs
are recommended to show resolution within eight weeks.
Brief Hospital Course:
___ hx of IDDM, PBC, asthma and previous pneumonias who
presented with sore throat, fevers, myalgias, arthralgias, and
cough productive of green-yellow sputum x 3days.
.
Active Issues:
# Fevers, productive cough: Likely infectious etiology and of
pulmonary origin. Differential includes CAP vs. viral
bronchitis vs. URI vs. Influenza. Patient's constellation of
symptoms suggest a viral etiology however CXR and physical exam
(significant rales bilaterally) are suggestive of multifocal
PNA. WBC within normal limits (5.8 on admission). Patient was
initially given oseltamivir for suspected flu. Influenza was
ruled out (negative DFA), given the time of year with her
underlying lung disease and inability to get vaccine (egg
allergy). Patient was also started on levofloxacin 750mg in the
ED which was continued for a course of 5 days. Symptoms were
managed with ibuprofen and minimal tylenol (patient has PBC) for
fevers and headache. Urine culture negative, blood cultures were
no growth to date on discharge. Sputum sample was contaminated.
Patient's symptoms improved with each day, with decreased SOB
and pleuritic chest pain. She looked well on discharge.
.
Chronic Issues:
# DIABETES MELLITUS: Hgba1c 10.7% in ___. She was continued on
her home lantus 22units Qam and covered with an insulin sliding
scale. Fingersticks were well controlled during admission.
.
# Hypothyoidism: Continued home levothyroxine.
.
# Asthma: Written for albuterol prn and fluticasone BID. Home
medications were not on formulary, but were restarted on
discharge. No wheezes were ever appreciated on exam.
.
# PRIMARY BILIARY CIRRHOSIS: continued home ursodiol.
.
Transitional Issues:
Patient was scheduled for a follow up appointment with her PCP.
She was given a prescription to finish her 5 day course of
levofloxacin.
Medications on Admission:
- ursodiol 300 mg Cap 3 Capsule(s) by mouth Two tablets in am
and one tablet in pm
- Lantus 100 unit/mL Sub-Q 22 units subcutaneous once a day
- Centrum Silver Tab
- Prilosec OTC 20 mg Tab 1 Tablet(s) by mouth once a day
- Humalog 100 unit/mL Sub-Q as directed by sliding scale
- Caltrate 600 600 mg (1,500 mg) Tab
- lactulose 10 gram/15 mL Oral Soln 15 ml by mouth two to three
times a day
- levothyroxine 88 mcg Tab 1 Tablet(s) by mouth once a day
- Contour Test Strips use as directed twice a day
- lancets use as directed three times a day
- Zyrtec 10 mg Tab Oral 1 Tablet(s) Once Daily
- Symbicort -- Unknown Strength 2 HFA Aerosol Inhaler(s) Twice
Daily
- ProAir HFA 90 mcg/Actuation Aerosol Inhaler Inhalation
2 HFA Aerosol Inhaler(s), as needed
- Nasonex ___ mcg/Actuation Spray Nasal 1 Spray, Non-Aerosol(s),
at bedtime
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Take your first dose tomorrow, ___ and your
second dose ___.
Disp:*2 Tablet(s)* Refills:*0*
2. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily): Take in the morning.
3. ursodiol 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. insulin glargine 100 unit/mL Solution Sig: ___ (22)
units Subcutaneous once a day.
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q8H
(every 8 hours) as needed for constipation.
8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation as needed as needed for shortness of breath or
wheezing.
13. Nasonex ___ mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal at bedtime.
14. Caltrate 600 + D 600 mg(1,500mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
15. insulin lispro 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: As per home sliding scale. Check
finger stick with meals and at bedtime.
16. ibuprofen 200 mg Tablet Sig: ___ Tablets PO three times a
day as needed for pain for 3 days.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: multilobar pneumonia
Secondary Diagnosis:
DIABETES MELLITUS
OSTEOARTHRITIS
OSTEOPOROSIS
PRIMARY BILIARY CIRRHOSIS
ASTHMA
HYPOTHYOIDISM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you in the hospital. You were
admitted for a pneumonia and are improving with antibiotic
treatment. You will need to continue taking Levofloxacin for
several days to ensure your infection if completely treated.
Please CONTINUE Levofloxacin 750mg by mouth for 2 more days
(starting tomorrow morning, ___.
You may take ibuprofen 200-400mg three times a day over the next
3 days as needed for headache. Do not continue this medication
long term.
Please continue to take all your home medications as prescribed.
No other changes have been made.
Followup Instructions:
___
|
10326564-DS-17 | 10,326,564 | 22,832,697 | DS | 17 | 2175-10-18 00:00:00 | 2175-10-18 14:00:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet / Epinephrine / Iodine / Optiray 350 / Aspirin / Egg /
Shellfish Derived / Lactose / Flu
Attending: ___
___ Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Right periprosthetic distal femur retrograde intramedullary nail
History of Present Illness:
The patient is a ___ y/o ___ speaking female with complex
medical history (see PMHx). She is s/p R Total Knee Repalcement
by Dr. ___ on ___, discharged to rehab on ___. On
___ she was working with ___ at rehab when the physical
therapist reportedly became frustrated and used physical force
to remove the rolling walker from the patient. The patient
screamed out in pain when she felt her right leg give way. She
was taken to ___ ED where x-rays demonstrated Right distal
femur periprosthetic fracture. Orthopedics was consulted and she
ultimately underwent surgical fixation of above fracture with
intramedullary nail.
Past Medical History:
DM2 on insulin, chronic liver dz c/b portal HTN, primary biliary
sclerosis, limited scleroderma (c/b ILD, asthma, mild pulm HTN,
multiple episdoes of PNA), OSA (not on CPAP), hypothyroid, GERD,
ulcers/gastritis, migraines (on topiramate), glaucoma, herniated
lumbar disc
Social History:
___
Family History:
Positive for hypertension, heart disease, diabetes, breast and
cervical cancer. No other malignancies or stroke.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Gen: Alert and oriented
Cardio: RRR
Resp: breathing unlabored
MSK:
RLE: Two knee and single thigh incision all visualized during
dressing change. Each incision c/d/i with staples in place. Mild
erythema and edema around knee, but no excessive warmth or
drainage. Foot and toes warm and well perfused, SILT in
superficial peroneal, deep peroneal, tibial, saphenous, and
sural distributions. Fires ___, AT, Gastroc.
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 periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for retrograde intramedullary nail,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#2. The
patient was given perioperative 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 was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is partial weight bearing in the
right lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
2. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg/0.4mL SC QPM Disp #*14 Syringe
Refills:*0
3. Glargine 17 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
8. Calcium Carbonate 500 mg PO TID
9. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
11. Glucose Gel 15 g PO PRN hypoglycemia protocol
Treatment guidelines for patients who are responsive and able to
swallow oral carbohydrates.
12. Milk of Magnesia 30 ml PO BID:PRN Constipation
13. Multivitamins 1 CAP PO DAILY
14. Vitamin D 400 UNIT PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, shortness of
breath
16. Cetirizine 10 mg oral daily
17. Fluticasone Propionate NASAL 2 SPRY NU BID
18. Lactulose 15 mL PO TID
19. Levothyroxine Sodium 50 mcg PO DAILY
20. Pantoprazole 40 mg PO Q24H
21. Topiramate (Topamax) 50 mg PO QHS
22. Ursodiol 600 mg PO QAM
23. Ursodiol 300 mg PO QPM
24. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right distal femur periprosthetic fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Activity as tolerated
- Pneumatic boots in bed
- Right lower extremity: Partial weight bearing
- Encourage turn, cough and deep breathe Q2h when awake
Physical Therapy:
- Activity as tolerated
- Pneumatic boots in bed
- Right lower extremity: Partial weight bearing
- Encourage turn, cough and deep breathe Q2h when awake
Treatments Frequency:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: Please change dressing daily or as needed to keep clean
and dry. OK to leave incisions open to air once non-draining.
