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10328776-DS-15 | 10,328,776 | 23,379,299 | DS | 15 | 2178-03-13 00:00:00 | 2178-03-13 16:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abd pain, fevers/chills, constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ with no significant past medical history who
presents as a referral from urgent care with constipation and
ketonuria.
He reports 3d constipation with associated diffuse abdominal
pain. He tried eating something yesterday but had an episode of
emesis 2hrs later, and has not tried eating again since.
Endorses
subjective fevers, chills, and sweats at home. Denies any sick
contacts or recent travels. He attempted OTC laxatives at home
and had a small amount of non-bloody, watery stool after. He was
seen at urgent care today where they obtained urine and basic
labs. Patient was discharged with Miralax, decusate and senna,
but was then called from the urgent care to be seen in the ED
due
to ketones in his urine.
In the ED, initial vital signs were: T 98.2, HR 88, BP 153/92,
O2
sat 100% RA
Labs were notable for:
WBC 31.2 (86.4% N)
HCO3 21
UA: 3 WBCs, neg nitrites, neg leuk esterase, large blood, 40
ketones
Studies performed include:
CT A&P with contrast:
1. Sigmoid colon diverticulitis. No drainable fluid collection
or
extraluminal gas.
2. Fat stranding around the decompressed bladder, may relate to
the acute diverticulitis, but correlate with urinalysis to
assess
for infection. Recommend correlation with urinalysis.
Patient was given:
- 1L NS
- 500 mg IV metronidazole
- 750 mg IV levofloxacin
- 4 mg IV morphine
Vitals on transfer: T 98.5 HR 76 BP 137/54 RR 14 O2 99% RA
Upon arrival to the floor, patient endorses the above history
and
adds that he has never had issues with constipation, but had an
episode of bloody diarrhea for which he underwent colonoscopy at
___. He believes this showed diverticulosis only. He has been
passing gas and reports that his abdominal pain has improved
since receiving morphine in the ED.
Past Medical History:
PAST MEDICAL HISTORY:
Diverticulosis
Tobacco abuse
Hematuria
Social History:
___
Family History:
FAMILY HISTORY:
No family history of IBD or colon cancer. No known family
history
of MI, CVA, or cancer.
Physical Exam:
PHYSICAL EXAM:
Vitals:
___ 0739 Temp: 98.0 PO BP: 143/91 HR: 58 RR: 18 O2 sat: 98%
O2 delivery: Ra
General: Obese, sleeping comfortably, readily roused,
appropriately interactive, in no acute distress.
HEENT: Normocephalic, PERRL, EOMI, oropharynx clear, MMM.
Neck: No cervical lymphadenopathy.
Lungs: Breathing comfortably on room air, clear to auscultation
bilaterally.
CV: Regular rate and rhythm, no murmurs
GI: Obese, non-distended, soft, minimally tender to palpation in
lower abdomen. No masses or hepatosplenomegaly appreciated
Ext: No cyanosis or edema. Spatulate-shaped nails, patient
reports they have been that shape since childhood.
Neuro: Alert, orientedx3. Able to readily discuss recent and
remote details of history. CN II-XII intact. Strength ___ in
arms
and legs. Sensation intact to light touch in hands and feet.
Pertinent Results:
==============
Admission Labs
==============
___ 02:53PM BLOOD WBC-31.2* RBC-4.98 Hgb-14.1 Hct-42.5
MCV-85 MCH-28.3 MCHC-33.2 RDW-14.3 RDWSD-44.4 Plt ___
___ 02:53PM BLOOD Neuts-86.4* Lymphs-4.6* Monos-7.7
Eos-0.2* Baso-0.2 Im ___ AbsNeut-26.94* AbsLymp-1.44
AbsMono-2.40* AbsEos-0.07 AbsBaso-0.06
___ 02:53PM BLOOD Glucose-95 UreaN-10 Creat-0.9 Na-137
K-3.8 Cl-98 HCO3-21* AnGap-18
___ 06:25AM BLOOD ALT-6 AST-8 LD(LDH)-159 AlkPhos-66
TotBili-0.9
___ 06:25AM BLOOD Albumin-3.5 Calcium-8.8 Phos-2.9 Mg-1.8
___ 03:20PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 03:20PM URINE Blood-LG* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-40* Bilirub-SM* Urobiln-4* pH-6.0 Leuks-NEG
___ 03:20PM URINE RBC-61* WBC-3 Bacteri-FEW* Yeast-NONE
Epi-1
==============
Discharge Labs
==============
___ 06:30AM BLOOD WBC-13.4* RBC-4.24* Hgb-12.1* Hct-36.7*
MCV-87 MCH-28.5 MCHC-33.0 RDW-14.2 RDWSD-44.9 Plt ___
___ 06:30AM BLOOD Neuts-75.9* Lymphs-11.0* Monos-9.2
Eos-2.8 Baso-0.5 Im ___ AbsNeut-10.18* AbsLymp-1.48
AbsMono-1.24* AbsEos-0.38 AbsBaso-0.07
___ 06:30AM BLOOD Glucose-84 UreaN-4* Creat-0.9 Na-141
K-3.5 Cl-102 HCO3-18* AnGap-21*
___ 06:30AM BLOOD ALT-10 AST-17 AlkPhos-78 TotBili-0.4
___ 06:30AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.4 Mg-1.9
==============
Microbiology
==============
___ Urine Culture
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN AND/OR GENITAL CONTAMINATION.
___ 3:59 pm BLOOD CULTURE #2.
Blood Culture, Routine (Pending): No growth to date.
___ 2:30 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending): No growth to date.
___ 11:58 am STOOL CONSISTENCY: WATERY
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.
==============
Imaging
==============
CT ABDOMEN/PELVIS WITH CONTRAST ___
1. Sigmoid colon diverticulitis. No drainable fluid collection
or
extraluminal gas.
2. Fat stranding around the decompressed bladder, may relate to
the acute
diverticulitis, but correlate with urinalysis to assess for
infection.
Recommend correlation with urinalysis.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
___ yo M with hx of diverticulosis who presents from urgent care
with ketonuria and complaint of 3d of abd pain, poor PO intake,
and constipation with fevers/chills, found to have sigmoid
diverticulitis with significant leukocytosis. Patient responded
well to medical management and was tolerating PO by discharge.
=============
ACUTE ISSUES:
=============
# Uncomplicated sigmoid colon diverticulitis
The patient presented with 3d LLQ abdominal pain associated with
subjective fevers/chills/sweats. Found to have possible sigmoid
diverticulitis without CT evidence of perforation or abscess. He
was treated for this diverticulitis as an inpatient given
significant leukocytosis to 31 on admission. His abdominal exam
was benign throughout his stay and he remained hemodynamically
stable. He was initially kept NPO but his diet was advanced to
regular diet by discharge and tolerated well. He received
maintenance IV fluids until he was drinking sufficient fluids.
His pain was well-controlled with just Tylenol while on the
floor. He was initially started on IV antiobiotics, but
transitioned to PO ciprofloxacin/flagyl for a 10d course:
___. Of note, his ___ records were obtained and his
colonoscopy report from ___ showed extensive diverticulosis and
6 polyps, 3 of which were adenomas. He was set up with a PCP and
outpatient GI f/u for colonoscopy.
# Leukocytosis
The patient had significant leukocytosis to 31 on admission,
higher than usually expected for diverticulitis. There was no hx
of diarrhea, he was never toxic-appearing, and he had no other
clear sources of infection. Cdiff PCR, blood and urine cultures
were negative. He also reported significant night sweats, but
these were contemporaneous with his abdominal sx and resolved
with treatment. His leukocytosis declined rapidly during his
stay, and was 13.4 on discharge.
# Ketonuria, fasting ketosis
Patient with 40 ketones on admission, likely in the setting of
poor PO over days prior to admission. This improved with IVF and
advancing diet, with reduction in ketones to 10 from 40 on day
of discharge. Patient with no history of diabetes, fasting
sugars while in house 80-90, unlikely DKA. Alcoholic ketosis on
differential, as patient stopped drinking >48 hours prior to
admission although no recent binging episodes.
# Microsopic hematuria
Etiology unclear. No signs/symptoms of UTI. Patient does have
punctate renal stone in the interpolar region of the left kidney
seen on CT. No evidence suggesting glomerular bleeding. Per
patient he has history of hematuria s/p cystoscopy at ___ in
___. However, he denies noticing any blood in his urine
recently. Note that he is age >___ and patient has had history of
smoking (25 pack years). The patient's ___ cystoscopy report of
___ was obtained and was unremarkable, the report also
alludes to CTU with no abnormalities. His urine culture showed
mixed flora consistent with contamination. The decision on
whether to arrange new urology f/u was deferred to his new PCP.
# EtOH use
Patient reporting ___ mixed drinks/day for past few months, on
prior baseline of 1/wk. Reports this is in setting of a new
relationship. No hx of withdrawal or complications thereof. No
evidence of withdrawal during his stay.
# Elevated BP without diagnosis of hypertension
Note that while inpatient, the patient's SBP ranged into the
150s; however this was in the setting of diverticulitis. Will
need to recheck as outpatient once abdominal pain improved.
# Constipation (resolved)
Presenting complaint, but per patient actually had very small
liquid stools ___ and ___, was passing flatus throughout his
stay, and had poor PO during this time. There was never signs of
ileus/obstruction on exam or imaging. Used miralax PRN and was
having regular BMs by discharge.
===============
CHRONIC ISSUES:
===============
# Obesity, BMI 42
We note that patient enjoys the finer foods in life, including
grilled cheese and fries instead of vegetables (does not like to
eat salads). In this setting he may benefit from further
discussion of diet and lifestyle modifications as an outpatient.
# Tobacco use. 1ppd, ___ yrs
- Patient offered nicotine patch but declined
===================
TRANSITIONAL ISSUES
===================
# Uncomplicated sigmoid colon diverticulitis
# History of colon polyps (___)
[] Ciprofloxacin 500 mg BID + metronidazole 500 mg PO Q8H x 10
days ending ___
[] Please help the patient arrange a ___ colonoscopy as an
outpatient in ___ weeks after episode of diverticulitis
# Leukocytosis
[] Please recheck CBC one week after discharge to ensure
leukocytosis resolved
# Fasting ketosis
[] Please recheck chem-7 in one week after discharge to make
sure anion gap has closed
# Microsopic hematuria
[] Please check UA one week after discharge
[] Please consider urology ___ as outpatient
# EtOH use
[] Please counsel patient on cessation of alcohol and connect
with resources as appropriate
# Elevated BP without diagnosis of hypertension
[] Please re-check BP at PCP ___ visit
# Obesity
[] Please counsel patient regarding lifestyle interventions
#Code: Full
#CONTACT: ___
Relationship: SISTER
Phone: ___
___ on Admission:
None
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
2. MetroNIDAZOLE 500 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
Uncomplicated sigmoid colon diverticulitis
Ketonuria, fasting ketosis
Microsopic hematuria
Elevated BP without diagnosis of hypertension
Obesity
EtOH use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
You were in the hospital because you had 3 days of abdominal
pain, fevers/chills, inability to eat or drink, and
constipation. You went to an urgent care clinic and were told to
come to the hospital because your lab values were unusual.
WHAT HAPPENED TO ME IN THE HOSPITAL?
While you were in the hospital your blood and urine were tested.
These tests showed signs of inflammation and of not eating much
in the past few days. You got a CT scan of your abdomen which
showed diverticulitis. This is a condition in which small
pouches form in your colon (large intestine) and become inflamed
or infected. You were given IV fluids and antibiotics to help
you stay hydrated and treat this infection. By the time you were
discharged you were eating, drinking, and taking antibiotics by
mouth.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
You should continue to take both of the antibiotics you were
prescribed (ciprofloxacin and metronidazole) for another 7 days.
It is also important that you ___ with your new PCP as
well as with the GI (gastroenterology) doctor. We have already
made the appointments for you.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10329125-DS-13 | 10,329,125 | 23,788,408 | DS | 13 | 2115-05-29 00:00:00 | 2115-05-30 18:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with a history of CAD s/p stent, HTN, hypothyroidism,
presenting from home after a syncopal episode.
Patient reports prior to today she was in her usual state of
health except for feeling slightly more fatigued than usual.
This morning she woke up and had crackers and cranberry juice
but did not have much of an appetite.
Per report of family, patient was making dinner on the day of
admission, when she began to complain of abdominal pain
described as a knot in her stomach. She took an omeprazole and
approximately 20 minutes later, sat down in a reclinging chair
because she was feeling unwell. She suddenly lost consciousness
for approximately 5 minutes. She began vomiting nonbloody
emesis. She was also incontinent of stool. No head strike. No
convulsions. She was not incontinent of urine and had no
evidence of tongue biting. Family turned patient on her side.
On EMS arrival, patient was hypotensive to the ___ and difficult
to arouse. Blood glucose was ___. Reportedly took ___ minutes
before patient became more interactive. Patient does not recall
anything from the episode.
In the ED, initial vitals were Temp not taken, HR 58 BP 152/64
RR 16 O2 sat 100% 4L. Labs were notable for WBC 14.6 with left
shift. Lactate normal. Urinalysis was concerning for infection
with 40 WBC, lg leuk and few bacteria. Cr was 1.4, with
otherwise normal electrolytes and LFTs. FAST was negative. CTA
torso showed no evidence of pulmonary embolism, AAA or acute
intra-abdominal process. Orthostatics were normal. Patient was
admitted to medicine for further management.
On arrival to the floor, has some slight stomach discomfort from
feeling hungry but otherwise has no complaints. Patient denies
urinary symptoms. She denies any drug use or excessive alcohol.
She denies any recent changes to medications.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. No dysuria. Denies arthralgias or
myalgias. Ten point review of systems is otherwise negative.
Past Medical History:
CAD s/p stent done at ___ approxmately ___ years ago
hypertension
hypothyroid
Social History:
___
Family History:
sister with MI at ___
brother with MI at ___
brother with hx of seizure after accident
Physical Exam:
ADMISSION EXAM:
============
VS: 97.8 120/70 67 20 98% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI. sclera anicteric. dry MM
Neck: supple, no JVD
CV: RRR. ___ systolic murmur heard throughout.
Lungs: CTAB, no w/r/r
Abdomen: soft, mildly tender in epigastric region. nondistended.
BS+. no suprapubic tenderness.
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: A&Ox3. EOMI. PERRLA. strength ___ in upper and lower
extremities. sensation grossly intact.
DISCHARGE EXAM:
============
VS: T 98 HR 58-67 BP ___ RR ___ O2 sat 92-98% RA
Wt: 62.1 kg
General: NAD, sitting comfortably in bed eating breakfast,
pleasant
HEENT: NCAT, PERRL, EOMI. sclera anicteric. dry MM
Neck: supple, no JVD
CV: RRR. ___ systolic murmur heard throughout, difficult to
appreciate S2.
Lungs: CTAB, no w/r/r
Abdomen: soft, mildly tender in epigastric region. nondistended.
BS+. no suprapubic tenderness.
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: A&Ox3. EOMI. PERRLA. strength ___ in upper and lower
extremities. sensation grossly intact.