Site: R knee
Description: staples with slight errythema @ incision site,
+edema.
Care: keep wound clean and dry, continue to monitor surgical
site for signs and symptoms of infection.
Site: R thigh
Description: staples c/d/i
Care: keep wound clean and dry, continue to monitor surgical
site for signs and symptoms of infection.
Followup Instructions:
___
|
10326617-DS-14 | 10,326,617 | 20,512,233 | DS | 14 | 2129-06-07 00:00:00 | 2129-06-08 00:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subdural Hematoma and traumatic Subarachnoid Hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male with no significant PMH was transferred to the
ED at ___ s/p fall while intoxicated which resulted in him
striking his head. He was consuming alcoholic beverages with his
friends and kicked an object while walking down the sidewalk.
This resulted in him falling backwards, striking his head on the
pavement. His friends noted blood dripping from the back of his
head and brought him to ___ where he underwent a
head CT which showed a right parietal SDH and traumatic SAH. He
was transferred to ___ for further evaluation. A repeat head
CT
was table. He was loaded with Dilantin and admitted to
neurosurgery for observation. He denies any LOC, blurred vision,
diplopia, or weakness of the extremities. He admits to
difficulty
recalling the events surrounding around his fall which he
attributes to alcohol consumption.
Past Medical History:
h/o Lyme disease ___ years ago
Social History:
___
Family History:
NC
Physical Exam:
T: 98.4 BP: 115/36 HR: 112 R: 16 O2Sats 96% RA
Gen: Lying in hospital bed; wearing hard cervical collar.
HEENT: Pupils: 3-2mm bilaterally. EOMs intact with 2-beats of
physiologic nystagmus.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3-2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally with
2-beats of physiologic nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Handedness: Right
On Discharge:
Intact
Pertinent Results:
___ CT head:
1. Compared to the previous outside study obtained 3 hours, 30
minutes prior, there is unchanged extent of right parietal
subdural hematoma, along with underlying intraparenchymal
contusions and subarachnoid hemorrhage along the adjacent sulci.
No new areas of hemorrhage are identified.
2. Persistent 3 mm leftward shift of normally midline
structures, with no evidence of ventricular entrapment or
hydrocephalus.
3. there is a non displaced fracture of the right parietal bone
best seen on coronal images
___ CT head: Unchanged subarachnoid, subdural hemorrhages and
intraparenchymal contusions compared to the study from
approximately 30 hr prior. Persistent minimal shift of the
midline.
Brief Hospital Course:
Mr. ___ was admitted to the neurosurgery service with a
right SDH. He was monitered with frequent neurochecks and SBP
control < 140. He was loaded with Dilantin in the ER and
maintained on 100mg BID. His cervical collar was cleared
clinically with a negative CT C-spine and his collar was
removed.
Repeat Head CT on ___ was stable and the patient remained
neurologically intact. His diet was advanced and he began to
mobilize.
At the time of discharge on ___ he was tolerating a regular
diet, ambulating without difficulty, afebrile with stable vital
signs.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain; fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours Disp
#*60 Tablet Refills:*0
5. Phenytoin Sodium Extended 100 mg PO Q8H
RX *phenytoin sodium extended [Dilantin Extended] 100 mg 1
capsule(s) by mouth three times a day Disp #*90 Capsule
Refills:*1
6. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Right Parietal SDH
Right Parietal Contusions
Right parietal bone fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending, no biking or contact sports.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
10327156-DS-3 | 10,327,156 | 27,724,572 | DS | 3 | 2141-05-18 00:00:00 | 2141-05-19 11:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
DYSPNEA
Major Surgical or Invasive Procedure:
Ultrasound guided Pericardiocentesis ___
After local anesthesia, using ultrasound and angiographic
guidance the pericardial space was entered via the subxiphoid
approach. A pericardial drain was advanced with removal of 270
cc of serosanguinous fluid that was then sent to the laboratory
for analysis. Post-drain echocardiogram images demonstrated near
resolution of the pericardial fluid and no evidence of RV
compromise. The pericardial drain was sutured in place to
gravity drainage. The patient left the cath lab in stable
condition.
History of Present Illness:
___ h/o non-Hodgkins lymphoma s/p mediastinal radiation in ___
and aortic stenosis presents with progressive DOE x3 weeks.
On the day of admission, the patient was preparing for a routine
screening outpatient colonoscopy. Upon review by the
anesthesiologist, the patient endorsed DOE and was found to have
peripheral edema. Although the patient was being worked up by
his PCP, due to concern for CHF, the procedure was canceled and
the patient was told be evaluated in the emergency department.
Per the patient, over the last 3 weeks, he has noted progressive
dyspnea on exertion. This began with decrease exercise
tolerance, however, over the last 2 weeks, he has become short
of breath with walking only two blocks. Patient denies any chest
pain, orthopnea, PND. No n/v/d, abdominal pain or fevers/chills.
No presyncope/syncope.
The patient has brought this complaint to his PCP who ordered ___
CTA chest after seeing an elevated D-dimer in the work up for
his dyspnea which did not show any thrombus.
In the ED, initial vitals were:
99.4 87 142/87 18 100% RA
Patient was given:
IVF 1000 mL NS 1000 mL
On the floor, the patient was hemodynamically stable and in no
acute distress breathing comfortably on room air.
Past Medical History:
ADENOMATOUS COLONIC POLYP
AORTIC STENOSIS, MILD
CHEST PAIN
HYPERCHOLESTEROLEMIA
IRON DEFICIENCY ANEMIA
PROSTATE CANCER
H/O LYMPHOMA s/p mediastinal radiation ___
Social History:
___
Family History:
Father: died of multiple myeloma age ___, hx CAD.
Uncles: MI
Mother: HTN
No FHx of colon ca
Physical Exam:
ADMISSION PHYSICAL
Vital Signs: 97.5 141/72 83 18 94ra
GEN: NAD
HEENT: sclerae anicteric
___: RRR, III/VI SEM, best heard at RUSB. No elevated JVP
LUNGS: No increased WOB, CTAB, mild bibasilar crackles
ABD: NTND
EXT: warm, 2+ DP pulses. Trace edema ankles b/l
NEURO: CN II-XII grossly intact
DISCHARGE PHYSICAL
VS: 97.2 98/56 76 18 97ra
Wt: 106.4kg->104.6kg->103.9
I/O 8hr ___
24hr 1620/1750
GEN: NAD
NECK: JVP not elevated
CV: RRR III/VI SEM
LUNGS: mild bilateral basilar crackles, no increased WOB
ABD: moderately distended, soft, nontender
EXT: warm, trace edema at ankle
Pertinent Results:
ADMISSION LABS
___ 09:30AM BLOOD WBC-7.4 RBC-4.02* Hgb-11.0* Hct-35.2*
MCV-88 MCH-27.4 MCHC-31.3* RDW-14.6 RDWSD-46.8* Plt ___
___ 09:30AM BLOOD Neuts-66.1 ___ Monos-11.1 Eos-2.4
Baso-0.5 Im ___ AbsNeut-4.87 AbsLymp-1.43 AbsMono-0.82*
AbsEos-0.18 AbsBaso-0.04
___ 10:13AM BLOOD Glucose-101* UreaN-17 Creat-1.0 Na-136
K-5.2* Cl-102 HCO3-23 AnGap-16
___ 09:30AM BLOOD ALT-60* AST-24 AlkPhos-93 TotBili-0.5
___ 09:30AM BLOOD proBNP-527*
___ 10:13AM BLOOD cTropnT-<0.01
___ 06:02AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2
PERTINENT LABS
___ 09:30AM BLOOD proBNP-527*
___ 10:13AM BLOOD proBNP-450*
___ 10:13AM BLOOD cTropnT-<0.01
___ 09:30AM BLOOD TSH-13*
___ 09:30AM BLOOD Free T4-1.1
___ 09:30AM BLOOD CRP-10.8* antiTPO-LESS THAN
___ 08:47AM BLOOD ALT-73* AST-45* AlkPhos-82 TotBili-0.4
___ 09:06AM BLOOD ALT-78* AST-65* AlkPhos-80 TotBili-0.4
___ 06:28AM BLOOD ALT-44* AST-26 LD(LDH)-176 AlkPhos-77
TotBili-0.3
___ 06:02AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ Pericardial Fluid Cytology
DIAGNOSIS:
Pericardial fluid:
NEGATIVE FOR MALIGNANT CELLS.
Predominantly blood.
DISCHARGE LABS
___ 10:20AM BLOOD WBC-7.6 RBC-4.01* Hgb-10.5* Hct-34.2*
MCV-85 MCH-26.2 MCHC-30.7* RDW-14.2 RDWSD-43.4 Plt ___
___ 08:47AM BLOOD Glucose-153* UreaN-18 Creat-1.1 Na-140
K-3.8 Cl-102 HCO3-27 AnGap-15
___ 08:47AM BLOOD ALT-73* AST-45* AlkPhos-82 TotBili-0.4
IMAGING
___ RUQ U/S
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is
no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: Imaged portion of the pancreas appears within normal
limits, without masses or pancreatic ductal dilation, with
portions obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 11.7 cm.
KIDNEYS: The right kidney measures 12.7 cm. The left kidney
measures 13.7 cm. Normal cortical echogenicity and
corticomedullary differentiation is seen bilaterally. There is
no evidence of suspicious masses, stones, or
hydronephrosis in the kidneys. In the left upper pole, there is
a 1.3 x 1.3 x 1.7 cm ovoid, anechoic structure without internal
flow, most likely a cyst.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
No ascites or evidence of cirrhosis.
___ TTE
Conclusions
Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is no pericardial effusion. The echo findings
are suggestive of pericardial constriction.
IMPRESSION: No recurrent pericardial effusion. Likely
pericardial constrictive physiology following effusion drainage
('effusive-constrictive' physiology)
Compared with the prior study (images reviewed) of ___,
the findings are similar.
___ Pericardiocentesis
Interventional Details
After local anesthesia, using ultrasound and angiographic
guidance the pericardial space was entered via the subxiphoid
approach. A pericardial drain was advanced with removal of 270
cc of serosanguinous fluid that was then sent to the laboratory
for analysis. Post-drain echocardiogram images demonstrated near
resolution of the pericardial fluid and no evidence of RV
compromise. The pericardial drain was sutured in place to
gravity drainage.The patient left the cath lab in stable
condition
___ TTE
Overall left ventricular systolic function is normal (LVEF>55%).
There is a very small pericardial effusion measuring up to 0.4
centimeters at the apex. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Very small pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
the size of the pericardial effusion is smaller consistent with
the interval pericardiocentesis. Echocardiographic evidence of
pericardial tamponade is no longer seen.
___ CXR
FINDINGS:
There is biapical and upper paramediastinal scarring compatible
with prior
radiation. There are small bilateral pleural effusions, similar
to prior. There is no superimposed consolidation or edema.
Cardiac silhouette is top-normal, similar to prior. No acute
osseous abnormalities.
IMPRESSION:
Persistent small effusions and biapical scarring, similar
compared to prior. Cardiac silhouette is stable, noting that
pericardial effusion had been present on prior exam.
MICROBIOLOGY
__________________________________________________________
___ 12:55 pm BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:45 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 2:00 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERICARDICAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I).
(formerly Peptostreptococcus species) Isolated from
only one set
in the previous five days. NO FURTHER WORKUP WILL BE
PERFORMED.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ 830PM ON
___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
__________________________________________________________
___ 2:00 pm FLUID,OTHER PERICARDICAL FLUID.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
ANAEROBIC CULTURE (Preliminary):
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
Brief Hospital Course:
___ yo man with history of NHL s/p mediastinal radiation ___,
prostate cancer s/p brachytherapy (___), who presents with DOE,
found to have pericardial effusion with tamponade, now s/p
pericardial drain.
#Constrictive cardiomyopathy secondary to pericardial effusion:
Patient presented with 3 weeks of progressive DOE and was
referred for inpatient evaluation during his pre-op screening
for an outpatient colonoscopy. Found to have bibasilar crackles,
pitting edema, elevated JVP to the ear at 90 degrees and pulsus
of 10mmHg on exam. TTE showed tamponade physiology and patient
was transferred to CCU for pericardialcentisis which drained
~280cc serosanguinous fluid with subjective improvement of
symptoms and then transferred back to the floor.
Fluid culture grew Peptostreptococcus in one bottle and started
on vancomycin (___). Patient is afebrile and hemodynamically
stable. After further discussion with ID, it was decided that
this was a contaminant and antibiotics were stopped on ___.
The etiology of the patient's effusion is unclear, however,
previous radiation in ___ for NHL is most likely etiology
causing some kind of constrictive process. Fluid studies
suggestive of effusion by LDH and albumin, although no single
criteria is diagnostic for exudative vs transudative pericardial
fluid. ___ have possible previous viral infection, such as
___ which may have caused effusion. HIV negative, HBV
serology negative. HCV negative in ___.
Regarding malignancy as an underlying etiology includes
leukemia/lymphoma. CBC wnl and cytology negative, though yield
from single study is unclear. CTA was not c/f lung CA and
although has h/o prostate CA, PSA is wnl. Will have outpatient
colonoscopy.
Hypo/hyperthyroidism unlikely given normal fT4, though elevated
TSH. Autoimmune also less likely given negative ___ in ___.
On ___ patient has elevated pulsus paradoxicus of ___
with bilateral crackles and pitting edema. Hemodynamically
stable and asymptomatic. Repeat TTE showed no effusion but
constrictive physiology which is concerning for pericardial
disease, likely related to previous radiation.
At discharge, patient was asymptomatic and hemodynamically
stable with good UOP after starting diuresis with furosemide
20mg IV on ___. Patient was switched to PO Lasix on ___ and
continued to have good UOP. Patient has had systolic BPs in the
mid ___, asymptomatic so his lisinopril was discontinued. In
addition, patient's simvastatin was changed to atorvastatin
which was initially started at 40mg, but then decreased to 20mg
given elevated LFTs (see bellow). Patient will see outpatient
cardiology and follow up with cardiac MRI.
#Transaminitis: Given patient's distended abdomen and signs of
right heart failure a RUQ u/s was obtained along with LFTs, all
of which were normal. However, after patient was switched from
simvastatin to atorvastatin 40mg, there was an elevation in
ALT/AST to 78/65 (baseline 44/26) and atorvastatin was decreased
to 20mg with plans to recheck LFTs as an outpatient.
#Renal Cyst: On abdominal ultrasound a mass, most likely a cyst
was found in the left kidney; described as "In the left upper
pole, there is a 1.3 x 1.3 x 1.7 cm ovoid, anechoic structure
without internal flow, most likely a cyst". Patient will follow
up as an outpatient.
#H/o adenomatous colon polyps: patient was planned for
surveillance routine colonoscopy prior to admission but was
cancelled given DOE. Will follow up as an outpatient.