Pertinent Results:
ADMISSION DATA:
============
___ 05:10PM BLOOD WBC-14.5* RBC-4.47 Hgb-14.7 Hct-46.6
MCV-104* MCH-32.9* MCHC-31.5 RDW-13.7 Plt ___
___ 05:10PM BLOOD Neuts-84.2* Lymphs-9.9* Monos-4.7 Eos-0.8
Baso-0.4
___ 05:10PM BLOOD ___ PTT-28.8 ___
___ 05:10PM BLOOD Glucose-83 UreaN-24* Creat-1.4* Na-139
K-4.3 Cl-103 HCO3-22 AnGap-18
___ 05:10PM BLOOD ALT-22 AST-27 AlkPhos-94 TotBili-0.3
___ 05:10PM BLOOD cTropnT-<0.01
___ 07:05AM BLOOD cTropnT-<0.01
___ 05:10PM BLOOD Lipase-60
___ 05:10PM BLOOD Albumin-4.2 Calcium-8.5 Phos-4.2 Mg-2.3
___ 05:18PM BLOOD Lactate-1.8
___ 05:00PM URINE Color-Straw Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:00PM URINE RBC-1 WBC-40* Bacteri-FEW Yeast-NONE
Epi-0
___ 05:00PM URINE CastHy-3*
___ 05:00PM URINE Mucous-RARE
Urine culture: ESCHERICHIA COLI, pansensitive
Blood cultures x 2: pending
ECG: Sinus rhythm. Prominent voltage in leads I and aVL and
prominent voltage in
the precordial leads consistent with left ventricular
hypertrophy. ST-T wave
changes. Q-T interval prolongation. No previous tracing
available for
comparison.
___ CTA chest, abdomen and pelvis impression:
1. No evidence of aortic injury or dissection.
2. No acute intra-thoracic or intra-abdominal injury.
DISCHARGE DATA:
============
___ 07:05AM BLOOD WBC-7.1# RBC-3.96* Hgb-13.5 Hct-40.4
MCV-102* MCH-34.2* MCHC-33.5 RDW-12.9 Plt ___
___ 07:05AM BLOOD Glucose-78 UreaN-23* Creat-1.3* Na-140
K-3.8 Cl-108 HCO3-23 AnGap-13
___ 07:05AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.3
___ 07:05AM BLOOD TSH-5.2*
___ TTE: LVEF 60%. Normal biventricular regional/global
systolic function. Mild to moderate aortic regurgitation.
Elevated left ventricular enddiastolic pressure and moderate
left atrial dilation in absence of significant mitral
regurgitation likely secondary to diastolic dysfunction.
Brief Hospital Course:
# Syncope: Patient monitored on telemetry without any notable
events. Negative for orthostatic hypotension x 2. Patient ruled
out for ACS with 2 negative troponins, no acute ECG changes, TTE
without evidence of ischemic wall motion abnormalities.
Neurology consulted for question of new onset seizure given
stool incontinence, LOC, and memory loss during the syncopal
episode. No neurological workup required during admission. Given
negative workup in hospital, determined that syncope is most
likely vasovagal syncope from stress of significant abdominal
pain.
# UTI: UA showing large leukocyte esterase with +WBCs. Pt was on
IV ceftriaxone, discharged with 1 more day of ciprofloxacin to
finish 3 day course. Patient without symptoms of dysuria or
increased urinary frequency. Urine cultures growing E. coli
pansensitive to all agents tested including ciprofloxacin.
# Abdominal pain: initially tender to palpation in epigastric
region. Lipase and LFTs within normal limits, CTA abdomen/pelvis
without acute intraabdominal pathology. Patient started on IV
PPI and zofran prn during admission with complete resolution of
abdominal pain. Patient able to tolerate full meals without
further nausea/vomiting/abdominal pain.
# History of CAD: continued ASA and fenofibrate. Unclear why
patient not on statin. Held atenolol and lisinopril during
admission given EMS report of hypotension during syncopal
episode, both were restarted on discharge given that the patient
was mildly hypertensive.
# HTN: atenolol and lisinopril as above. HCTZ held given ___,
reported hypotension, and decreased PO intake compared to usual.
___: Cr 1.4 on admission, unclear what patient's baseline is.
Likely due to dehydration given high BUN:Cr ratio. Given 1L
normal saline with improvement to 1.4. Patient also resumed
normal PO intake.
Transitional issues:
- TSH mildly elevated 5.2, consider increasing synthroid dose.
- Consider starting patient on statin given history of CAD.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. fenofibrate 54 mg oral daily
4. Hydrochlorothiazide 25 mg PO DAILY
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. fenofibrate 54 mg oral daily
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q24H Duration: 1 Day
take in AM and ___ on ___
RX *ciprofloxacin 250 mg 1 tablet(s) by mouth twice daily Disp
#*2 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Vasovagal syncope
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 the ___
___. You were admitted because you had an
episode of syncope (lost consciousness). You had several
different studies here to rule out emergency conditions such as
heart attack, pulmonary embolism, aortic dissection, and
ruptured aortic aneurysm, all of which were negative. The
neurologists here did not think that you had a seizure. The most
likely explanation is that you had a vasovagal episode in which
you lost consciousness because you were having significant
abdominal pain. Your abdominal pain has resolved and you were
able to eat meals without problems.
- Please make sure to keep yourself well hydrated and nourished,
eat 3 full and balanced meals a day. Avoid skipping meals.
___ MD's
Followup Instructions:
___
|
10329125-DS-14 | 10,329,125 | 25,418,400 | DS | 14 | 2115-08-16 00:00:00 | 2115-08-16 15:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F w/ CAD s/p stent who presented to ED w/
epigastric abdominal pain x1 w/ vomiting, and found to have
intermittent LBBB during vomiting in ED. She reports some loose
stools, but no recent antibiotics.
ED Course:
- 96.3 70 150/68 18 98% pain ___
- EKG sinus, NA, NI, STE in AVR
- guaiac neg
- cardiology c/s: Unlikely symptoms her symptoms are related to
ACS. As they started this AM has ruled out for ACS given single
enzymes. Echo at ___ revealed no AS, moderate Aortic
regurgitation.
- 1L NS
On medicine floor, patient reports pain improved to ___. No
other symptoms. Overall, feels somewhat better.
ROS: Full 10 pt review of systems negative except for above.
Past Medical History:
- CAD s/p 1 x stent done at ___ ___
- HTN
- Hypothyroid
- Diastolic dysfunction (EF 60%, ___
- moderate Aortic regurgitation
Social History:
___
Family History:
Significant family history of cardiac disease.
-sister with MI at ___
-brother with MI at ___
-brother with hx of seizure after accident
-grandmothers with breast cancer
Physical Exam:
ADMISSION:
VS: 97.8 131/51 HR 56 sat 96% on RA
Gen: NAD
HEENT: clear OP
CV: NR, RR, systolic murmur
Pulm: CTAB, nonlabored
Abd: soft, NT, ND; no tenderness appreciated by 21:00 on ___
GU: no Foley
Ext: no edema
Skin: no lesions noted
Neuro: A&O, moving all ext
Psych: flat affect
DISCHARGE:
vitals: 99.0 126/77 HR 69 sat 99% on RA
Abd: soft, mild L-side and epigastric tenderness to palpation,
ND
Pertinent Results:
___ 02:00AM BLOOD WBC-11.0# RBC-3.85* Hgb-12.5 Hct-38.2
MCV-99* MCH-32.5* MCHC-32.7 RDW-12.9 Plt ___
___ 08:10AM BLOOD WBC-8.2 RBC-3.92* Hgb-12.7 Hct-38.0
MCV-97 MCH-32.5* MCHC-33.5 RDW-12.8 Plt ___
___ 02:00AM BLOOD ___ PTT-33.3 ___
___ 02:00AM BLOOD Glucose-101* UreaN-20 Creat-1.0 Na-143
K-4.2 Cl-108 HCO3-23 AnGap-16
___ 08:10AM BLOOD Glucose-69* UreaN-15 Creat-0.8 Na-139
K-4.2 Cl-104 HCO3-22 AnGap-17
___ 02:00AM BLOOD ALT-16 AST-20 CK(CPK)-54 AlkPhos-153*
TotBili-0.1
___ 02:00AM BLOOD Lipase-86*
___ 07:55AM BLOOD Lipase-43
___ 02:00AM BLOOD CK-MB-2 proBNP-751*
___ 02:00AM BLOOD cTropnT-<0.01
___ 07:55AM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD Albumin-4.2 Calcium-9.6 Phos-4.4 Mg-2.1
___ 08:10AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.9
___ 05:37AM BLOOD Lactate-0.8
-----------
- CT abd/pelv w/ contrast ___ IMPRESSION: **Preliminary
Report**
1. No acute intra-abdominal abnormality.
2. Sigmoid diverticulosis without diverticulitis
**Preliminary Report**
.
- CXR PA/Lat ___ IMPRESSION: No pneumonia, edema or pleural
effusion.
Brief Hospital Course:
Ms. ___ is a ___ F w/ CAD s/p stent who presented to ED w/
epigastric abdominal pain x1 w/ vomiting, and found to have
intermittent LBBB during vomiting in ED.
# Abdominal Pain, epigastric: Unclear etiology. Likely GERD. ___
be strong anxiety component. PCP has also wondered about
depression/axiety in the past. Lipase mildly elevated then
normal when rechecked in ED. CT abd/pelv in ED unremarkable.
Trop <0.01 x2 in ED. EKG showed elevation. Seen by Cardiology in
ED who thought not concerning for ACS, though does have CAD s/p
stent. Started Ranitidine BID. Consider outpatient eval by GI.
Acetaminophen PRN. Lorazepam prn anxiety.
.
# EKG Changes: STE in AVR ___ in ED w/ intermittent LBBB
which appears to be rate related. Seen by Cardiology in ED who
thought not concerning for ACS. Did have 8 beat NSVT on
telemetry.
.
# CAD: s/p stent ___ at ___. Started Metoprolol succinate 25mg
daily. Unclear why not on statin; please strongly consider as
outpatient. Home Lisinopril and ASA daily.
.
# HTN: Stable. Home Amlodipine and Lisinopril.
.
# Hypothyroidism: Home Levothyroxine.
.
# Diastolic dysfunction (EF 60%, ___: Not on diuretics at
home.
.
# ?Anxiety: f/u w/ PCP
.
# CONTACT: ___ ___
# CODE: Full
.
## TRANSITIONAL ISSUES:
- Started Metoprolol succinate 25mg daily
- unclear why not on statin w/ CAD s/p stent; please strongly
consider as outpatient
- consider psych work-up for ?anxiety; flat/odd affect
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. fenofibrate 54 mg oral daily
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Acetaminophen 500 mg PO Q6H:PRN pain
7. fenofibrate 54 mg oral daily
8. Ranitidine 150 mg PO BID
to treat your abdominal pain by decreasing acid.
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth twice daily Disp
#*60 Tablet Refills:*2
9. Metoprolol Succinate XL 25 mg PO DAILY
to treat your heart.
RX *metoprolol succinate [Toprol XL] 25 mg 1 tablet extended
release 24 hr(s) by mouth once daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, you were admitted to ___ for evaluation of upper
abdominal and lower chest pain. While you were here, we checked
an EKG and performed blood tests. There were no signs of any new
heart abnormalities. You were started on Metoprolol since this
very important for your known coronary artery disease.
Followup Instructions:
___
|
10329501-DS-7 | 10,329,501 | 25,487,443 | DS | 7 | 2149-01-29 00:00:00 | 2149-01-29 13:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, fatigue, and exertional shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a PMH of CAD
and severe AS who presents with 3 days of generalized weakness
found to have Hb of 7.5.
Over the past few weeks, Mr ___ has noted weight loss and
bloating. He claims he has been trying to lose weight to help
with knee arthritis and denies nausea with the weight loss. His
son notes that he has been depressed since having an altercation
with his wife and stopped eating because of this. The patient
claims to eat a variety of foods including meats and vegetables
(but not dairy due to lactose intolerance)
Over the past few days he has felt more fatigued, and yesterday
he began to develop dyspnea on exertion and worsening fatigue
while walking to work, after only ___. The patient was seen by
his cardiologist yesterday who noted anemia on his bloodwork.
He
has never had anemia before and has not noted any black or
bloody
stools. He denies any AC besides ASA 81. He was told to present
to the ED for further workup.
ED Course:
PE notable for SBP 99/48, HR 72-->102, ___ SEM, soft abd with
mild TTP in LQ, heme neg stool
Labs notable for WBC 3.0, Hb 7.6, PLT 122, abs retic 0.01,
Hapto<10, LDH ___, B12<150, Folate 13, UA 6.3,
ROS: Denies hematemesis, BRBPR, or melena. Also denies nausea,
vomiting, fever/chills, HA, dizziness, SOB, CP. All other
systems
were reviewed and are negative.
Past Medical History:
DM
HTN
AS
HLD
Social History:
___
Family History:
No history of valvular disease or other cardiac
disease that he is aware of.
Physical Exam:
Admission Exam:
___ Temp: 98.2 PO BP: 109/59 HR: 70 RR: 18 O2 sat: 99%
O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
___: 1+ pitting edema noted, worse than "normal" per pt report.
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:
Pertinent Results:
___ 11:00AM BLOOD WBC: 3.0* Hgb: 7.6* MCV: 122* Plt Ct:
112*
Myelos: 1* RBC Mor: SLIDE REVIEWED___
___ 11:00AM BLOOD Poiklo: 1+* Macrocy: 3+* Schisto: 1+*
Tear
Dr: 1+* RBC Mor: SLIDE REVIEWED*
___ 11:00AM BLOOD Creat: 0.8 Glucose: 119* LD(LDH): ___
TotBili: 1.0 cTropnT: <0.01
___ 11:00AM BLOOD calTIBC: 200* VitB12: <150* Folate: 13
Hapto: <10* Ferritn: 450* TRF: 154*
___ 11:00AM BLOOD TSH: 0.92
URINE CULTURE (Pending):
I personally reviewed the ECG and my interpretation is:
First degree AV block, PR 320 ms, HR 98, QtC 505, early R wave
transition.
CXR
INDICATION: ___ with aortic stenosis, anemia// assess for volume
overload
The lungs are clear. There is no consolidation, effusion, or
edema. Cardiac silhouette is mildly enlarged as seen previously.
No acute
osseous abnormalities.
IMPRESSION:
Cardiomegaly without superimposed acute cardiopulmonary process.
No pulmonary edema.