TRANSITIONAL ISSUES:
VS: 97.2 98/56 76 18 97ra
Wt: 106.4kg->104.6kg->103.9
I/O 8hr ___
24hr 1620/1750
[ ] Please follow up patient's weight (discharge weight 103.9kg)
[ ] Please assess volume status and need for continuing diuresis
and need for uptitration or downtitration of current regimen
[ ] Please ensure patient gets cardiac MRI with gadolinium as
outpatient to further characterize visceral/parietal
pericardium; this was ordered in ___ prior to discharge, PCP
emailed regarding prior authorization
[ ] Please recheck BP and consider restarting lisinopril
[ ] Please recheck LFTs and consider transaminitis workup if
they have not improved on lower dose of statin or with diuresis
[ ] Please recheck Chem 7
[ ] RUQ U/S showed in the left upper pole of the left kidney a
1.3 x 1.3 x
1.7 cm ovoid, anechoic structure without internal flow, most
likely a cyst. Please follow up if further imaging is required.
# CODE: Full
# CONTACT: ___ (Wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Simvastatin 80 mg PO QPM
3. Aspirin 81 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
4. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
5. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride 20 mEq 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Pericardial Effusion
Constrictive Cardiomyopathy
SECONDARY DIAGNOSIS
Non-___ Lymphoma status post mediastinal radiation in ___
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your
hospitalization. You came to the hospital because you were
having shortness of breath. We did an ultrasound of your heart
that showed significant fluid which was drained. We did a repeat
ultrasound after the drainage that also showed the sack around
your heart (your pericardium) was thickened and therefore
effecting how well your heart can beat. We gave you a medication
called Lasix to help remove the extra fluid and your started to
feel better. We will have you follow up with a cardiologist and
get an MRI of your heart.
We are going to continue you on your Lasix at home. Please weigh
yourself everyday.
If your weight goes DOWN more than 6 pounds, DO NOT take your
Lasix and call your PCP ___ at ___ to let him
know.
If your weight goes UP more than 3 pounds,call your PCP ___.
___ at ___ to let him know.
Your discharge medications and follow up appointments are
detailed below.
We wish you the best!
Your ___ Care team
Followup Instructions:
___
|
10327635-DS-13 | 10,327,635 | 26,814,057 | DS | 13 | 2184-04-22 00:00:00 | 2184-04-23 17:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is an ___ year old man with h/o HTN, EtOH use,
dementia who was transferred from an OSH with bradycardia,
syncope and new brain and lung masses. History gathered from
records, patient, and daughter ___.
The patient syncopized 3x at home over the last few days, last
episode on day of presentation. The last episode was witnessed
by his son. He was sitting at the table and went to stand up and
his muscles locked as if he was having a seizure. His son put
him in the chair and he fell out of the chair, landing on his
face and striking his head, + LOC. He was nonresponsive with
eyes open to his son and he called EMS. No tongue bite or
incontinence. The patient denies falling today and told his
daughter afterwards that he was sleeping and was awoken by the
doorbell where his son and EMS were waiting to take him to the
hospital. He was found to have a HR of ___, SBP in ___ in the
field. FSG wnl. He was given atropine and glucagon and went to
___, where HR remained in the 40-50s, SBP ranged 75-144
and was given another dose of atropine and an amp of calcium
gluconate. CT head showed a new 2cm cystic mass in the right
parietal lobe, and CXR showed a new lung mass in the LUL. Labs
notable for Troponin neg x1, CK-MB flat, lactate 2.1. The
patient was transferred to the ___ ED for further management.
At admission, he had no complaints. He endorsed a 17lb
unintentional weight loss recently and his daughter is unsure if
he has had any workup for this. Denies cough or hemoptysis.
Denies recent focal neuro deficits. Per daughter, no known h/o
CKD or anemia.
Past Medical History:
HTN
HLD
EtOH use
Dementia
Hernia repair
Social History:
___
Family History:
Mother with DM. No known FH of malignancy.
Physical Exam:
Discharge Exam:
VS - Temp 97.6, BP 140/73, HR 73, R 18, O2-sat 100% RA
Tele: NSR, SB
GENERAL - cachectic, sitting in chair, engageable, cooperative
HEENT - ecchymosis over L temple, sclerae anicteric
NECK - no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement,
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH - no cervical LAD
NEURO -
Attention: A&O to name and date, unable to name ___
___" but does say "___," unable to explain reason for
admission or discuss cancer diagnosis.
No focal neurologic deficits noted.
Pertinent Results:
LABS
Admission:
___ 04:05PM BLOOD WBC-8.3 RBC-4.03* Hgb-12.4* Hct-36.7*
MCV-91 MCH-30.6 MCHC-33.6 RDW-13.4 Plt ___
___ 04:05PM BLOOD Neuts-80.3* Lymphs-11.5* Monos-5.9
Eos-2.0 Baso-0.3
___ 04:05PM BLOOD Plt ___
___ 04:05PM BLOOD ___ PTT-32.1 ___
___ 04:05PM BLOOD Glucose-65* UreaN-35* Creat-1.7* Na-141
K-4.2 Cl-105 HCO3-26 AnGap-14
___ 04:05PM BLOOD ALT-10 AST-21 AlkPhos-74 TotBili-0.3
___ 04:05PM BLOOD Lipase-56
___ 04:05PM BLOOD cTropnT-<0.01
___ 04:05PM BLOOD Albumin-3.7
___ 04:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:25PM BLOOD ___ pO2-42* pCO2-54* pH-7.34*
calTCO2-30 Base XS-1 Comment-GREEN TOP
___ 04:25PM BLOOD Lactate-1.2
Other important labs:
___ 07:35AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9 Iron-56
___ 07:35AM BLOOD calTIBC-233* VitB12-336 Folate-13.1
Ferritn-202 TRF-179*
___ 07:35AM BLOOD cTropnT-<0.01
Discharge:
___ 05:50AM BLOOD WBC-6.5 RBC-4.16* Hgb-12.8* Hct-38.4*
MCV-92 MCH-30.8 MCHC-33.5 RDW-13.7 Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD Glucose-75 UreaN-20 Creat-0.9 Na-141
K-3.9 Cl-106 HCO3-25 AnGap-14
IMAGING:
CT Chest (___):
1. Left hilar mass occluding left upper bronchus resulting
lobar collapse, nearly occluding left upper lobe pulmonary
artery, and invading left atrium via the left superior
pulmonary vein. Ipsilateral mediastinal lymphadenopathy and
metastases to both adrenal glands.
2. Calcified asbestos-related pleural plaques.
3. Moderate-sized hiatal hernia, with distal esophageal wall
thickening.
Brain MRI (___): pending, preliminary read is that right
frontal lesion is consistent with metastasis
EKG (___):
Sinus rhythm. Occasional ventricular premature contraction.
Compared to
tracing #1, ventricular premature contraction is new. Otherwise,
no other
significant diagnostic change.
Brief Hospital Course:
___ with HTN, dementia, EtOH use and recent weight loss who
presented with syncope in setting of bradycardia and
hypotension, and found to have lung mass with likely metastatic
disease to bilateral adrenals and brain, who is now being
transferred to ___ for further care.
Active issues:
#Syncope/Bradycardia/Hypotension: Patient presented after
syncopal episode associated with bradycardia and hypotension.
EKG revealed sinus bradycardia, nodal agents held on admission.
. No significant events on telemetry during hospitalization.
Etiology of syncopal episode remains unclear. Patient was
orthostatic during hospitalization. Possible metastatic brain
involvement and invasion of left atrium by newly found lung mass
(likely new diagnosis lung ca, see below) suggests that syncope
has possible cardiogenic or neurologic component. (See imaging
reports.) EEG unable to be obtained secondary to agitation;
though description of syncopal episode was not entirely
consistent with seizure. No repeat events during
hospitalization. Cardiac/anti-hypertensive medications continued
to be held at time of transfer. Please consider restarting
amlodipine, quinapril, and atenolol if patient is persistently
hypertensive.
#Lung/brain mass: Likely new metastatic lung cancer with mets to
brain and adrenals.
Patient was found to have chest and brain lesions on OSH
imaging. On chest CT performed at ___, a large left lung mass
was noted that showed extension into the left atrium and
metastasis to the bilateral adrenal glands. Brain MRI was
pending at ___, but preliminary read suggests that the
right frontal lesion may represent metastasis. Family meeting
was held and case discussed at length with patient's PCP, Dr
___. Patient's family was undecided as to whether to pursue
biopsy / diagnosis with potential for palliative treatment vs
transition to comfort focused care. At request of patient's
HCP, Mr ___ was transferred to his PCP's service at ___
for ongoing goals of care discussion and further evaluation if
desired.
#Delirium: Patient has history of delirium during
hospitalizations. Patient had intermittent delirium that
responded well to redirection, maintaining a comfortable/stable
environment, and having family accompaniment. Patient required
restraints for short period within first 24h of admission. He
was administered haldol 1 mg and olanzapine 2.5 mg
intermittently with good effect, but did not require any
restraints/medications for agitation on day of transfer.
___: Patient had elevated admission Cr that downtrended during
hospitalization with initial fluid treatment and increased po
intake. Considered to be of pre-renal etiology. Discharge Cr =
0.9.
Chronic issues:
#Anemia: Patient found to be mildly anemic at admission (37).
Anemia studies were unremarkable aside from mildly low TIBC and
transferrin, possibly suggestive of anemia of chronic
inflammation. Hct remained stable during stay and was 38.4 at
discharge.
#HTN: Patient was hypotensive at OSH and at presentation to
___. Cardiac medications (amlodipine, atenolol, quinapril)
were held, with uptrending BP. At discharge BP was 140/73 off
medication. Cardiac medications continued to be held at time of
transfer secondary to recent hypotensive and bradycardic
episode. Please consider restarting amlodipine, quinapril, and
atenolol if patient is persistently hypertensive.
Transitional issues:
#Pending blood culture
#Pending official Brain MRI read. Preliminary read is that the
right frontal lesion is consistent with metastasis.
#Family meeting held on ___ (Daughters ___ and ___
___, and son ___ present). Results of chest CT
discussed. ___ discussed with PCP (Dr. ___. Decision
was made to transition to palliative care and transfer patient
back to ___.
#Code status still officially FULL CODE, pending further
discussion with family and Dr. ___.
#HCP: ___, daughter, ___
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Atenolol 100 mg PO DAILY
2. Quinapril 20 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Simvastatin 10 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Donepezil 5 mg PO DAILY
8. moxifloxacin *NF* 0.5 % OS QID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Simvastatin 10 mg PO DAILY hyperlipidemia
3. Donepezil 5 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. moxifloxacin *NF* 0.5 % OS QID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lung mass
Brain mass
Syncope
Discharge Condition:
Confused - always.
Alert and interactive.
Out of bed with assistance to chair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after fainting at home. As
part of the evaluation for your fainting, we discovered a mass
in your chest and brain. These masses are concerning for cancer.
After discussing your imaging results with you and your family,
we decided to transfer your care to ___. You will be
following up with your PCP, ___ you arrive at ___.
___.
It was a pleasure taking care of you at ___
___.
Followup Instructions:
___
|
10327730-DS-15 | 10,327,730 | 28,499,956 | DS | 15 | 2167-11-11 00:00:00 | 2167-11-11 16:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
egg
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ woman with a pmhx. significant for
dementia (?Alzheimer's Disease), HTN, and type II DM who is
admitted from assisted living facility after fall.
According to nurse at ___ assisted living facility
(patient is unable to give accurate history), Ms. ___ was in
her usual state of health until day prior to admission when she
fell down. Although actual fall was unwittnessed, aides rushed
immediately to ___ side and there was little concern for
loss of consciousness. Patient had bruising to her nasal bridge
and on her chin. Of note, patient was being treated for a UTI
and missed her dose of Bactrim yesterday and this morning.
Upon arrival in emergency department, initial vitals were: 98.8
64 125/63 16 96%. A CT head and C-spine were negative on prelim
leads.
ROS: Unable to obtain due to acute delirium, though patient
does deny pain.
Past Medical History:
--Alzheimer's Disease
--Breast Cancer
--HTN
--DM II
Social History:
___
Family History:
Unable to answer in current state of mind.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.0, 158/70, 82, 18
GENERAL: Elderly lady, very agitated, cut on bridge of nose and
ecchymosis on chin
CHEST: Does not cooperate to give inspiratory effort
CARDIAC: RRR, no MRG
ABDOMEN: +BS, soft, patient gets upset when I try to palpate
abdomen
EXTREMITIES: Abrasion on left shin, no edema bilaterally
NEURO: A&O x1, moving all 4 extremities
Pertinent Results:
___ 12:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 08:20PM GLUCOSE-111* UREA N-15 CREAT-1.0 SODIUM-138
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-28 ANION GAP-16
___ 08:20PM estGFR-Using this
___ 08:20PM WBC-8.2 RBC-3.70* HGB-11.8* HCT-34.8* MCV-94
MCH-31.8 MCHC-33.8 RDW-13.9
___ 08:20PM NEUTS-67.0 ___ MONOS-6.3 EOS-2.0
BASOS-0.5
___ 08:20PM PLT COUNT-217
CT SPINE ___:
There is no acute fracture or malalignment. Straightening of
the
normal cervical lordosis is likely positional. An osseous
fragment at the
inferior clivus may be a spur or enthesophyte. There is
multilevel
degenerative change with facet hypertrophy and uncovertebral
osteophytes. Posterior disc osteophyte complex at C5-C6 does
not significantly narrow the spinal canal. There is
mineralization and thickening of the transverse ligament at
C1-C2. Prevertebral soft tissue thickness is maintained.
IMPRESSION: No acute fracture or malalignment.
CT HEAD ___:
The study is limited by motion artifact. There is no acute
intracranial hemorrhage, edema, mass effect or major vascular
territorial
infarct. Prominent ventricles and sulci are compatible with
global
age-related volume loss. Basal cisterns are patent. There is no
shift of
normally midline structures. Gray-white matter differentiation
is preserved.
Atherosclerotic calcifications are seen in the intracranial
carotid arteries
and vertebral arteries. Hypoattenuation in the subcortical and
periventricular
white matter is likely sequelae of chronic microvascular
ischemic disease. Evaluation for calvarial fracture is limited
by motion, but no displaced
fracture is identified. No obvious nasal bone fracture is seen.
There is mild mucosal thickening in the ethmoid air cells. The
remainder of the visualized paranasal sinuses, mastoid air cells
and middle ear cavities are clear.
IMPRESSION: Motion artifact limits study, but no evidence of
acute
intracranial injury. No obvious nasal bone fracture.
Brief Hospital Course:
This is a ___ woman with history of dementia, HTN, and
DMII, with recent UTI, now with fall and acute delirium.
#MECHANICAL FALL: Patient with unwitnessed fall at assisted
living facility. C-spine imaging without fracture. Head CT
unremarkable. She has a small abrasion on bridge of nose but
did not endorse pain so the fall was for the most part
non-injurious. Patient is at risk of falls given severe
dementia. The recent urinary tract infection may have
contributed to gait imbalance and delirium increasing risk of
falls. Physical therapy evaluated the patient and recommended
discharge back to ___ with 24 hour care. For gait training would
ambulate multiple times per day with hand held assist.
.
#DELIRIUM: The patient was very agitated on admission to the
medicine service. There was no evidence of urinary tract
infection on urinalysis and culture negative at time of
discharge. The etiology was likely due to not getting her
scheduled medications and being in an unfamiliar environment.