Discharge Labs
___ 07:22AM BLOOD WBC-4.1 RBC-2.34* Hgb-9.3* Hct-26.1*
MCV-112* MCH-39.7* MCHC-35.6 RDW-20.6* RDWSD-81.5* Plt ___
___ 06:45AM BLOOD Neuts-44 ___ Monos-0* Eos-6 Baso-0
Atyps-2* AbsNeut-0.92* AbsLymp-1.05* AbsMono-0.00* AbsEos-0.13
AbsBaso-0.00*
___ 07:22AM BLOOD Plt ___
___ 07:22AM BLOOD ___ 06:45AM BLOOD ___ D-Dimer-713*
___ 07:22AM BLOOD Ret Aut-0.8 Abs Ret-0.02
___ 07:22AM BLOOD Glucose-104* UreaN-4* Creat-0.7 Na-139
K-4.4 Cl-107 HCO3-20* AnGap-12
___ 07:22AM BLOOD LD(LDH)-1611*
___ 07:22AM BLOOD Phos-2.5* Mg-1.9
___ 07:22AM BLOOD Hapto-18*
___ 11:00AM BLOOD TSH-0.92
___ 07:22AM BLOOD 25VitD-<5*
Brief Hospital Course:
ACUTE/ACTIVE PROBLEMS:
#Pancytopenia (Hb 7.5-->7.8, WBC 3.0-->2.0, PLT 122-->80s)
#Macrocytic anemia (MCV 115)
#Hemolysis (LDH>1000, Hapto<10)
#B12 and folate deficiency
Presented after a month of poor po intake and crash dieting with
macrocytosis, hemolysis, schistocytes and B12/folate deficiency.
Pancytopenia is most likely related to vitamin deficiency given
high
MCV/low B12 with schistos explained by severe AS. Other
possibilities considered include malabsorption of B12 d/t
pernicious anemia.
Much lower on the differential were a tickborne illness such as
Babesia or a primary marrow process (tear drops, low retic). The
Low hapto, high LDH, and low retic were concerning for hemolysis
however fibrinogen was normal, ddimer not significantly
elevated and TLS labs normal. Therefore APML was thought to be
highly unlikely and hematology did not think the patient
required a BMBx. During the hospitalization, the patient did
receive 2 blood transfusions for Hb <8 due to his known CAD and
AS. He did not require any cryo as his fibrinogen was above 150.
He received 4 days of IV cyanocobalamin (___) and po folic
acid, which were continued on discharge. His vitamin D was
undetectable so he received 50,000 units on ___
#Long QtC 505
- avoided prolonging meds
CHRONIC/STABLE PROBLEMS:
#AS: avoided preload reducing agents
#Pre-DM: held metformin, received ___
#HLD: Atorvastatin 40 mg PO QPM
#CAD: Aspirin 81 mg PO DAILY, Toprol xl 25 daily
TRANSITIONAL ISSUES
[ ] discharged with several new meds including 50,000 units of
vitamin d once weekly for 6 weeks, po b12/folate (hematologist
to set up weekly B12 injections), and multivitamin. Encourage pt
to have a well balanced diet.
[ ] evaluate for depressive symptoms as pt's family believes
this is contributing to his not eating.
[ ] On discharge intrinsic factor ab was pending. If positive
will need GI follow up and likey lifely IV B12 injections.
[ ] recommend referral to weight loss clinic for supervised
weight loss
[ ] recheck cbc, ldh, hapto at discharge follow up appointment
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 100 mcg PO DAILY b12 deficiency
RX *cyanocobalamin (vitamin B-12) 100 mcg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 tab-cap
by mouth once a day Disp #*30 Tablet Refills:*0
4. Vitamin D ___ UNIT PO 1X/WEEK (MO) Duration: 6 Weeks
RX *ergocalciferol (vitamin D2) [Drisdol] 50,000 unit 1
capsule(s) by mouth once weekly Disp #*5 Capsule Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. MetFORMIN (Glucophage) 500 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Pancytopenia due to B12 and folate deficiency
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 fatigue and found to be
anemic. We believe this is due to B12 which is a nutritional
deficiency. It is very important to eat a variety of foods when
you diet and aim not to lose more than 2 pounds a week. Please
follow-up with your primary care doctor who can refer you to a
weight loss clinic for further guidance. We will also set up an
appointment with a hematologist who can continue to give you
vitamin B12 infusions.
When you are discharged you should continue to take folate, a
multivitamin, and vitamin D.
Followup Instructions:
___
|
10330091-DS-6 | 10,330,091 | 24,994,937 | DS | 6 | 2148-09-17 00:00:00 | 2148-09-18 06:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with diabetes mellitus, hypertension, chronic pain from
multilevel spinal stenosis, presented with chest pain since 3 am
on ___. Patient is a very poor informant, but states she woke up
from sleep at 3 am with pain in the middle of her chest
radiating straight through to her back and to her left shoulder
blade. She thought it was "gas pain," which she gets fairly
often, but this felt different. It was associated with
diaphoresis and nausea when she woke up. No vomiting, no
pleuritic pain. She always feels unsteadiness but this is her
baseline. She had intermittent shortness of breath. No headache.
She was given ASA 325 mg by EMS.
In the ED, initial vitals were T 98.4 HR 76 BP 159/87 RR 24 SaO2
100% on 4 Lpm via Nasal Cannula. Patient continued to complain
of ___ chest pain but had equal bilateral upper extremity BP.
EKG showed NSR, normal axis, T wave inversions in II, III, avF.
There was T wave flattening in the lateral leads, similar to
prior tracings. CBC and chem 7 wnl (K was hemolyzed) however
troponin was noted to be 0.68, rising to 1.06 four hours later.
She was given nitroglcyerin twice with resolution of chest pain.
She was started on heparin gtt and admitted for NSTEMI.
On arrival to the cardiology floor, patient was comfortable. She
denied ongoing chest pain or shortness of breath. She did report
some Right shoulder discomfort and epigastric pain, which are
baseline for her.
Past Medical History:
# Hypertension
# Type 2 DM complicated by
# peripheral neuropathy
# multiple hernia repairs in past / bowel resection for ?
incarcerated hernia --(**patient poor informant, no OMR records
-done at ___)
# chronic abdominal pain
# ___ Right Knee replacement
# ? hx of ischemic colitis in ___
# Urge urinary incontinence (seen by urology
Social History:
___
Family History:
Father with MI in his ___
Physical Exam:
General: Elderly ___ woman in NAD, comfortable,
pleasant
VS: T 98.4 HR 76 BP 159/87 RR 24 SaO2 100% on 4 L/min via NC
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm; no murmurs, rubs or gallops
Lungs: soft crackles at right base, decreased breath sounds on
right side
Abdomen: soft, non-tender, not distended, BS+
Ext: warm and well perfused; no clubbing, cyanosis or edema; 2+
distal pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
___ 02:00PM BLOOD WBC-7.2 RBC-4.36 Hgb-12.9 Hct-40.6 MCV-93
MCH-29.5 MCHC-31.6 RDW-14.8 Plt ___
___ 02:26PM BLOOD ___ PTT-31.2 ___
___ 02:00PM BLOOD Glucose-214* UreaN-13 Creat-0.9 Na-140
K-5.7* Cl-103 HCO3-26 AnGap-17
___ 07:50AM BLOOD Calcium-10.2 Phos-3.1 Mg-1.7
___ 02:00PM BLOOD CK-MB-38* MB Indx-5.0
___ 02:00PM BLOOD cTropnT-0.68*
___ 06:54PM BLOOD cTropnT-1.06*
___ 08:45PM BLOOD CK-MB-32* MB Indx-4.6
___ 07:50AM BLOOD CK-MB-19* cTropnT-0.57*
ECG ___ 1:19:32 ___
Sinus rhythm. Non-specific T wave abnormalities in the inferior
leads. Compared to the previous tracing of ___ there are no
changes noted.
CXR ___
Mild cardiomegaly is noted again without signs of pulmonary
edema. Visualized lung fields are clear without any focal
opacities, pleural effusions or pneumothorax. The mediastinal
silhouette is unremarkable.
Echocardiogram ___:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with inferior and
inferolateral hypokinesis. The remaining segments contract
normally (LVEF = 40%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation.
Brief Hospital Course:
___ with type II diabetes mellitus, hypertension, ongoing
cigarette use, spinal stenosis, presenting with several hours of
chest pain relieved by NTG, inferior T wave inversions on EKG,
and troponin elevation all indicative of an NSTEMI.
ACUTE ISSUES:
# NSTEMI: Patient presented with several hours of burning chest
pain radiating to her back and shoulder that occurred at rest
and was relieved by NTG. She also had new T wave inversions in
the inferior leads and elevated troponin, diagnostic of an
NSTEMI. Patient without previously diagnosed cardiovascular
disease, however has many risk factors: hypertension, DM, age,
family history (father with MI), current smoker. The patient was
started on a heparin gtt and was given aspirin. An
echocardiogram showed reduced LVEF at 40% (indicative of mild LV
systolic dysfunction, most likely acute) and wall motion
abnormalities in the lateral and inferior areas. Peak CK-MB was
38 on the initial specimen, raising the possibility that the
infarct was at least a day old and less acute than suspected.
The team discussed treatment options with the patient, including
medical management with anticoagulation/anti-platelet therapy
vs. coronary angiography with possible intervention given the
risks of recurrent infarction and/or death given high risk
features of her acute coronary syndrome presentation. The
patient decided that she wanted to forgo treatment and leave
AMA. The risks of leaving without definitive therapy, including
further heart damange or death, were discussed with the patient
and she expressed her understanding. She left against medical
advice. She was discharged on aspirin, clopidogrel, atenolol,
atorvastatin, amlodipine, and lisinopril. Her HCTZ and potassium
supplementation were stopped. She should get her electrolytes
checked on ___. She should follow up with her PCP and ___
cardiologist after discharge.
CHRONIC ISSUES:
# Hypertension: Stable. Was continued on amlodipine, atenolol,
lisinoprol. Her HCTZ and potassium supplementation were stopped.
She should get her electrolytes checked on ___.
# Type II diabetes mellitus: No active issues. Her home oral
antihyperglycemics were held in house and she was placed on ISS.
# Spinal stenosis: Chronic process with DJD and neuropathic
pain. Also with right arm weakness. Her home medications were
continued: Percocet, gabapentin and tizanidine.
TRANSITIONAL ISSUES:
- Follow up with cardiology after discharge
- Consider cardiac rehab; information was given to the patient
- Started patient on atorvastatin and clopidogrel
- Stopped HCTZ and thus stopped potassium supplementation
- Check electrolytes on ___ to ensure potassium stable after
stopping supplementation
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Docusate Sodium (Liquid) 100 mg PO BID
2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
3. Vitamin D 400 UNIT PO DAILY
4. Amlodipine 5 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Atenolol 50 mg PO DAILY
7. Gabapentin 600 mg PO DAILY
8. GlipiZIDE XL 2.5 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Lisinopril 5 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Oxybutynin 5 mg PO DAILY
14. Simvastatin 10 mg PO DAILY
15. Tizanidine 2 mg PO DAILY
16. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. GlipiZIDE XL 2.5 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Amlodipine 5 mg PO DAILY
7. Aspirin 325 mg PO DAILY
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Gabapentin 600 mg PO DAILY
10. Lisinopril 5 mg PO DAILY
11. Oxybutynin 5 mg PO DAILY
12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
13. Tizanidine 2 mg PO DAILY
14. Vitamin D 400 UNIT PO DAILY
15. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
16. Outpatient Lab Work
Diagnosis: NSTEMI 410.9
Please check chem-10 and fax results to Dr. ___ at
___
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ST segment myocardial infarction
Coronary artery disease
Hypertension
Diabetes mellitus, type II, with
Peripheral neuropathy
Chronic kidney disease, stage 2
Mild left ventricular diastolic dysfunction, likely acute
Spinal stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
YOU ARE LEAVING AGAINST MEDICAL ADVISE.
You were admitted for a heart attack. You were put on
anticoagulation to manage your heart attack and were given
several medications. We wanted to keep you in the hospital for
further medical therapy, however, you decided to leave against
medical advice. You were able to state that there are risks to
leaving against medical advice which include on-going symptoms,
heart failure, and death.
Please take your medications at home, as they will help prevent
further heart attacks. Please get your electrolytes checked on
___. In addition, please follow up with cardiology as
an outpatient.
Best,
Your ___ care team
Followup Instructions:
___
|
10330091-DS-9 | 10,330,091 | 27,344,689 | DS | 9 | 2149-02-18 00:00:00 | 2149-02-18 18:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: ischemic bowel
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F resident of the ___
admitted to the ED with emesis and ___ malfunction. CT scan
revealed massive ischemic gut - including most of her bowel
(large and small), free air, and portal venous gas. Surgery
(Dr. ___ was consulted and felt this was a terminal event,
that surgery would not be successful. She is now admitted for
comfort
focused care.
Past Medical History:
FROM ___:
Hypertension
Type 2 DM complicated by peripheral neuropathy
Right arm weakness ___ stroke/cervical stenosis
multiple hernia repairs in past / bowel resection for ?
incarcerated hernia
chronic abdominal pain
___ Right Knee replacement
? hx of ischemic colitis in ___
Urge urinary incontinence
Subarachnoid hemorrhage ___
___ Status epilepticus (___)
History of NSTEMI in ___, left AMA without cath, on
ASA/plavix initially (plavix held due to SAH)
Social History:
___
Family History:
FROM OMR:
Father with MI in his ___
Physical Exam:
ROS: Patient unable
PE: Lying in bed, sleeping, appears comfortable
Abd: distended
Pertinent Results:
___ 07:07AM ___ ___
___ 03:45AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 03:45AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 03:45AM ___
___ 03:45AM ___
___
CT reviewed: IMPRESSION:
1. Pneumatosis throughout the distal small bowel, cecum,
ascending colon, transverse colon and distal colon with
associated free ___ air and extensive portal venous
gas. These findings are concerning for bowel ischemia and
urgent surgical consultation recommended. A small amount of
thrombus in the superior mesenteric artery causes minimal
narrowing, however, however there is opacification of the
superior mesenteric artery throughout.
2. Subcutaneous emphysema in the left lower quadrant due to the
placement of the ___.
Brief Hospital Course:
Ms. ___ was admitted to the Hospital Medicine service with
unsurvivable ischemic bowel. She was provided with comfort
focused care, including a morphine gtt titrated to comfort. Her
family remained at her bedside and she passed away a couple of
hours after arriving to ___.
Dr. ___ the family/HCP/NOK and they declined
autopsy.
PCP - Dr. ___ via email of admission and death.
Medications on Admission:
Not confirmed.
Full list in paper chart from SNF
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Bowel ischemia
Discharge Condition:
Deceased
Discharge Instructions:
Patient was admitted with bowel necrosis and perforation. She
was seen by surgery and deemed inoperable. She was made CMO in
the emergency department and passed away shortly after arriving
to the floor.
Followup Instructions:
___
|
10330106-DS-20 | 10,330,106 | 25,085,326 | DS | 20 | 2175-02-28 00:00:00 | 2175-03-11 20:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
neck pain
Major Surgical or Invasive Procedure:
LP
Physical Exam:
Gen: Alert; NAD.
Skin: No rash.
HEENT: NC/AT. No sinus tenderness. MMM. No pharyngeal erythema.
No TMJ tenderness.
Neck: Rotation RoM limited by pain. Full RoM w/
flexion/extension.
CV: Well-perfused throughout.
Pulm: Nonlabored breathing.
Abd: NT/ND.
Extr: B/l feet w/ above-average curvature / high arches. No
C/C/E.
Neur:
MS: A&Ox4. Fluent speech.