She was given haldol on the day of admission with good effect.
The following day, she was less agitated and more re-directable.
She showed some improvement in functional mobility when working
with physical therapy but does appear to be functioning below
her baseline. If the patient has agitation despite being back in
home environment would recommend low dose oral haldol BID PRN as
needed for agitation.
.
# DM II: Metformin and glyburide were held during admission
and restarted at time of discharge.
.
# HYPERTENSION: The HCTZ was held during the hospitalization
as she appeared initially dry on exam and blood pressure was
130-140 systolic during admission.
# COMMUNICATION: Healthcare ___son) ___,
___ and ___, ___
# CODE STATUS: Full code now according to ___, but needs to
talk more with ___ who is the other HCP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 6.25 mg PO DAILY
2. GlyBURIDE 1.25 mg PO BID
3. ___ *NF* (cranberry extract) 500 mg Oral BID
4. Gabapentin 100 mg PO BID
5. Memantine 10 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO QAM
7. MetFORMIN (Glucophage) 500 mg PO QPM
8. Gabapentin 100 mg PO DAILY
Discharge Medications:
1. Gabapentin 100 mg PO BID
2. Memantine 10 mg PO BID
3. ___ 500 mg *NF* (cranberry fruit concentrate) 500 mg
Oral BID Reason for Ordering: Wish to maintain preadmission
medication while hospitalized, as there is no acceptable
substitute drug product available on formulary.
4. ___ *NF* (cranberry extract) 500 mg Oral BID
5. MetFORMIN (Glucophage) 500 mg PO QPM
6. GlyBURIDE 1.25 mg PO BID
7. MetFORMIN (Glucophage) 1000 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical fall
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to participate in your care. You were admitted
after a fall at rehab. You had imaging of your neck and head
that did not show any acute injury. You were seen by physical
therapy and will need assistance walking. Your home medications
were continued.
Followup Instructions:
___
|
10327910-DS-6 | 10,327,910 | 23,682,387 | DS | 6 | 2143-04-18 00:00:00 | 2143-04-18 16:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Ultrasound guided fluid aspiration
History of Present Illness:
___ s/p bilateral oophorectomy for leiomyoma with
___ focal periumbilical pain without fevers or chills.
Gradual onset. Dull with intermittent sharp spasms. Subjective
fever. No nausea, vomiting, abdominal distension, change in
bowel
habits, hematuria or dysuria. Last BM/flatus day of
presentation.
Hx notable for breast CA s/p bilateral partial nephrectomy,
chemotherapy. Denies family or personal history of IBD, CRC,
diverticulitis. Denies recent unintentional weight loss,
malaise,
fatigue.
In ED, AFVSS, abdomen soft, no peritoneal signs. Focal
infraumbilical tenderness without appreciable fluctuance. WBC
10.7. CT abd/pelvis with 3.5cm subfascial fluid collection
consistent with intraabdominal abscess.
(+) infraumbilical pain as per HPI
(-) headache, vision changes, otorrhea, rhinorrhea, sore throat,
SOB, cough, chest pain, dyspnea on exertion, palpitations,
nausea, vomiting, abdominal distention, diarrhea, melena,
hematochezia, dysuria, hematuria, bony pain, muscle aches, easy
bruising, heat/cold intolerance, mood changes
Past Medical History:
Unsigned notes are not to be used for clinical decision making.
They are not final.
Note Date: ___
Signed by ___, MD on ___ at 3:56 am Affiliation:
___
NEEDS COSIGN
Acute Care Surgery | ED Consultation
Date/Time of Consult: ___ 2300
Consult Requested by: ___ [___]
Attending: Dr. ___: ___, PGY-2
Reason for Consult/CC: ___
HPI: ___ s/p bilateral oophorectomy for leiomyoma with
___ focal periumbilical pain without fevers or chills.
Gradual onset. Dull with intermittent sharp spasms. Subjective
fever. No nausea, vomiting, abdominal distension, change in
bowel
habits, hematuria or dysuria. Last BM/flatus day of
presentation.
Hx notable for breast CA s/p bilateral partial nephrectomy,
chemotherapy. Denies family or personal history of IBD, CRC,
diverticulitis. Denies recent unintentional weight loss,
malaise,
fatigue.
In ED, AFVSS, abdomen soft, no peritoneal signs. Focal
infraumbilical tenderness without appreciable fluctuance. WBC
10.7. CT abd/pelvis with 3.5cm subfascial fluid collection
consistent with intraabdominal abscess.
PMH: HTN, DM, hypothyroid, Gastritis (H.pylori), LBP,
Costochondritis, Xerostomia, Hypothyroidism, Breast CA s/p
chemotherapy, previously on tamoxifen
PSH: bilateral partial mastectomies (___), laparoscopic
bilateral oophorectomy ___ ___
Social History:
___
Family History:
Mother: ___ CA (___) ___ bilateral mastectomy,
Father:
Physical Exam:
On admission:
VS: T 98.6, HR 80, BP 133/82, RR 18, SaO2 100%rm air
GEN: NAD, A/Ox3
HEENT: MMM, EOMI, no scleral icterus
CV: RRR, no M/R/G
PULM: CTAB
BACK: No CVAT
ABD: soft, obese, well healed infraumbilical laparoscopic port
site, focal infraumbilical tenderness, no rebound or guarding.
EXT: WWP, distal pulses intact
On discharge:
GEN: NAD, A/Ox3
HEENT: MMM, EOMI, no scleral icterus
CV: RRR, no M/R/G
PULM: CTAB
BACK: No CVAT
ABD: soft, obese, clean, dry and intact wound site s/p
ultrasound guided aspiration, much improved pain without rebound
or guarding.
EXT: WWP, distal pulses intact
Pertinent Results:
___ 05:57AM GLUCOSE-98 UREA N-10 CREAT-0.5 SODIUM-139
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
___ 05:57AM CALCIUM-8.7 PHOSPHATE-4.4 MAGNESIUM-2.3
___ 05:57AM WBC-9.1 RBC-3.77* HGB-10.7* HCT-32.0* MCV-85
MCH-28.3 MCHC-33.3 RDW-13.3
___ 05:57AM ___ PTT-30.1 ___
___ 07:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-SM
___ 06:20PM ALBUMIN-4.6
___ 06:20PM LIPASE-23
___ 06:20PM ALT(SGPT)-63* AST(SGOT)-50* ALK PHOS-128* TOT
BILI-0.4
___ 06:20PM GLUCOSE-94 UREA N-14 CREAT-0.6 SODIUM-140
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
___ 06:27PM LACTATE-1.1
___ 06:20PM NEUTS-71.6* ___ MONOS-2.6 EOS-1.5
BASOS-0.6
___ 06:20PM ___ PTT-29.5 ___
URINE CULTURE (Final ___: <10,000 organisms/ml
___ 2:48 pm ABSCESS PERIUMBILICAL ABSCESS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ AND IN PAIRS.
___: CT abd/pel [prelim] - subfascial umbilical 3.5x2.8x2.5cm
intraperitoneal abscess, amenable to percutaneous fluid
collection, right adrenal nodules largest 2.8x3.0cm -
incompletely characterized.
___: IMPRESSION: Technically successful US guided aspiration of
a subumbilical abscess with 6mls of purulent fluid. No immediate
complication. Sample sent for microbiological analysis.
Brief Hospital Course:
Patient's pain was well controlled with analgesia, and serial
examinations were not worsening. Patient had uneventful night
the day of her presentation, was made n.p.o. for her procedure.
On the ___ the patient underwent successful ultrasound-guided
aspiration of the suspect lesion, notable for purulent drainage.
The full report is available in separate radiology report, but
in short was technically uncomplicated, unsuccessful, and well
tolerated by the patient. After the procedure the patient was
advanced regular diet, ate a regular meal at night, was advanced
to oral pain medications.
Vital signs continued to be stable throughout the evening and
night post procedure. Upon waking the morning of the ___, the
patient felt completely resolved. Patient want to go home, was
tolerating oral pain medications, full diet, ambulatory, vital
signs stable, clinically well-appearing. Her antibiotic regimen
was discontinued due to achieving primary source control.
Advised patient to return if feeling worse in any way, and gave
her wound care instructions.
Patient had good understanding of the procedure, prehospital
course, and indications for return to emergency room. Patient
advised that she followup likely with her gynecologist who
performed the initial procedure, but we advised her that she is
welcome to return to the acute care surgery service for followup
instead. Patient was discharged without incident.
Medications on Admission:
Atenolol 100, Evoxac 30''', Omeprazole 20, Levothyroxine
112, Flexeril 10, Tylenol ___, Pravastatin 40, Felodipine 10
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. Evoxac *NF* (cevimeline) 30 mg Oral TID
* Patient Taking Own Meds *
3. Felodipine 10 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Pravastatin 40 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
RX *Percocet 5 mg-325 mg q6hr Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Sub-fascial fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen here and evaluated for abdominal pain. After a
thorough history, physical, evaluation, and radiological
studies, we believe the source of year pain was from a fluid
collection in your abdomen by your bellybutton.
The radiologists aspirated the fluid out that collection, sent
it for analysis, for which the preliminary results are
reassuring. No pain was much improved after the procedure, you
were tolerating a regular diet, and you wanted to go home.
The pain may return, and if it does he should seek evaluation
for at. Call the obstetrician/gynecologist who performed your
initial operation to discuss her care further with them. We
would recommend a follow up appointment with them. Of course,
if you cannot get an appointment with your doctor, you are
welcome to return here to the Acute Care Surgery clinic for
further evaluation and treatment.
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
|
10328470-DS-19 | 10,328,470 | 27,861,197 | DS | 19 | 2141-07-11 00:00:00 | 2141-07-11 15:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
nausea and abdominal pain
Major Surgical or Invasive Procedure:
none during this hospitalization
History of Present Illness:
Per Colorectal Surgery Admission Note:
___ with extensive UC refractory to medical treatment, now s/p
laparoscopic proctocolectomy with ileostomy formation performed
on ___. She was discharged on ___ and presented to ED on ___
with increasing abdominal discomfort and vomiting. She was
diagnosed with portal vein thrombosis via ___ pelvis and was
started on heparin gtt and subsequently transitioned to
coumadin.
She was then discharged on ___ and she noted that the abdominal
discomfort never resolved. On ___ night, she again had an
episode
of profuse vomiting of bilious fluid with anorexia and inability
to tolerate fluid. She expressed no fever, or chills and the
ileostomy was putting out good output. Abdomen was not becoming
more distended and she was notably anxious.
Past Medical History:
HTN
Hyperlipidemia
IBD- ULCERATIVE COLITIS - First diagnosed in ___ when she
presented with bloody stool
GERD
MIGRAINES
DIVERTICULOSIS
DJD
OSTEOARTHRITIS
.
PSHx
S/p hysterectomy
S/p L benigh breast cyst removal
s/p tooth implant
s/p nasal surgery
Social History:
___
Family History:
Sister had ovarian cancer now in remission. Her mother died from
a
"hole" in her heart. Her father died of ___ at ___.
No FH of colitis. MGM had DM.
Physical Exam:
At time of Discharge:
General: Doing well, ambulating w some evidence of
deconditioning complaining of weakness, tolerating a regular
diet,
VSS
A&OX3
Cardio/Pulm: HR 91 regular, no shortness of breath at rest, no
chest pain
Abd: obese, soft, ileostomy with flatus and liquid stool output,
minimalling tender to palpation
___: no lower extremity edema
Pertinent Results:
___ 12:25AM BLOOD WBC-8.2 RBC-3.41*# Hgb-9.9* Hct-32.0*#
MCV-94 MCH-29.0 MCHC-30.9* RDW-16.6* Plt ___
___ 12:25AM BLOOD Neuts-80.3* Lymphs-8.7* Monos-10.7
Eos-0.2 Baso-0.1
___ 06:50AM BLOOD ___
___ 06:54AM BLOOD ___ PTT-29.2 ___
___ 03:50PM BLOOD ___
___ 09:30AM BLOOD ___
___ 06:31AM BLOOD ___
___ 06:55AM BLOOD ___
___ 06:54AM BLOOD Glucose-96 UreaN-32* Creat-0.5 Na-130*
K-4.5 Cl-96 HCO3-24 AnGap-15
___ 07:16AM BLOOD Glucose-97 UreaN-20 Creat-0.5 Na-131*
K-3.9 Cl-102 HCO3-21* AnGap-12
___ 06:31AM BLOOD Glucose-116* UreaN-19 Creat-0.4 Na-132*
K-3.9 Cl-102 HCO3-22 AnGap-12
___ 06:55AM BLOOD Glucose-79 UreaN-18 Creat-0.5 Na-130*
K-3.8 Cl-99 HCO3-24 AnGap-11
___ 12:25AM BLOOD Glucose-103* UreaN-19 Creat-0.6 Na-132*
K-4.9 Cl-97 HCO3-25 AnGap-15
___ 12:25AM BLOOD ALT-19 AST-22 AlkPhos-97 TotBili-0.3
___ 06:54AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.0
___ 07:16AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.9
___ 12:25AM BLOOD Albumin-3.2* Calcium-9.0 Phos-5.1*#
Mg-2.0
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 12:26 ___
IMPRESSION:
1. Status post colectomy and end ileostomy. Diffusely dilated
small bowel
loops are worse compared to ___. Findings are suspicious
for
obstruction at the level of exit through the abdominal wall.
2. Portal venous thrombosis is improved. The thrombi in anterior
and posterior branches of right portal vein are smaller. The SMV
thrombosis has resolved. Splenic vein is patent.
3. There are small bilateral pleural effusions. Right pleural
effusion is
similar in size compared to prior. Small amount of air in the
right pleural space is likely related to possible prior
instrumentation. Left pleural effusion is increased.
Brief Hospital Course:
___ was readmitted to the inpatient Colorectal Surgery
Service for intractable nausea and decreased ileostomy output.
The patient was nauseated and given promotility medications
including: reglan, erythromycin. Her ileostomy output gradually
improved as did the nausea. She was tolerating a
post-gastrectomy diet consisting of small portions. Her INR was
elevated on admission and coumadin was titrated, when her INR
was 2.9 on ___ and 1mg of Warfarin was given. Self care was
encoraged. Self care of the ostomy was encoraged. She continued
to drain a small amount of peritoneal fluid which was likely
relate to malnutrition. On ___ she was pasing only small
amounts of stool from the ostomy, she was taking clear liquids.
A CT scan was preformed which showed mild ileus with possible
partial obstruciton at the abdominal wall. Her INR was elevated
and coumadin was held. The stoma was digitalized in the evening
and after, began to put out large amounts of gas and liquids
stool. Her nausea improved. The following day she was tolerating
a regular diet and continued to put out liquid stol and flatus
from the ileostomy. She was visited by the ___ team however, she
felt she could not participate related to fatugue. She tolerated
all of her medications by mouth. SHe was given 1mg of coumadin.
On ___, she was improved, she was becoming quite
deconditioned however, took a shower with minimal assistance of
nursing ___. She toelrated a regular breakfast. Her
nutritional status was concerning and calroie counts wer
initiated. Her INR was noted to be 3.5. The rehabilitation
facility should home coumadin ___ and restart when INR below
3 and at a dose of 0.5mg.