CN: PERRL. EOMI. Symmetric face. Tongue midline.
Motor: B/l deltoids, biceps, triceps, wrist flexors/extensors,
hamstrings, quadriceps, ankle flexors/extensors ___ strength.
Reflexes: 2+ at biceps, patellae, Achilles. No cross
abductors. Toes downgoing.
___: Intact to light touch throughout.
Brief Hospital Course:
Ms. ___ is a ___ y/o woman w/ no significant PMH presenting
w/ ___ months of headache and neck pain. Due to continuation of
symptoms and concern for meningismus representing subacute
meningitis, pt referred to ED for further evaluation.
CSF analysis was significant for pleocytosis (out of proportion
to RBCs in CSF). Due to these concerning signs/symptoms, pt was
admitted for empiric treatment for bacterial meningitis w/ IV
abx (CTX and vancomycin).
Imaging found fluid collection in L maxillary sinus concerning
for possible nidus of CNS infection. ENT consulted; scope showed
no evidence of sinusitis.
Pt was also found to have component of cervical muscle spasms,
which were at least contributing to cervical/head pain. Started
on tizanidine. ___ evaluated pt for possible limitations due to
pain; evaluated her as not needing further therapy at this time.
Pain was also treated w/ acetaminophen prn and ibuprofen prn.
Cultures (blood and CSF) remained negative by day of D/C
(___). Abx were discontinued.
Pt was discharged to f/up w/ primary care and w/ Neurology.
Transitional issues:
Pt was given rx for amitriptyline to be started if head and
cervical pain requires acetaminophen and ibuprofen more often
than half of the days of the week.
We recommend that pt have serum Tb test obtained to r/o the
possibility of Tb infection as cause.
Discharge Disposition:
Home
Discharge Diagnosis:
neck pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure taking care of you. You were admitted for
concern for meningitis. You underwent a lumbar puncture which
showed an elevated white count and thus you were started on
antibiotics. However, your cultures have remained negative and
thus the antibiotics were discontinued. For your associated neck
pain you were started on a muscle relaxer tizanidine. We also
will try you on a medication called amitriptyline for headache
prevention.
We would like for you to still get one more blood test performed
to test for tuberculosis, since sometimes chronic meningitis can
be associated with this. Your PCP can perform this test.
Please follow up with your PCP. We will also arrange an
outpatient neurology appointment for you. if you don't hear from
the clinic within the next few days, please call the number
below.
W
Followup Instructions:
___
|
10330241-DS-18 | 10,330,241 | 23,531,394 | DS | 18 | 2137-04-22 00:00:00 | 2137-04-23 21:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Percocet / codeine / bandaids / oxycodone
Attending: ___
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo woman with hx migraine and remote R
zoster ophtalmicus c/b residual R V1 numbness and OD mydriasis
who presents to the ED with dizziness.
Ms. ___ woke at 0100 this morning and walked downstairs to
get a glass of water. She felt like her balance was off, but
was
able to walk. She went back to bed. When she awoke in the
morning, she felt severe room-spinning. She also felt like her
eyes were "jumping around". This room spinning sensation
persisted.
This sensation is best when she is still with her eyes open, but
worsens whenever she moves her head or whenever she closes her
eyes and is still. These symptoms precipitated a panic attack
at
home this morning.
She received prednisone 60 mg and meclizine 25 mg in the ED and
then became very nauseated, throwing up multiple times. She had
no nausea before taking these medications.
This presentation was preceded by several months of change in
balance. She noticed that over the past several months she has
been more clumsy, dropping things as well as walking into
walls/door frames. She is not sure if these things occurred
more
than one side than the other but thinks that she may have
dropped
things more from her right hand. She also noted that several
weeks ago it was more difficult to balance during some
difficulty
with yoga poses that she was previously able to perform.
Ms. ___ had a fever, cough, nasal congestion on ___.
She had tinnitus on the L ___. She has R ear fullness and
decreased hearing today.
She has history of migraines without aura. She has headaches up
to 4x/week, and takes amitriptyline 25 mg qhs for prophalyxis.
She takes sumatriptan for the headaches, but always runs out of
her 12 tablets each month. She then takes ibuprofen. She has
never seen a neurologist.
She has had some weight loss in the last year, intentional.
No other history of episodes of >24 hours of a focal neurologic
deficit.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies night sweats.
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:
migraine
chronic nephrolithiasis
bipolar disorder on GBP
ADHD
h/o zoster ophtalmicus at age ___ with residual OD mydriasis and
R
V1 sensory loss.
Social History:
___
Family History:
M: migraine
MGM: perforated eardrum
Physical Exam:
========================================
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 96.6 HR: 73 BP: 129/75 RR: 18 SaO2: 100% RA
General: Awake, cooperative, intermittently tearful. Sitting
hunched over emesis basin when I enter room.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions. Mild
erythema R external auditory canal, worse near the TM. No
vesicles.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive to exam. Speech is fluent
with normal grammar and syntax. No paraphasic errors.
Comprehension intact to complex commands. Normal prosody.
-Cranial Nerves: R pupil 5mm and fixed. L pupil 3->2. VFF to
confrontation. EOMI without nystagmus. Head impulse without
corrective saccade. Facial sensation intact to light touch
except
decr R V1. Face symmetric at rest and with activation. Weber
louder on ___ with air>bone bilaterally. Palate elevates
symmetrically. ___ strength in trapezii bilaterally. No
dysarthria.
- Motor: Normal bulk and tone. No drift. No tremor nor
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Abductors
L 3 2 2 2 2
R 3 2 2 2 2
Plantar response was flexor bilaterally.
-Sensory: Intact to LT throughout.
- Coordination: Pt complains that FTN is difficult on L, though
evaluation for dysmetria limited by pt impersistence. Fine RAM
are mismeasured and dysrhtyhmic on L. Overshoot with mirroring
on
L. FTN, RAM, and mirroring without dysmetria on R. No
past-pointing.
- Gait: Normal initiation. Narrow base. Pt gradually veers
toward
R, corrects when she comes close to a nearby object but then
again gradually veers toward the R. Romberg with falling
backward
x2.
DISCHARGE PHYSICAL EXAM:
========================
left AMA so no exam at time of discharge-- exam below reflects
exam during AM rounds
**
asymmetric pupils, no nystagmus, with
full eye movements. She has decreased facial sensation over her
right trigeminal 1. Uvula and palate slightly asymmetric on the
left. Motor with no drift fine finger movements and rapid
alternating with a rapid and symmetric. She is full power.
Deep
tendon reflexes are symmetric and brisk. Sensory exam with
decreased light touch, temperature, vibration in her right leg.
Area of largest altered sensation involves light touch from
right
knee distally, but dense as anesthesia involves pinprick
involving her right foot coordination exam with no dysmetria on
finger-nose-finger. She has slight dysdiadochokinesia on fine
finger movements, but not on rapidly alternating movements. She
has slight increased rebound on the left. There is trace
overshoot on finger mirror bilaterally. Her gait is cautious
with some swaying. She frequently reaches out to steady her
balance but does not fall.
Pertinent Results:
ADMISSION LABS
___ 12:33PM BLOOD WBC: 5.1 RBC: 4.47 Hgb: 14.5 Hct: 42.4
MCV: 95 MCH: 32.4* MCHC: 34.2 RDW: 12.6 RDWSD: 43.___
___ 12:33PM BLOOD Neuts: 52.9 Lymphs: ___ Monos: 7.9 Eos:
2.8 Baso: 0.6 Im ___: 0.4 AbsNeut: 2.69 AbsLymp: 1.80 AbsMono:
0.40 AbsEos: 0.14 AbsBaso: 0.03
___ 12:33PM BLOOD Glucose: 88 UreaN: 8 Creat: 0.7 Na: 142
K:
4.8 Cl: 103 HCO3: 25 AnGap: 14
___ 12:33PM BLOOD ALT: 17 AST: 17 AlkPhos: 69 TotBili: 0.4
___ 12:33PM BLOOD Albumin: 4.6 Calcium: 10.1 Phos: 2.8 Mg:
2.0
___ 12:33PM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG
Bnzodzp: NEG Barbitr: NEG Tricycl: NEG
IMAGING:
+ MRI ___
There is no evidence of intracranial hemorrhage, edema, masses,
mass effect, midline shift or infarction. The ventricles and
sulci are normal in caliber and configuration. There is no
abnormal enhancement after contrast administration. No
diffusion abnormalities are detected. Major intracranial
vascular flow voids are preserved. Dural venous sinuses are
patent. Orbits are unremarkable. There is mild mucosal
thickening in the bilateral ethmoid air cells and a right
maxillary sinus mucous retention cyst.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with hx migraine and remote R
zoster opthalmicus c/b residual R V1 numbness and OD mydriasis
who presents to the ED with one day of vertigo superimposed on
months of increased clumsiness and walking into walls.
#Peripheral vestibulopathy
___ is a ___ year old female with a history of migraines
without aura and remote R zoster opthalmicus c/b residual R V1
numbness who presents with acute dizziness (vertigo) as well as
gait instability for several months. Her initial exam was
notable for L dysmetria, mismeasuring and overshoot on
mirroring. Of note, no nystagmus and chronic right V1 sensory
loss. There were no vesicles in either ear. Gait was notable for
cautious with some sway. Given the acute onset and dysmetria,
there was concern for a cerebellar process There was concern for
a brainstem or cerebellar process such as vascular or
demyelinating lesion. Given her additional more subacute issues
w/ gait instability there was also concern for a mass. MRI with
and without contrast was obtained which showed no acute process
on preliminary review. Otherwise, she had unremarkable labs
including UA without infection.
Before next steps could be addressed patient left against
medical advice.
TRANSITIONAL ISSUES:
===================
[] Trend symptoms of dizziness as outpatient. If symptoms do not
improve, consider referral to ENT.
[] Patient expressed wish to possibly transition off of
gabapentin given possible side effect of unsteadiness. She would
be willing to trial ___ or other medication for her bipolar
disorder. Please continue to discuss as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 900 mg PO TID
2. Methylphenidate SR 40 mg PO QAM
3. Omeprazole 20 mg PO DAILY:PRN Heartburn
4. Sumatriptan Succinate 50 mg PO ONCE MR1 Migraine
5. Acetaminophen 1000 mg PO Q6H
6. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Gabapentin 900 mg PO TID
3. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
4. Methylphenidate SR 40 mg PO QAM
5. Omeprazole 20 mg PO DAILY:PRN Heartburn
6. Sumatriptan Succinate 50 mg PO ONCE MR1 Migraine
Discharge Disposition:
Home
Discharge Diagnosis:
Vertigo and dizziness, unclear etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because you had dizziness. Given that
you had some abnormal neurologic signs, such as unsteadiness and
clumsienss of the left side, and swaying to the side while
walking, we were concerned for a problem in the brain, such as
an infection, stroke or mass. To look into this, you had an MRI
brain performed, which on preliminary review did not show any
evidence of this -- the final report is unavailable at this
time.
We were considering next steps to look into your symptoms,
including other medications to improve your symptoms, pending
the final MRI results.
However, at this time, you have elected to leave AGAINST MEDICAL
ADVICE (AMA), which is your right as a patient. In leaving
against medical advice, you are accepting the risk of worsening
of symptoms, including death.
It was a pleasure taking care of you.
Warm Regards,
Your ___ care team
Followup Instructions:
___
|
10330554-DS-13 | 10,330,554 | 27,236,055 | DS | 13 | 2159-03-16 00:00:00 | 2159-03-17 23:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
unsteady gait
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old right handed man with a history of HTN,
DM, ETOH abuse, hyperlipidemia and prostate cancer s/p resection
who
presents with unsteadiness on standing when waking this AM.
The patient reports being in his usual state of health last
night when going to bed. He awoke around midnight and then
around 4 am to use a bedside urinal and each time he had a drink
or two of vodka. He stood on both of these occasions and does
not recall feeling unsteady but did not try to walk. At 5 am he
woke up and once he stood up felt very unsteady. It required
multiple attempts to get on his feet and after taking a few
steps he sat back down for fear that he would fall. He denies
room spinning. Describes it as "not having control of myself"
and says it felt somewhat like rocking on a boat. He did not
feel pulled to one side or another. He says he could feel his
feet and denied any lack of coordination of the hands or feet.
He has chronic low back pain that is slightly worse this morning
but he attributes that to going to the gym yesterday. Also has a
mild headache. He has usual numbness in his right foot.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, parasthesiae. Has
chronic urinary incontinence.
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
- Hyperlipidemia
- history of DM, now diet controlled and off medications
- Gout
- prostate cancer s/p resection
Social History:
___
Family History:
Mother died in ___ of MI. No strokes or seizures in family.
Physical Exam:
ADMISSION EXAMINATION:
Vitals:T 97.3 HR 77 BP 169/71 RR 20 97% RA
General: Well appearing, NAD.
HEENT: NC/AT
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Speech was not dysarthric. Able to follow both midline and
appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Wide based, stumbles to the right. steady on Romberg.
============================
DISCHARGE EXAMINATION:
Vitals:T 97.9 HR 78 BP 155/80 RR 20 100% RA
General: Well appearing, NAD.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric. Able to follow
both midline and
appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
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.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Wavers on Romberg a bit but is much improved, no ataxia
while sitting.
Pertinent Results:
ADMISSION LABS:
___ 06:30AM BLOOD WBC-5.9 RBC-4.65 Hgb-15.2 Hct-44.5 MCV-96
MCH-32.7* MCHC-34.1 RDW-13.4 Plt ___
___ 06:30AM BLOOD Neuts-59.3 ___ Monos-6.4 Eos-3.3
Baso-0.9
___ 06:30AM BLOOD Glucose-108* UreaN-17 Creat-1.2 Na-140
K-4.3 Cl-102 HCO3-26 AnGap-16
___ 03:31PM BLOOD ALT-45* AST-35 AlkPhos-88 TotBili-0.4
RELEVANT LABS:
___ Cholest-167 Triglyc-142 HDL-44 CHOL/HD-3.8 LDLcalc-95
___ %HbA1c-6.6* eAG-143*
___ VitB12-596 Folate-14.5
TOX SCREEN:
___ 06:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
==============================
IMAGING:
CT HEAD ___: No evidence of acute intracranial process.
Chronic changes as described above.
CTA HEAD/NECK ___:
1. Nonvisualization of the right vertebral artery from its
origin. This is likely due to occlusion of unknown chronicity.
Minimal retrograde flow into the V4 segment of the right
vertebral artery.
2. Focal narrowing of the distal ICA just before the entrance
into the carotid canal. This may be due to predominantly soft
plaque; however, consideration should be given to dissection.
Would recommend an MRI and MRA with fat sat to further evaluate.
MRI/MRA ___:
1. No acute intracranial abnormality, with no evidence of
infarct.
2. Occluded right vertebral artery.
3. The post contrast MRA of the neck adds little to the previous
evaluation by CT. No cresentic hyperintensity is seen adjacent
to the distal left ICA to suggest acute dissection, but the exam
is severely motion degraded and does not fully cover the area of
interest on the prior CTA.
Brief Hospital Course:
Mr. ___ is a ___ yo RH man with PMH of HTN, HLD, diet
controlled DM and EtOH use who presented with gait instability
after waking up from sleep. His examination did not show
appendicular cerebellar signs, though he did have some swaying
with Romberg and unsteady gait.
# NEURO: unsteady gait with no acute infarct on MRI. CTA showed
likely chronic occlusion with collaterals and focal narrowing of
L distal ICA with soft plaque. MRA did not show clear dissection
but very poor quality study. The source of his unsteadiness was
most likely due to chronic cerebellar injury from alcohol abuse.
Patient with started on 325mg aspirin and simvastatin was
increased to 40mg daily with LDL goal < 70 (current LDL 97). He
was monitored on telemetry throughout the admission with no
events.
# CV: Patient with history of HTN, home lisinopril/amlodipine
were held during the admission given concern for stroke but was
restarted on discharge. Patient reported that he has been taking
Labetalol regularly even though there is no active prescription
in the record since ___. We alerted the PCP and
discharged him on labetalol 200mg BID, but may need further
adjustment as outpatient.
# TOX: EtOH abuse (1 pint of vodka per day). Patient was
monitored on CIWA, did well and did not require lorazepam.
Patient has gone to AA in the past and expressed interest in
trying again. We encouraged the patient to get in touch with his
sponsor and join and local group.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 300 mg PO DAILY
4. Colchicine 0.6 mg PO DAILY:PRN gout
5. Amlodipine 10 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Labetalol 200 mg PO BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*2
2. BuPROPion (Sustained Release) 300 mg PO DAILY
3. Colchicine 0.6 mg PO DAILY:PRN gout
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 40 mg PO DAILY
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
6. Amlodipine 10 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. Labetalol 200 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Gait difficulty, likely related to alcohol
use; right vertebral artery occlusion and left ICA stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure to take care of you at ___
___. You were admitted because of the difficulty with
walking. The MRI of your head did not show any stroke, but it
did show narrowing and blockage of the blood vessels that go to
your head, likely from high cholesterol and blood pressure. We
believe your difficulty with walking may be related to your
alcohol use and strongly encourage you to re-join the AA group
and to quit drinking.
Your aspirin and simvastatin (Zocor) was increased to help
prevent further narrowing of the blood vessels to the head.
Please take it EVERY day as prescribed to decrease risk of
strokes.
Please take the medications as prescribed to better control the
risk factors for stroke.
Followup Instructions:
___
|
10330554-DS-14 | 10,330,554 | 27,676,928 | DS | 14 | 2160-11-22 00:00:00 | 2160-11-25 14:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L-sided flank pain and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with DM, HTN, TIA, tobacco abuse, obesity, and asthma who
presented to clinic with cough and atypical chest pain. He had a
URI three weeks ago and recovered but has residual persistent
cough x 3 weeks productive of yellow sputum. He also has had
L-sided chest pain x 1 week, described as dull, throbbing
persistent pain, not pleuritic and not associated with exertion
or positional change. It does not radiate and he has had no SOB,
nausea, lightheadedness. Patient was seen in clinic today with
EKG which showed new TWI in I, II, aVL, V3, prompting transfer
to ED. He takes full dose aspirin daily for history of TIA. In
the ED, initial VS: 98.4 193/92 77 20 98% RA. Exam notable for
expiratory wheezes. Troponins negative. Given duonebs. Admitted
for r/o ACS.
Past Medical History:
HTN
Hyperlipidemia
History of DM, now diet controlled and off medications
Gout
Prostate cancer s/p resection
Social History:
___
Family History:
Mother died in ___ of MI. No strokes or seizures in family.
Physical Exam:
ADMISSION
VS: 98.3 166/83 66 19 97% RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP difficult to assess secondary to body
habitus.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. TTP over left chest wall.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE
VS: 97.9, 166-72/83-97, 66-74, ___ RA
I/O: 360/250 // NR
Wt 114 kg
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP difficult to assess secondary to body
habitus.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4. TTP over left chest wall.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
___ 09:10PM BLOOD WBC-6.5 RBC-4.54* Hgb-14.5 Hct-43.4
MCV-96 MCH-31.9 MCHC-33.4 RDW-13.7 Plt ___
___ 09:10PM BLOOD Neuts-60.7 ___ Monos-5.9 Eos-1.7
Baso-0.2
___ 09:32PM BLOOD ___ PTT-28.4 ___
___ 09:10PM BLOOD Plt ___
___ 03:26AM BLOOD Glucose-216* UreaN-24* Creat-1.2 Na-136
K-4.1 Cl-101 HCO3-22 AnGap-17
___ 09:10PM BLOOD Glucose-108* UreaN-24* Creat-1.1 Na-138
K-4.3 Cl-105 HCO3-18* AnGap-19
___ 03:26AM BLOOD CK(CPK)-325*
___ 09:20AM BLOOD cTropnT-PND
___ 03:26AM BLOOD CK-MB-4 cTropnT-<0.01
___ 09:10PM BLOOD cTropnT-<0.01
___ 09:10PM BLOOD proBNP-89
___ 03:26AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0
Exercise stress test ___
INTERPRETATION: ___ yo man with HTN, HL and DM was referred to
evaluate an atypical chest discomfort and baseline ECG
abnormalities.
The patient completed 10 minutes and 0 seconds of a Gervino
protocol
representing a poor exercise tolerance for his age; ~ ___ METS,
however
similar exercise tolerance to ETT performed in ___. No chest,
back,
neck or arm discomforts were reported by the patient during the
procedure. In the presence of 0.5-1 mm ST segment depression and
T wave
inversion noted inferolaterally at baseline, no additional ST
segment
changes were noted from baseline. Nonspecific T wave
normalization was
noted inferior and in leads V5 and V6. The rhythm was sinus with
occasional APBs and rare VPBs. Resting systolic and diastolic
hypertension with an appropriate blood pressure response to
exercise.
In the presence of beta blocker therapy, the heart rate response
to
exercise was blunted.
IMPRESSION: Limited/fair exercise tolerance, however similar to
that
reported on ETT in ___. No anginal symptoms or additional ST
segment
changes from baseline. Nonspecific T wave normalization.
Baseline
systolic and diastolic hypertension with an appropriate blood
pressure
response to exercise. Blunted heart rate response. No ischemia
at good
workload.
CXR ___
FINDINGS:
The cardiac, mediastinal and hilar contours appear stable.
There is no
pleural effusion or pneumothorax. The lungs appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Brief Hospital Course:
___ with DM, HTN, tobacco abuse, obesity, and asthma who
presented to clinic for persistent cough for ___s
L-sided chest pain, admitted for r/o ACS.
# Chest Pain: Patient has atypical chest/L-sided flank pain pain
x 1 week which is TTP, described as throbbing. It is atypical
but given he is a diabetic smoker, HTN with history of TIA, the
EKG changes with new TWI are concerning. However ACS ruled out
with three sets of enzymes, EKG and stress test. Continued home
ASA 325 mg, home Atorvastatin 40 daily, and labetalol 200 mg
BID.
# Chronic Cough: Patient with cough now for 3 weeks, likely
post-infectious, no fevers, chills and CXR negative. Given prn
Guaifenesin during admission and on discharge.
# HTN: Continued home amlodipine, lisinopril, labetalol
# HL: Continued home atorvastatin.
# T2DM: Held home metformin, gave HISS
# H/o TIA: Continued ASA 325
# Asthma: Continued flovent and alb inh
# Gout: Continued allopurinol
# Substance use: Significant alcohol use and smoking. CIWA Q4H
(no diazepam for now, but to start if needed). MVI, folate,
thiamine.
Transitional issues:
- New medication: Guaifenisen prn for cough
- Follow up with PCP and cardiologist
- Continue good work with smoking cessation
- Diabetes and weight management
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. BuPROPion (Sustained Release) 300 mg PO DAILY
3. Colchicine 0.6 mg PO DAILY:PRN gout
4. Multivitamins 1 TAB PO DAILY
5. Amlodipine 10 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Labetalol 200 mg PO BID
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Allopurinol ___ mg PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheeze
12. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheeze
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. BuPROPion (Sustained Release) 300 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Labetalol 200 mg PO BID
9. Lisinopril 40 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ liquid(s) by mouth q6h prn
Refills:*0
12. Colchicine 0.6 mg PO DAILY:PRN gout
13. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Atypical chest pain
Post-viral URI cough
Secondary:
Diabetes
Hypertension
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dr. ___,
You came to the hospital with pain on the left side of your
chest/abdomen with changes on your EKG (which monitors the
electrical activity of your heart) and a persistent cough for
the past week. We did an exercise stress test but it did not
show any damage to your heart. The pain may be related to your
persistent cough. The cough is likely from your recent viral
illness and possible worsening of your asthma from the illness.
We will give you an inhaler and cough medication on discharge.
It was a pleasure taking care of you.
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
|
10330868-DS-22 | 10,330,868 | 26,637,528 | DS | 22 | 2169-10-09 00:00:00 | 2169-10-09 16:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Avelox / Cipro / Levaquin / codeine / Sulfa (Sulfonamide
Antibiotics) / Quinolones
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Right hepatic artery angiogram and coil embolization
History of Present Illness:
Patient is a ___ year old female with history of SLE who is s/p
lap ccy 2 weeks ago at ___ presents with worsening
RUQ pain, chills, SOB, and several episodes of syncope last
evening. Patient had an uneventful post-op course from lap ccy
and was recovering well at home, back to her usual activities,
until last night, when she began to experience RUQ and right
shoulder pain after eating ___ fries during dinner.
She went to bed around 9pm, and awoke at midnight feeling
unwell. She was experiencing chills, cold sweats, shortness of
breath, and worsening RUQ pain radiating to her shoulder at that
time. She got up to try to go to the bathroom from her living
room (she had been asleep on the sofa) but passed out on the
living room floor upon standing. She awoke soon afterwards, and
tried to make it to the bathroom again, and this time made it
into the kitchen before passing out again. At this point, she
tried crawling into her bathroom and was calling for her husband
___ help her. She has vague memory of the events that
followed, but believes she lost consciousness ___ times in
total, however denies any head strike or injuries from her
falls.
Her husband called ___ and patient was taken to ___
___. Her vitals were stable and her HCT was 37.0 at that
time. A CT was performed which was concerning for a hepatic
pseudoaneurysm with moderate hemoperitoneum, and the patient was
transferred to ___ at that time for further care.
Past Medical History:
Past Medical History: SLE, GERD, asthma, migraines, HLD
Past Surgical History: lap ccy (2 weeks ago), sinus surgery,
footsurgery for plantar fascitis
Social History:
___
Family History:
Non-contributory
Physical Exam:
T98.8 P78 BP151/81 RR16 Pox98RA
GEN: NAD, AAOx3, pale without hair
HEART: RRR S1S2
PULM: CTAB, no respiratory distress
AB: soft, mild TTP in RUQ, nondistended, normal bowel sounds
EXT: peripheral pulses intact bilaterally
Pertinent Results:
___ 11:05AM BLOOD WBC-12.7*# RBC-3.54* Hgb-10.1* Hct-30.4*
MCV-86 MCH-28.7 MCHC-33.4 RDW-12.9 Plt ___
___ 04:45PM BLOOD WBC-8.0 RBC-3.17* Hgb-9.0* Hct-26.4*
MCV-83 MCH-28.3 MCHC-34.1 RDW-13.2 Plt ___
___ 08:00PM BLOOD WBC-7.8 RBC-3.11* Hgb-8.9* Hct-26.8*
MCV-86 MCH-28.5 MCHC-33.1 RDW-12.9 Plt ___
___ 03:30AM BLOOD WBC-6.4 RBC-2.99* Hgb-8.6* Hct-25.4*
MCV-85 MCH-28.6 MCHC-33.7 RDW-13.2 Plt ___
___ 03:00PM BLOOD Hct-29.4*
___ 04:33AM BLOOD WBC-6.3 RBC-3.08* Hgb-9.0* Hct-26.2*
MCV-85 MCH-29.3 MCHC-34.6 RDW-13.0 Plt ___
___ 12:50PM BLOOD Hct-28.6*
___ embolization ___
FINDINGS: Large 2 cm bilobed pseudoaneurysm with a broad-base
arising from the right hepatic artery.
IMPRESSION: Successful embolization of the right hepatic artery
with no further bleeding into the pseudoaneurysm.
Brief Hospital Course:
The patient was admitted to the Acute Care Surgery Service on
___ a bleeding hepatic pseudoaneurysm and underwent a right
hepatic artery angiogram and coil embolization. Please see the
separately dictated procedure note for details of procedure. The
patient was ___ transferred to ICU for further care, and
then transferred to the hospital floor when her hematocrit was
stable. The hospital course was uneventful and the patient was
discharged to home.
Hospital Course by Systems:
Neuro: Pain was well controlled, initially with IV regimen which
was transitioned to oral regimen once tolerating oral intake.
Given home verapamil for migraines. Given zofran,
prochlorperazine, and a scopolamine patch for nausea.
Cardiovascular: Remained hemodynamically stable.
Pulmonary: Oxygen was weaned and the patient was ambulating
independently without supplemental oxygen prior to discharge.
GI: CT showed bleeding pseudoanuerym off right hepatic artery.
Right hepatic artery angiogram and coil embolization on HD1.
Diet was advanced as tolerated afterwards.
GU: Patient was able to void independently.
Heme: Hematocrit monitored closely. Stable at 28.6 prior to
discharge. Received heparin subcutaneously and pneumatic
compression boots for DVT prophylaxis.
Endocrine: Home levothyroxine given.
The patient was discharged to home in stable condition. The
patient was given instructions to follow-up in the ___ clinic in
___ weeks. The patient also also advised to follow up with her
surgeon and PCP ___ 1 week. The patient received instructions
outlining activity and diet, as well as a prescription for
zofran.
Medications on Admission:
levothyroxine
verapamil
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN headache
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
8 hours Disp #*30 Tablet Refills:*0
4. Verapamil SR 240 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding hepatic pseudoanuerym
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Acute Care Surgery service on ___
with a bleeding pseudoanuerym off right hepatic artery. You
underwent a right hepatic artery angiogram and coil
embolization. Your hemocrit and your vital signs have been
stable. You are now ready to complete your recovery at home.
Please follow the instructions below:
-You may resume normal activity as tolerated. No strenuous
activity until you follow up with your surgeon or your primary
care provider.
-You may resume a normal diet as tolerated.
-You are advised to follow up in the Acute Care Surgery clinic
in ___ weeks. Please call ___ to schedule this
appointment.
-You are also advised to follow up with your surgeon and your
primary care provider ___ 1 week.
-Please call the clinic, or go to the emergency department, if
you develop dizziness, fatigue, or for anything else that
concerns you.
Followup Instructions:
___
|
10330900-DS-17 | 10,330,900 | 24,267,319 | DS | 17 | 2123-01-23 00:00:00 | 2123-01-23 16:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L foot infection
Major Surgical or Invasive Procedure:
___: L foot debridement and wound vac application
History of Present Illness:
___ with PMH sig for DM presents to the ED as instructed by Dr.
___ yesterday in clinic due to left foot infection. He has a
chronic ulceration that has been present for several months and
regularly seen by Dr. ___ care. Pt denies any systemic
signs of infection.