Medications on Admission:
Metoprolol Succinate XL 25 mg PO DAILY
PredniSONE 20 mg PO DAILY Duration: 5 Days On steroid taper.
20mg of prednisone for 5 days starting ___ decrease by 5mg
Q5 days
Simvastatin 20 mg PO QPM
Ranitidine 150 mg PO BID
OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Acetaminophen 1000 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Megestrol Acetate 400 mg PO BID
3. Metoprolol Tartrate 25 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
5. PredniSONE 10 mg PO DAILY Duration: 7 Days
taper by 5mg every 7 days
Tapered dose - DOWN
6. Ranitidine 150 mg PO BID
7. Warfarin 0 mg PO DAILY16
Please hold dose on ___, INR 3.5, restart when INR is below
3 at 0.5mg daily
8. Simvastatin 5 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Nausea and vomiting related to ileus from imodium vs partial
stricture at ileostomy.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to ___ for nausea. ___ were recently
hospitalized previously for a portal vein thrombosis, for which
___ have been started on coumadin for. ___ have progressed. It
seems as though your nausea was related to a slow down of your
small bowel which was possibly related to imodium which ___ were
taking at home and a partial narrowing at the ileostomy. These
two problems have resolved and ___ are now passing stool from
the ilesotomy. It is important to crae for the ileosotmy as ___
have in the past. ___ have a new ileostomy. The most common
complication from a new ileostomy placement is dehydration. The
output from the stoma is stool from the small intestine and the
water content is very high. The stool is no longer passing
through the large intestine which is where the water from the
stool is reabsorbed into the body and the stool becomes formed.
___ must measure your ileostomy output for the next few weeks.
The output from the stoma should not be more than 1200cc or less
than 500cc. If ___ find that your output has become too much or
too little, please call the office for advice. The office nurse
or nurse practitioner can recommend medications to increase or
slow the ileostomy output. Keep yourself well hydrated, if ___
notice your ileostomy output increasing, take in more
electrolyte drink such as Gatorade. Please monitor yourself for
signs and symptoms of dehydration including: dizziness
(especially upon standing), weakness, dry mouth, headache, or
fatigue. If ___ notice these symptoms please call the office or
return to the emergency room for evaluation if these symptoms
are severe. ___ may eat a regular diet with your new ileostomy.
However it is a good idea to avoid fatty or spicy foods and
follow diet suggestions made to ___ by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
___ will need to continue to take your coumadin. ___ INR on the
day of discharge is 3.5 and ___ goal is 2.0-3.0. It is important
that the dose is held today ___ and ___ have an INR check at
rehab tomorrow and they restart at a low dose of 0.5mg. Please
try to avoid falling while on this medication. Please monitor
yourself for signs and symptoms of bleeding: weakness, bruising,
feeling weak or faint. Avoid foods with vitamin K like dark
leafy greens. When ___ are discharged, ___ should continue to
have your coumadin monitored and dosed by ___ GROUP
___.
___ will continue your Prednisone taper. ___ started 10mg of
prednisone today and ___ will continue to tapet by 5mg every 7
days until ___ are off prednisone. Until this time please
montior yourself for signs of steroid withdrawal: weakness,
abdominal pain, feeling teird, nausea, vomiting. Please call our
office right away with any questions or concerns.
___ must continue to increase your intake of food. This is vital
in your recovery! ___ should be eating ___ meals daily with
enusre or other nutritional suppplement. At the rehab, they
should have a nutritionist visit ___ and keep calorie counts and
then ___ should bring these with ___ to clinic next week. Please
try to increase the amount of food ___ are taking.
___ are now stable and ready for discharge.
Followup Instructions:
___
|
10328573-DS-12 | 10,328,573 | 28,384,221 | DS | 12 | 2145-01-16 00:00:00 | 2145-01-29 10:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p dirt bike crash with left hip and shoulder pain
Major Surgical or Invasive Procedure:
___ Chest tube placement at outside hospital
History of Present Illness:
___ yo M s/p helmeted dirt bike crash presented to outside
hospital with left sided shoulder and hip pain. Found to have a
left pneumothorax and subsequently had a chest tube inserted. He
was transferred to ___ for further management.
Past Medical History:
Depression/anxiety
Left meniscus repair ___
s/p tonsillectomy and adenoidectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge Physical Exam:
VS: 97.9, 73, 115/69, 16, 98%ra
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis. Left
chest tube site CDI covered in occlusive dressing.
ABDOMEN: soft, nontender to palpation, non-distended.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 05:45AM BLOOD WBC-9.2 RBC-4.35* Hgb-12.8* Hct-38.7*
MCV-89 MCH-29.4 MCHC-33.1 RDW-12.5 RDWSD-40.7 Plt ___
___ 05:27AM BLOOD WBC-13.1* RBC-4.41* Hgb-13.0* Hct-38.8*
MCV-88 MCH-29.5 MCHC-33.5 RDW-12.7 RDWSD-40.6 Plt ___
___ 07:39PM BLOOD WBC-16.8* RBC-4.93 Hgb-14.4 Hct-42.8
MCV-87 MCH-29.2 MCHC-33.6 RDW-12.4 RDWSD-39.1 Plt ___
___ 05:45AM BLOOD Glucose-95 UreaN-9 Creat-0.9 Na-140 K-4.0
Cl-101 HCO3-30 AnGap-13
___ 05:27AM BLOOD Glucose-120* UreaN-10 Creat-0.9 Na-140
K-4.1 Cl-102 HCO3-26 AnGap-16
___ 07:39PM BLOOD Glucose-102* UreaN-14 Creat-1.0 Na-140
K-4.1 Cl-102 HCO3-26 AnGap-16
___ 05:45AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.0
___ 05:27AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.1
___ CXR:
Supine portable AP view the chest provided. There is a left
apical E directed chest tube in place. No discernible
pneumothorax. Lungs appear relatively clear. Cardiomediastinal
silhouette appears normal. No acute fracture.
___ CXR:
Compared to prior chest radiographs ___ through ___
one at 13:06.
Tiny left apical pneumothorax unchanged, small left pleural
effusion new,
since earlier in the day following removal of the left pleural
drainage
catheter. Aside from minimal atelectasis at the bases, lungs
are clear.
Heart size normal.
Brief Hospital Course:
The patient was admitted to the ___ Service on ___
(transferred from OSH) for evaluation and treatment after a
motorcycle crash. Injuries identified were left sided rib
fractures with an associated left pneumothorax. A chest tube had
been inserted at the OSH. Admission chest X-Ray revealed chest
tube in place with no discernible pneumothorax. The patient was
hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. Tertiary trauma survey was negative for
any missed injuries. 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.
The chest tube was placed to waterseal and subsequently removed
on HD3. Post-pull CXR showed tiny left apical pneumothorax
unchanged. The patient was pulling ___ on his incentive
spirometer and was saturating 98% on room air with no reported
pain.
.
At the time of discharge on HD4, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, was in no
respiratory distress, and pain was well controlled. The patient
was discharged home without services. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
..
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Sertraline 50 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN pain
RX *ibuprofen 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*20 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
6. Senna 8.6 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left sided rib fractures
Left pneumothrax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Trauma Surgery Service at
___ on ___ after a dirt bike crash. You had a CT scan of
your head, neck, chest, abdomen, and pelvis to assess for
injuries. You were found to have multiple left sided rib
fractures and a air in your lung space (pneumothorax). You had a
chest tube placed in the lung space to help the lung re-expand.
Your lungs were assessed with x-rays and the tube was removed
once your lung re-expanded.
You are now doing better, ambulating, tolerating a regular diet,
and your pain is better controlled. You are now ready to be
discharged to home to continue your recovery.
Please note the following discharge instructions:
* Your injury caused multiple left sided rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
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