Past Medical History:
Diabetes, high blood pressure, high cholesterol and CAD.
Social History:
___
Family History:
Significant for numerous members w/ Diabetes mellitus and
hypertension. History of stroke.
Physical Exam:
Admission:
Gen: NAD, cooperative
LLE focused exam: There a full-thickness ulceration on the
plantar lateral aspect of the left foot which measures about 2
cm x 3 cm. + probe to bone with serous drainage. No purulence
noted. +malodor. Mild varus deformity to the midfoot/RF. DP
pulse palpable, dopplerable ___. +cellulitis to left foot.
Discharge:
Gen: NAD, cooperative
LLE focused exam: Plantar lateral ulceration with granular
base. No local signs of infection. DSD. Neurovasc status remains
at baseline.
Pertinent Results:
___ 09:40AM BLOOD WBC-7.5 RBC-3.45* Hgb-9.8* Hct-31.1*
MCV-90 MCH-28.4 MCHC-31.5 RDW-14.7 Plt ___
___ 09:40AM BLOOD Neuts-70.7* ___ Monos-4.8
Eos-4.5* Baso-0.3
___ 09:40AM BLOOD Plt ___
___ 09:40AM BLOOD Glucose-320* UreaN-13 Creat-1.1 Na-135
K-4.5 Cl-104 HCO3-25 AnGap-11
___ 10:35AM BLOOD CRP-31.0*
___ 10:35AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2
___ 05:40AM BLOOD CRP-16.0*
___ 09:49AM BLOOD Lactate-1.1
___ 10:35AM BLOOD SED RATE-PND
___ 05:40AM BLOOD SED RATE-PND
___ 05:40AM BLOOD WBC-5.5 RBC-3.36* Hgb-9.7* Hct-30.8*
MCV-92 MCH-28.9 MCHC-31.5 RDW-15.4 Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:08AM BLOOD WBC-6.5 RBC-3.38* Hgb-9.5* Hct-30.7*
MCV-91 MCH-28.2 MCHC-31.1 RDW-16.1* Plt ___
___ 05:08AM BLOOD Plt ___
___ 05:08AM BLOOD Glucose-232* UreaN-13 Creat-1.1 Na-140
K-4.1 Cl-106 HCO3-31 AnGap-7*
___ 07:00PM BLOOD Vanco-17.4
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ 3:43 pm TISSUE BONE LEFT FOOT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Preliminary):
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT in
this culture..
ANAEROBIC CULTURE (Final ___:
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP..
___. EU ___ 10:37 AM
KNEE (AP, LAT & OBLIQUE) LEFT; TIB/FIB (AP & LAT) LEFT; ANKLE
(AP, MORTISE & LAT) LEFT; FOOT AP,LAT & OBL LEFT Clip #
___
Reason: eval for osteo
UNDERLYING MEDICAL CONDITION:
History: ___ with L leg pain, h/o diabetes
REASON FOR THIS EXAMINATION:
eval for osteo
Final Report
INDICATION: Left leg pain. History of diabetes.
COMPARISON: None.
TECHNIQUE: Left lower extremity, total of eleven views,
including views of the right knee, tibia and fibula, left ankle
and foot.
FINDINGS:
Right knee: The joint compartment spaces appear preserved.
There is no
evidence for fracture, dislocation, bone destruction. No joint
effusion is appreciated. Moderate superior and inferior
patellar spurs are noted.
Left tibia and fibula: There is periosteal reaction that
appears benign along the both the tibia and fibula. A most
common explanation for this type of appearance is venous stasis
although hypertrophic osteoarthropathy of a possible diagnosis.
Left ankle: The tibiotalar joint appears mildly narrowed. The
ankle mortise appears congruent. Small ossicles are probably
chronic immediately distal to the fibula.
Left foot: There is substantial bone destruction and involving
the lateral midfoot. Specifically, parts of the cuboid and
bases of the fourth and fifth metatarsals are destroyed with the
as sclerosis periosteal reaction and a large ulceration
including air that appears to probe down to the bone surface.
There is a rocker bottom type appearance to the foot as well as
a the of areas of all foot. Soft tissues are diffusely swollen
about the foot. The patient is status post on amputation of the
fourth middle and distal parts of the proximal phalanges. The
bones appear demineralized.
IMPRESSION:
1. Large lateral plantar ulceration along the mid foot with
extensive bone destruction involving adjacent bony structures,
probably at least subacute in time course.
2. Periosteal reaction along the tibia and fibula, which could
be seen with a number of causes including venous stasis and
hypertrophic osteoarthropathy.
___ SURG FA5 ___ 10:09 AM
CHEST PORT. LINE PLACEMENT Clip # ___
Reason: 49cm left ___. ___
UNDERLYING MEDICAL CONDITION:
___ year old man with new picc
REASON FOR THIS EXAMINATION:
49cm left picc. ___
Wet Read: YXXS SUN ___ 10:58 AM
Lung volumes are very low with bilateral opacities suggesting
worsening
pulmonary edema. Left PICC line terminates in the low SVC. There
is no
pneumothorax.
The findings were telephoned to ___, IV care nurse by ___
___ at 10:40
am, ___, at the time of discovery.
Wet Read Audit # ___ ___ SUN ___ 10:42 AM
Lung volumes are very low with bilateral opacities suggesting
worsening
pulmonary edema. Left PICC line terminates in the low SVC. There
is no
pneumothorax.
The findings were telephoned to ___, IV care nurse by ___
___ at 10:40
am, ___, at the time of discovery.
Final Report
EXAMINATION:
CHEST PORT. LINE PLACEMENT
INDICATION:
___ year old man with new picc // 49cm left ___. ___
Contact name:
___
TECHNIQUE: Chest single view
COMPARISON: ___.
IMPRESSION:
Lung volumes are very low with bilateral opacities suggesting
worsening
pulmonary edema. Left PICC line terminates in the low SVC. There
is no
pneumothorax.
Brief Hospital Course:
Mr. ___ was admitted to the Podiatric Surgical Service afer
presenting to Dr. ___ and subsequently the ED with a L
foot infection. He was started on IV abx. Upon arrival to the
floor, he was made NPO w/ IV fluids and taken to the OR ___
for a L foot debridement and wound vac application. The patient
tolerated the procedure without complications, (for full
procedure notes please see op report). Wound cultures were
obtained and he was continued on broad spectrum antibiotics
prior to obtaining culture results. His blood pressure was
elevated throughout admission that was controlled with IV and
oral metropolol as he responded and was normotensive. He was
asymptomatic throughout the event. The infectious disease team
was consulted and made reccomendations on antibiotics. A PICC
was placed on ___. He was discharged ___. He will
follow up with his PCP in regards to his blood pressure and with
podiary for management of pedal care. Patient understands to be
non weightbearing to his foot with wound vac in place @ rehab.
Patient understands and is amenable to plan.
Medications on Admission:
Gabapentin, aspirin, ibuprofen and furosemide.
Discharge Medications:
1. Gabapentin 800 mg PO TID
2. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. Lisinopril 20 mg PO DAILY
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Tamsulosin 0.4 mg PO DAILY
6. Vancomycin 1000 mg IV Q 12H
7. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every eight (8)
hours Disp #*42 Vial Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L foot infection
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 ___. You were admitted
to the Podiatric Surgery service after you presented to Dr.
___ and subsequently the ED for a L foot infection.
You underwent a L foot debridement and wound vac placement on
___. The procedure was uneventful. You were given IV
antibiotics while here. A PICC line was placed. You are being
discharged with the following instructions:
ACTIVITY:
There are restrictions on activity. Please remain non weight
bearing to your L foot until your follow up appointment. You
should keep this site elevated when ever possible (above the
level of the heart!)
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.
You need to be nonweightbearing to your left foot for optimal
healing potential.
BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep
your dressing CLEAN, DRY and INTACT. You can use a shower bag
taped around your ankle/leg or hang your foot/leg outside of the
bathtub.
Avoid taking a tub bath, swimming, or soaking in a hot tub for 4
weeks after surgery or until cleared by your physician.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery.
You have also had two antibiotics added: IV Vancomycin and IV
Zosyn. You will likely need a 6 week course of each of these.
You will be following up with the infectious disease specialists
for this.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is not unusual for several weeks and small,
frequent meals may be preferred.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments.
If a follow up appointment was not made prior to your discharge,
please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are ___
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
___
|
10330900-DS-18 | 10,330,900 | 20,979,762 | DS | 18 | 2123-11-07 00:00:00 | 2123-11-07 14:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L. foot/ankle swelling
Major Surgical or Invasive Procedure:
Left lower extremity debridement and biopsy
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: This is a ___ year old man with a
PMH significant for diabetes, CAD and chronic left foot
ulceration who presented with swelling ___ the left foot.
The patient reports that he just returned from ___. He noted
that he had a fracture ___ his left ankle prior to his trip to
___. He had been there x3 weeks and when he returned, he noted
significant swelling ___ the left foot up to the level of the
knee. Of note, at triage, the patient was markedly hyperglycemic
to FSBS >500 and serum >700.
ED resident noted that patient had burping and hiccups and a
vague complaint of chest pain that he was unable to fully
characterize, without dyspnea. Initial troponin was negative. He
received full-dose aspirin.
Vitals on arrival to the ED: 0 98.2 86 184/86 16 99%/RA.
- Labs were significant for:
- Imaging of the left foot/ankle revealed: [1.] large lateral
plantar ulceration along the left mid foot with subcutaneous gas
tracking anteriorly and into the dorsal aspect of the foot. The
extent of bony destruction appears relatively unchanged. The
subcutaneous air and dorsal swelling appears increased since
prior study and these findings are concerning for osteomyelitis.
[2.] No acute fracture or dislocation at the tibia/fibula. Lower
extremity subcutaneous soft tissue swelling.
- He received: 1L NS, 10 units regular insulin, 10 mg Reglan IV,
4.5 g IV Zosyn (04:28) and ASA 324 mg.
He was taken urgently to operating by podiatry with ICU
admission following for further workup and medical management.
On arrival to the MICU he has no particular complaints. Notes he
returned from ___ on ___.
REVIEW OF SYSTEMS:
Denies chest pain, nausea, vomitting, shortness of breath, or
dysuria.
Past Medical History:
- Diabetes mellitus, complicated by peripheral neuropathy
- Coronary artery disease
- Hypertension
- Hyperlipidemia
- Chronic left foot wound (managed by ___ Podiatry)
Social History:
___
Family History:
Notes his parents are deceased
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
============================
VITALS - afebrile, BP 136/59, HR 69, 98% RA
GENERAL - appears somewhat sedated post-operatively, able to
answer simple questios
HEENT - dry appearing mucus membranes, EOMI
CARDIAC - ___ systolic murmur best heard at LUSB
PULMONARY - Clear to auscultation bilaterally
ABDOMEN - soft, non-tender to palpation
EXTREMITIES - LLE with dresssing ___ place, 2+ edema to the left
knee, RLE with 1+ edema to the knee
SKIN - no rash
Pertinent Results:
LABS ON ADMISSION:
====================
___ 02:10AM BLOOD WBC-13.9*# RBC-3.97* Hgb-11.3* Hct-35.2*
MCV-89 MCH-28.5 MCHC-32.1 RDW-13.6 RDWSD-44.1 Plt ___
___ 02:10AM BLOOD Neuts-91.0* Lymphs-5.1* Monos-3.2*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-12.62* AbsLymp-0.71*
AbsMono-0.45 AbsEos-0.01* AbsBaso-0.03
___ 02:10AM BLOOD Glucose-735* UreaN-27* Creat-1.8* Na-130*
K-5.9* Cl-83* HCO3-24 AnGap-29*
___ 02:10AM BLOOD CK(CPK)-390*
___ 02:10AM BLOOD cTropnT-<0.01
___ 02:00PM BLOOD CK-MB-3 cTropnT-<0.01
___ 02:10AM BLOOD Calcium-8.9 Phos-4.6* Mg-2.2
___ 02:17AM BLOOD Lactate-2.5* K-4.1
Micro:
==========
___ 6:00 am TISSUE L ___ METATARSAL BONE .
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by ___. ___ (___)
ON ___
AT 11:32 AM.
TISSUE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
___ 6:00 am SWAB DEEP LEFT FOOT .
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI ___
PAIRS.
WOUND CULTURE (Preliminary):
___ 6:00 am SWAB LEFT FOOT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI ___
PAIRS.
WOUND CULTURE (Preliminary):
Blood cultures ___:
IMAGING:
=========
CXR ___:
1.4 cm rounded opacity projecting over the left anterior second
rib.
Dedicated CT is recommended for further evaluation. No
pneumonia.
RECOMMENDATION(S): Chest CT for further evaluation of the 1.4
cm opacity.
___ US ___:
IMPRESSION: Preliminary Report
1. No evidence of deep venous thrombosis ___ the left lower
extremity veins.
2. The left peroneal veins were not well-visualized by
ultrasound.
LLE x-ray ___:
IMPRESSION:
1. Large lateral plantar ulceration along the left mid foot
with subcutaneous gas tracking anteriorly and into the dorsal
aspect of the foot. The extent of bony destruction appears
relatively unchanged. The subcutaneous air and dorsal swelling
appears increased since prior study and these findings are
concerning for osteomyelitis.
2. No acute fracture or dislocation at the tibia/fibula. Lower
extremity subcutaneous soft tissue swelling. Unchanged
periosteal reactions at the tibia/fibula which may be due to
venous stasis versus hypertrophic osteoarthropathy.
Brief Hospital Course:
This is a ___ year old man with a PMH significant for diabetes,
CAD and chronic left foot ulceration who presented with left
foot swelling, found to be markedly hyperglycemic, with a
leukocytosis, and imaging concerning for osteomyelitis and soft
tissue infection.
ACTIVE ISSUES.
# L foot osteomyelitis, gas gangrene
Patient with chronic left foot ulcer that has been managed by
___ Podiatry. ___ ED, patient afebrile, with swelling and
imaging with emphysema and also concern for osteomyelitis.
Received Zosyn ___ ED and vancomycin ___ the PACU. Brought to OR
by Podiatry swiftly after admission and underwent debridement of
wound. Patient is known MRSA carrier. Surgical tissue cultures
were positive for proteus, corynebacterium, and multi-drug
resistant E. coli. Patient was treated with vancomycin and zosyn
(day 1: ___. His left foot wound was managed with
wet-to-dry dressing changes daily. After discussion between
patient, family, and Dr. ___ surgeon), patient
elected for ___. BKA was performed on ___ by vascular surgery.
Please refer to operative note for details. Post-operatively, he
did well. He received 20mg IV lasix x 1 for POD ___ for stump
edema. His dressing was taken down on POD #2, and there was no
oozing, and the staple line showed no evidence of necrosis and
was healing well. He will have these staples removed ___ one
month. He worked with ___ daily starting on POD #1, and tolerated
this well. He tolerated a regular diet, and his pain was
transitioned to PO pain medication without issue. He was
discharged to rehab on POD #4 ___ stable condition.
# R foot plantar ulcer
Patient had pre-existing latero-plantar ulcer on R foot. This
was superficial and measured 4cm x 3.5cm. This wound was
inspected daily and managed with dry dressing changes. There
were no signs of infection of the wound. Size and depth was
stable during this admission.
# Diabetes Mellitus - Latent Autoimmune Diabetes of Adulthood
Phenotypically type 1 DM. On admission had serum blood glucose
735, and ketones ___ urine, but was not acidemic. Was initially
treated with NPH 20u BID, and then transitioned to
lantus/humalog sliding scale. His blood glucose has been labile
with a low fasting sugar of 49 and high of 265. His lantus was
up-tirated to 24u daily (his most recent ___ dose per his
pharmacy, though past clinic notes show he was on 30u qhs ___ ___. His blood glucose continued to be elevated despite an
aggressive insulin standing and sliding scale. ___
___ was consulted and followed throughout his post-operative
course, making daily changes as needed. They increased his
insulin regimen on the day of discharge for glucoses ___ the
400s, and this will need to be followed closely. He was given
instructions for his insulin management at ___, and will follow
up at the ___ ___ one month.
# GERD
Patient had significant reflux, hiccuping, and epigastric
discomfort concerning for atypical presentation of MI. ECG on
admission showed RBBB that appeared new compared to prior. Trops
X 2 also negative. Given omeprazole and maalox cocktail for
symptomatic managment. Repeat ECG on morning of ___ showed
no evidence of ischemia. Patient was continued on pantoprazole
with symptomatic improvement.
# Ileus
KUB showed large stool and possible ileus. He had continued
ileus despite PO bowel regimen. Despite being able to pass small
amounts of liquid stool, he had significant abdominal distension
and frequent hiccups, and occasional nausea and emesis. He
received PR bisacodyl and subsequent large soft bowel movements.
His hiccuping, nausea, and emesis resolved, and he tolerated
solid foods.
# Acute Kidney Injury
Creatinine on admission was 1.8 from baseline from baseline of
Cr 1.1-1.2. Consistent with pre-renal etiology ___ setting of
infection, polyuria. Lisinopril and furosemide were held.
Creatinine improved with IVF to baseline 1.1-1.2. Lisinopril
20mg PO daily was re-started and creatinine remained stable at
1.2.
CHRONIC ISSUES.
# CORONARY ARTERY DISEASE.
Patient has a history of anterior wall MI ___ 1990s per outside
records. He had reports of epigastric discomfort ___ ED, so trops
were obtained that were negative x2. EKG showed RBBB that was
new from prior. T-wave inversions ___ V1-V3 likely secondary to
conduction abnormality. ___ the setting of anemia, and blood loss
from OR, aspirin was held. Recommend re-starting at discharge.
# HYPERTENSION
Takes lisinopril, furosemide, and atenolol at ___. Initially
antihypertensives were held due to concerns of infection.
Patient's blood pressure was hypertensive to 160s systolic, so
was started on metoprolol 25mg PO bid and lisinopril 20mg PO
daily. Furosemide was held as patient was euvolemic on exam. ___
re-start furosemide if he develops positive fluid balance. An
echocardiogram performed on ___ showed preserved
biventricular function (LVEF >65%), and mild LVH consistent with
hypertensive heart.
# HYPERLIPIDEMIA.
-on rosuvastatin
TRANSITIONAL ISSUES:
=========================
- CXR showed 1.4 cm rounded opacity projecting over the left
anterior second rib.
Dedicated CT is recommended for further evaluation.
- Has Diabetes Mellitus (Latent Autoimmune Diabetes of
Adulthood) - phenotypically type 1. Will benefit from ___
appointment as outpatient.
- HTN: takes lisinopril 20mg daily, atenolol 25mg daily, and
furosemide 80mg BID. No evidence of heart failure, so furosemide
was held during this admission and continued to be euvolemic.
Recommend holding furosemide, but can re-start if signs of fluid
overload.
- Patient requests transfering primary care to ___. Please
schedule a new PCP for this patient with ___ provider. He may
follow with Dr. ___, his ___ resident physician.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 80 mg PO BID
2. Tamsulosin 0.4 mg PO QHS
3. Lisinopril 20 mg PO DAILY
4. Gabapentin 800 mg PO TID
5. Pantoprazole 40 mg PO Q24H
6. Atenolol 25 mg PO DAILY
7. Ranitidine 150 mg PO BID:PRN heartburn
8. Rosuvastatin Calcium 20 mg PO QPM
9. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Gabapentin 800 mg PO TID
2. Lisinopril 20 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Ranitidine 150 mg PO BID:PRN heartburn
5. Rosuvastatin Calcium 20 mg PO QPM
6. Tamsulosin 0.4 mg PO QHS
7. Docusate Sodium 100 mg PO BID
Take this while you are taking the oxycodone
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*60 Capsule Refills:*0
8. Atenolol 25 mg PO DAILY
9. Furosemide 80 mg PO BID
10. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*30 Tablet Refills:*0
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 to 6 hours
Disp #*60 Tablet Refills:*0
12. Senna 8.6 mg PO BID:PRN constipation
Take this while you are taking the oxycodone
RX *sennosides [___] 8.6 mg 1 capsule by mouth daily Disp
#*30 Tablet Refills:*0
13. Glargine 20 Units Breakfast
Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
L foot osteomyelitis
SECONDARY DIAGNOSIS
Diabetes Mellitus
Hypertension
Ileus
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 came to the hospital because of a severe bone infection ___
your left foot called osteomyelitis. We performed a surgery to
remove the dead tissue. We treated you with antibiotics to
prevent the infection from spreading. Given the severity of
disease and the amount of unhealthy tissue ___ your foot,
amputation was felt to be the best option. Please follow the
guidelines below to ensure a rapid recovery.
DIVISION OF VASCULAR AND ENDOVASCULAR SURGERY
LOWER EXTREMITY AMPUTATION
DISCHARGE INSTRUCTIONS
ACTIVITY
You should keep your amputation site elevated and straight
whenever possible. This will prevent swelling of the stump and
maintain flexibility ___ your joint.
It is very important that you put no weight or pressure on
your stump with activity or at rest to allow the wound to heal
properly.
You may use the opposite foot for transfers and pivots, if
applicable. It will take time to learn to use a walker and
learn to transfer into and out of a wheelchair.
BATHING/SHOWERING:
You may shower when you feel strong enough but no tub baths or
pools until the incision is fully healed.
After your shower, gently dry the incision well. Do not rub
the area.
WOUND CARE:
Please keep the wound clean and dry. It is very important that
there is no pressure on the stump. If there is no drainage,
you may leave the incision open to air.
Your staples will remain ___ your stump for at least 4 weeks.
At your followup appointment, we will see if the incision has
healed enough to remove the staples.
Before you can be fitted for prosthesis (a man-made limb to
replace the limb that was removed) your incision needs to be
fully healed.
YOUR VASCULAR SURGEON WILL DETERMINE WHEN/IF THE STAPLES ARE
READY TO BE REMOVED FROM YOUR STUMP! IF THERE ARE ANY
QUESTIONS ABOUT THIS, YOUR OTHER PROVIDERS SHOULD CALL THE
VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE
STAPLES WILL BE REMOVED ___ THE OFFICE AT YOUR FOLLOWUP
APPOINTMENT.
Followup Instructions:
___
|
10330990-DS-13 | 10,330,990 | 21,349,618 | DS | 13 | 2113-08-20 00:00:00 | 2113-08-21 05:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
paroxetine / rosuvastatin / ethyl alcohol / aspirin / salicylate
/ penicillin V / erythromycin base / celecoxib / lamb / mushroom
/ squash
Attending: ___.
Chief Complaint:
aphasia s/p TPA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an ___ year old woman with a history of MI s/p
CABG x 4 in ___, who presented with acute onset of aphasia and
R sided weaknesss, s/p TPA at an OSH, who was transferred to
___ for post TPA management.
Family is not available at the bedside and the patient is
aphasic, so history was gleaned from bedside charts. The patient
was eating dinner with her neice around 5 ___ when she suddenly
started choking on food. Her niece noted R sided weakness and
difficulty speaking, so called ___. The patient was taken to
___ where NIHSS = 10 with plegic R side, mixed
aphasia but able to follow commands, R facial droop, ?
extinction to light touch on the R. She got TPA and her R sided
weakness improved. NIHSS improved to a 7 or 8. She was
transferred to ___ and here her exam was basically stable with
NIHSS = 8 for R facial droop, dysarthria, aphasia, ? L sensory
defecit. CTA head and neck was preformed which showed no
complete occlusion or continued thrombus, although she does have
significant intracranial and extracranial atherosclerosis.
EKG was checked at ___ and was noted to be normal, and
it was rechecked upon arrival to ___ and showed diffuse ST
elevations. Cardiology saw the patient stat and felt she either
had a STEMI, or demand ischemia which causes ST elevations in
the setting of prior CABG. Repeat EKG was checked in the ED and
was mostly normalized. Trop T was elevated only to 0.03. The
patient denied chest pain. Cardiology felt that the patient was
very high risk for cardiac cath and would defer procedure in the
setting of TPA, unless she became hemodynamically unstable. They
recommended aspirin, statin, and beta blocker (when able from a
neurologic perspective).
Past Medical History:
- CABG x 4 in ___ at ___ (Dr. ___
- Left pleural effusion postoperative s/p CABG, s/p
thoracocentesis
- left upper lobe lung nodule, followed at ___
- s/p MI
- DM2
- CVA
- B12 deficiency
- ___ Neuropathy
- DJD/LS
- dementia
- HLD
- Asthma
- ___ disease
Social History:
___
Family History:
Mother had breast cancer and died from this; father died of an
MI; brother had a myocardial infarction but is alive and well.
Physical Exam:
ON ADMISSION:
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no bruits, RRR
Neurologic Examination:
___ Stroke Scale score was 8
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 2
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 2
10. Dysarthria: 1
11. Extinction and Neglect: 0
- Mental Status -
Awake, alert, follows simple commands. Incomprehensible speech:
overall with a paucity of speech, but she likely has a mixed
aphasia since she is babbling somewhat with syllables without
meaning, but at other times appears frustrated and unable to
communicate. ++ dysarhtria as well.
- Cranial Nerves -
Equal and reactive pupils. + blink to threat bilaterally. Able
to
look at examiner fully to the R and to the L. R facial droop.
Symmetric palate elevation and tongue protrusion.
- Motor -
Muscule bulk and tone were normal. No drift. No tremor or
asterixis.
Delt Bic Tri ECR IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5
R 5 5 ___ 5 5 5 5
- Sensation -
The patient indicates there may be a sensory change on the R arm
compared to the L but is unable to further describe it
- DTRs -
___ throughout.
- Cerebellar -
FNF intact.
DISCHARGE EXAM:
Neurologic:
Mental Status: Awake, alert. Minimal verbal output with mumbled
syllables but no clear spontaneous speech. Does not repeat.
Oriented to place (able to choose "hospital" from a list, but
not the year). Follows midline commands. Mimics well.
Cranial Nerves: Decreased blink to threat on the right side.
Right nasolabial fold flattening.
Motor: Tone is symmetric bilaterally. Moves all extremities
antigravity. Right side is slower to activate and can be
overcome; on confrontation testing right-sided deltoids, triceps
and biceps were at least ___, wrist extensors ___ and finger
extensors ___. Lower extremity moves at least antigravity.
Sensory: Responds to noxious stimuli in all extremities, much
slower on RUE.
Pertinent Results:
ADMISSION LABS:
___ 09:15PM BLOOD WBC-9.5 RBC-4.71 Hgb-14.0 Hct-40.5 MCV-86
MCH-29.7 MCHC-34.5 RDW-13.4 Plt ___
___ 09:15PM BLOOD Neuts-84.0* Lymphs-8.7* Monos-6.0 Eos-0.7
Baso-0.6
___ 09:15PM BLOOD ___ PTT-26.5 ___
___ 09:15PM BLOOD Glucose-177* UreaN-22* Creat-1.0 Na-139
K-3.8 Cl-104 HCO3-25 AnGap-14
___ 08:50AM BLOOD CK(CPK)-147
___ 09:15PM BLOOD ALT-15 AST-22 AlkPhos-89 TotBili-0.4
___ 08:50AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.7 Cholest-336*
___ 08:50AM BLOOD %HbA1c-6.0* eAG-126*
___ 08:50AM BLOOD Triglyc-82 HDL-100 CHOL/HD-3.4
LDLcalc-220*
___ 09:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Leukocytosis workup:
WBC increased from 10.6 to 23.6 on ___ and has since been
downtrending. Differential showed 84% neutrophils but no left
shift. Patient was afebrile. This triggered an infectious
workup. CXR showed no pneumonia.
MICROBIOLOGY:
___ URINE CULTURE-FINAL NEGATIVE
___ BLOOD CULTURE x2 - NO GROWTH TO DATE
CARDIAC ENZYMES:
___ 09:15PM BLOOD cTropnT-0.03*
___ 08:50AM BLOOD CK-MB-21* MB Indx-14.3* cTropnT-0.50*
___ 06:25PM BLOOD CK-MB-16* cTropnT-0.56*
___ 04:59AM BLOOD CK-MB-10 cTropnT-0.55*
___ 03:37PM BLOOD cTropnT-0.47*
IMAGING:
CTA head/neck ___:
1. No evidence of definite acute intracranial hemorrhage or mass
effect. Subtle hyperdensity along the left tentorium could be
due
to partial volume averaging or early hemorrhage.
2. Brain parenchymal volume loss, sequelae of chronic
microangiopathy, and prior infarcts.
3. No evidence of aneurysm, vascular malformation, or occlusion
within the vasculature of the head and neck.
4. Scattered atheromatous disease including calcification of the
bilateral proximal internal carotid arteries without evidence of
significant stenosis by NASCET criteria.
5. Focal areas of narrowing within more distal branches of
intracranial vasculature, likely representing atheromatous
disease.
6. Ground-glass right upper lobe pulmonary nodules, as described
above.
RECOMMENDATION(S): Recommended dedicated chest CT imaging for
further valuation pulmonary nodules.
Head CT ___:
1. No change to acute intracranial hemorrhage within the medial
left temporal lobe. No new areas of hemorrhage.
2. Hypodensity involving the left parietal lobe, compatible with
developing infarct.
3. Stable right frontal encephalomalacia.
Echo ___:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild to moderate regional left ventricular systolic
dysfunction with hypokinesis of the inferior and inferolateral
walls and distal septum. The remaining segments contract
normally
(biplane LVEF = 38 %). The estimated cardiac index is normal
(>=2.5L/min/m2). No intraventricular thrombus is seen. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no
mitral valve prolapse. Mild to moderate (___) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD. Mild-moderate mitral
regurgitation. Moderate pulmonary artery hypertension.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
Brief Hospital Course:
___ year old woman with a history of MI s/p CABG x 4 in ___, who
presented with acute onset of aphasia and R sided weaknesss as
well as STEMI, s/p TPA at an OSH for acute stroke, who was
transferred to ___ for post TPA management.
# Left MCA Ischemic Strokes (parietal and frontal):
MRI confirms left MCA stroke of the inferior division as well as
distal superior division branch. Her course has been complicated
by worsening of right sided weakness after presentation as well
as a small left medial temporal lobe hemorrhage which is likely
from the tPA. On exam she has profound aphasia and right sided
weakness. Stroke workup revealed HBA1c 6, LDL 220. She was
started on ASA 81mg and atorvastatin 80mg daily. SBP was
maintained under 160 given the hemorrhage. She was monitored on
tele for afib as a cardioembolic source is the most likely
etiology of her stroke. There were frequent PVCs but no atrial
fibrillation on her telemetry. She was discharged with ___ of
Hearts monitor for 30 days monitoring.
# ST Elevation Myocardia Infarction and acute systolic heart
failure:
Upon arrival to the ___ ED after receiving tPA at ___
___, the patient developed ST elevations in her inferior and
septal leads. She was seen by cardiology and was not taken to
the cath lab since the recent tPA bolus would make this
procedure too high risk. The tPA given for stroke likely helped
treat her STEMI as well. Given the concurrent STEMI with stroke,
she may have a cardioembolic source for both (with the most
likely etiology being afib, although this has not been
caputured). Alternatively, her STEMI may be neurogenic,
particularly as she infarcted her insula. She developed hypoxia
from pulmonary edema ___ requiring IV lasix. Echo revealed
an EF of 38%, worsened from recent echo ___ with EF
50-55%. She was unable to be anticoagulated acutely after the
STEMI given her IPH. Cardiology was consulted. She was started
on lisinopril, aspirin, atorvastatin, and metoprolol. Her blood
pressure has been elevated and so her lisinopril has been
increased to 20 mg daily and her metoprolol has been advanced to
goal metoprolol succinate 100 mg daily.
# Leukocytosis:
Developed elevated WBC count ___ but without meeting other SIRS
and had no other sign of infection. CXR, UA, and cultures were
unrevealing of an infectious source and her WBC count trended
down.
# Hyperglycemia:
During her hospitalization she had elevated blood sugars to the
200s. Her A1c was 6.0% as an outpatient. In conjunction with her
leukocytosis this was thought to be secondary to a stress
reaction after her stroke and her STEMI. She was started on
lantus and an insulin sliding scale rather than an oral diabetes
medication in anticipation that her elevated blood sugars would
resolve over time.
TRANSITION OF CARE:
- Cardiology: Will require cardiac catheterization when she is
able to be anticoagulated, two weeks after her hemorrhagic
transformation (___).
- Should receive metoprolol tartrate 25 mg tonight, then start
metoprolol succinate 100 mg daily tomorrow.
- Fluid status and electrolytes: was on furosemide 20 mg daily
and KCl 10 mg BID at home; here after acute pulmonary edema
required furosemide 20 mg IV daily. After transitioning to oral
diet, developed electrolyte abnormalities consistent with
dehydration so her lasix was held. Her electrolytes should be
monitored daily to determine the appropriate diuretic regimen.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - (x) No (hemorrhagic transformation)
4. LDL documented? (x) Yes (LDL = ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO BID
2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. AtroVENT HFA (ipratropium bromide) 17 mcg/actuation
inhalation TID:PRN as directed
5. Klor-Con 10 (potassium chloride) 10 mEq oral BID
6. Nitroglycerin SL 0.4 mg SL PRN as directed
7. Clopidogrel 75 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Cyanocobalamin 1000 mcg IM/SC MONTHLY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Glargine 5 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO Q8H Duration: 1 Day
one dose of metoprolol tartrate on ___ at 2200 then metoprolol
succinate on ___ AM.
6. Metoprolol Succinate XL 100 mg PO DAILY
one dose of metoprolol tartrate on ___ at 2200 then metoprolol
succinate on ___ AM.
7. Ondansetron 4 mg NG Q8H:PRN Nausea
8. AtroVENT HFA (ipratropium bromide) 17 mcg/actuation
inhalation TID:PRN as directed
Has not needed while inpatient.
9. Cyanocobalamin 1000 mcg IM/SC MONTHLY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Klor-Con 10 (potassium chloride) 20 mEq ORAL DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute ischemic stroke
ST-elevation myocardial infarction
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of difficulty speaking
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- high blood pressure
- high cholesterol
We are changing your medications as follows:
- starting aspirin 81 mg
- starting atorvastatin 80 mg
- starting metoprolol
- starting lisinopril
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10331080-DS-16 | 10,331,080 | 29,863,754 | DS | 16 | 2166-05-10 00:00:00 | 2166-05-10 14:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Beeswax / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug) / aspirin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Exploratory laparoscopy with reduction of internal
hernia
History of Present Illness:
Ms. ___ is a ___ year old woman status post lap RNYGB in
___ presenting with three days of nausea, vomiting and left
sided abdominal pain. She reports the symptoms started after she
ate on ___ and have been worsening, so she went to OSH
today. She feels better with pain medication. She had a BM this
am and has flatus. She had a past episode a few weeks ago that
resolved on its own. She denies fever or chills. She denies
NSAID, ASA or tobacco use. Occasional alcohol.
Past Medical History:
In terms of her past medical history:
1. Asthma.
2. Hyperlipidemia.
3. Depression.
4. Foot pain.
Past Surgical History:
1. Rhinoplasty.
2. Lumpectomy for benign disease.
3. Inguinal hernia.
4. Laparoscopic Roux-en-Y gastric bypass in ___.
Social History:
___
Family History:
Family history is significant for diabetes, lung cancer, colon
cancer or breast cancer.
Physical Exam:
VS: T 98.4 HR 72 BP 152/96 RR 18 O2 100% RA
Constitutional: NAD
Neuro: Alert and oriented x 3
Cardiac: RRR, NL S1,S2
Lungs: CTA B
Abd: Soft, non-distended, appropriate ___ tenderness
to palpation, no rebound tenderness/guarding
Wounds: Abd lap sites with steri-strips, CDI; no periwound
erythema
Ext: No edema
Pertinent Results:
___ 10:16PM BLOOD WBC-17.0*# RBC-4.57 Hgb-12.1 Hct-37.1
MCV-81* MCH-26.5* MCHC-32.7 RDW-14.1 Plt ___ Neuts-87.5*
Lymphs-8.0* Monos-3.5 Eos-0.6 Baso-0.3 ___ PTT-24.9*
___
___ 08:00AM BLOOD WBC-16.0* RBC-4.49 Hgb-11.7* Hct-36.9
MCV-82 MCH-26.1* MCHC-31.8 RDW-14.1 Plt ___ Ret Aut-1.2
Glucose-95 UreaN-7 Creat-0.5 Na-140 K-3.9 Cl-105 HCO3-26
AnGap-13 ALT-18 AST-22 AlkPhos-64 TotBili-0.4 calTIBC-399
VitB12-1087* ___ Ferritn-12* TRF-307 TSH-2.7
PTH-38 VITAMIN B1-PND
___ 06:50AM BLOOD WBC-8.0 RBC-4.24 Hgb-11.0* Hct-34.4*
MCV-81* MCH-25.9* MCHC-32.0 RDW-14.2 Plt ___ Glucose-81
UreaN-4* Creat-0.5 Na-139 K-3.7 Cl-104 HCO3-26 AnGap-13
Calcium-8.4 Phos-2.6* Mg-1.8
Imaging:
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
OUTSIDE FILMS READ ONLY
IMPRESSION:
1. Evidence of a high-grade obstruction in the distal efferent
limb of the gastric bypass of an abrupt transition point just
proximal to the
jejuno-jejunal anastomosis. There is no evidence of significant
bowel wall edema, surrounding stranding, or perforation.
2. Cortical defect with some calcifications in the mid pole of
the right
kidney, likely from prior injury or infection.
3. Small non-obstructing right renal stone.
Brief Hospital Course:
Ms. ___ was transferred to the Emergency Department on ___ with due to findings of high-grade bowel obstruction
seen on ABD/Pelvic CT scan. Upon arrival, she was placed on
bowel rest, given antiemetics, IVF and pain medication. Given
CT scan findings and physical exam, she was urgently taken the
operating room where underwent an exploratory laparoscopy with
reduction of internal hernia. Post-operatively, she was
extubated and transferred to the PACU for recovery. Once deemed
stable, she was then transferred to the general surgical ward
for ongoing monitoring.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA and then
transitioned to oral Roxicet once tolerating a stage 2 diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On POD2, the NGT
was removed and her diet was advanced sequentially to a
Bariatric Stage 5 diet, which was well tolerated. Patient's
intake and output were closely monitored. Of note, nutrition
labs were within acceptable limits except ferritin of 12 and
iron saturation of 11%. The patient was discharged to home with
daily multivitamins and an additional iron + vitamin C
supplement with need to repeat labs in 2 months.
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 stage 5
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:
Buspar 7.5 BID
Sertraline 100 Daily
Vitamin B12 500 MCG Daily
Vitamin D (dosage uncertain)
Biotin (dosage uncertain)
MVI w/ minerals daily
Discharge Medications:
1. BusPIRone 7.5 mg PO BID
2. Docusate Sodium (Liquid) 100 mg PO BID:PRN Constipation
RX *docusate sodium 50 mg/5 mL 10 ml by mouth twice a day Disp
#*250 Milliliter Refills:*0
3. Miconazole Nitrate Vag Cream 2% 1 Appl VG HS Duration: 7 Days
4. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ ml
by mouth every four (4) hours Disp #*250 Milliliter Refills:*0
5. Sertraline 100 mg PO DAILY
6. Vitamin B-12 *NF* (cyanocobalamin (vitamin B-12)) 500 mcg
Oral Daily
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Vitamin D 0 UNITS PO DAILY
9. biotin *NF* Dose is Unknown mg Oral Daily
10. Iron Plus Vitamin C *NF* (iron fum-vit C-ascorbate sod) 65
mg iron- 125 mg Oral Daily
Please have your iron studies rechecked in 2 months.
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Internal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with abdominal pain and underwent
an abdominal/pelvic CT scan, which was suggestive of a small
bowel obstruction. You were taken to the operating room for an
exploratory laparoscopy, have recovered in the hospital and are
now preparing for discharge to home with the 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. Also, please take
any new medications as prescribed. Please add Iron + Vitamin C
daily and have your iron studies repeated in two months.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10331356-DS-6 | 10,331,356 | 25,860,123 | DS | 6 | 2135-09-17 00:00:00 | 2135-09-17 18:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
amoxicillin / clavulanic acid / pravastatin / simvastatin
Attending: ___.
Chief Complaint:
Right elbow pain
Major Surgical or Invasive Procedure:
Right olecranon open reduction internal fixation
History of Present Illness:
___ right hand dominant male presents with the above fracture
s/p mechanical fall. He fell off his bike 2 days ago, no head
strike, while reaching for his cell phone. Landed on his right
elbow. Denies taking blood thinners. He states he had moderate
pain at the time, but not enough to go to the ED. Yesterday, he
states the pain got worse. He went to his PCP yesterday who was
concerned for a cellulitis and prescribed on PO Ceftin. Today,
he
had worsening pain so he presented to ___ where
radiographs
showed a comminuted intraarticular olecranon fracture.
Past Medical History:
-HTN
-T2DM
Social History:
___
Family History:
non contributory
Physical Exam:
Right upper extremity:
- Splint c/d/i
- Fires EPL/FPL/DIO
- SILT axillary/radial/median/ulnar nerve distributions
- Fingers WWP
Pertinent Results:
___ 03:47PM GLUCOSE-119* UREA N-18 CREAT-0.8 SODIUM-141
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
___ 03:47PM WBC-9.5 RBC-4.33* HGB-13.0* HCT-40.7 MCV-94
MCH-30.0 MCHC-31.9* RDW-12.9 RDWSD-44.3
___ 03:47PM NEUTS-60.7 ___ MONOS-9.2 EOS-3.4
BASOS-0.3 IM ___ AbsNeut-5.76 AbsLymp-2.49 AbsMono-0.87*
AbsEos-0.32 AbsBaso-0.03
___ 03:47PM PLT COUNT-263
___ 03:47PM ___ PTT-29.6 ___
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 olecranon fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a right olecranon fracture open
reduction and 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 worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non weight bearing in the right upper extremity in a splint, and
will be discharged on aspirin 325mg daily x4 weeks for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Discharge Medications:
1. Aspirin 325 mg PO DAILY Duration: 28 Days
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
right olecranon fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non-weight bearing of right upper extremity in splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take aspirin 325 mg daily for 4 weeks
WOUND CARE:
- You may shower but keep your splint dry at all times. 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 splint 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
Followup Instructions:
___
|
10331433-DS-8 | 10,331,433 | 24,652,138 | DS | 8 | 2183-03-06 00:00:00 | 2183-03-06 19:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amoxicillin / Lipitor / pravastatin / Remeron / Zocor
Attending: ___
Chief Complaint:
Epistaxis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient sent from ___ without discharge summary,
med list or summary of recent events. History is gathered from
wife who is also unsure of many of the details. Currently trying
to obtain records from ___ in ___.
___ M on coumadin for afib, h/o coranary artery bypass graft
surgery, HTN, HLD, dementia presented with epistaxis and ___.
The patient at 7pm last evening developed spontaneous epistaxis
of his left nare. No lightheadness or weakness. He presented to
the ___, where INR was 4.2. There in the ED his nares
were packed and he was given FFP and vitamin K. Given that
___ does not have ENT coverage he was transferred to ___.
Per Wife He was recently admitted about ___ weeks ago to
___ for cellulitis, blood stream infection and "infection
of the heart" and was taking an IV medication every 4 hours at
rehab.
Per the wife, the patient also suffers from dementia, was
recently placed on a medication for this, and he gets confused
at times.
In ___ ED, initial vitals were: 97.7 64 134/68 18 97%. Labs
were significant for creatinine of 3.1 (baseline 1.4), hct of
37.3 (was 42 at OSH), INR of 2.8 and PTT of 44.0, UA with 151
RBCs and 13 WBCs. Tbili was 1.7 with Dbili 1.4, and LDH was 339.
Fibrinogen normal at 298. Renal ultrasound did not show
hydronephrosis. He was given 2 doses of cephalexin, metoprolol
tartrate 37.5mg, and 500ml NS.
On the floor, he is unable to provide much history. He denies,
dyspnea, chest pain, burning on urnation.
Past Medical History:
CAD
Atrial fibrillation
Diabetes
Hypertension
Dementia
HLD
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 150/80 75 18 99%RA
General: alert, oriented, but inattentive at times, no acute
distress
HEENT: left nare with nasal packing and crusted blood on outer
nare
Neck: unable to assess JVP due to habitus
Lungs: Clear to auscultation bilaterally but breath sounds
muffled throughout, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: sever scaling and discoloration of lower extremities below
knees.
Neuro: CN ___ grossly intact, moves all extremities without
issue.
DISCHARGE PHYSICAL EXAM:
Vitals: 97.7 110-120/48-62 ___ 18 98-100%RA
I/O: 640/800
General: alert, oriented to person, situation, but inattentive
at times, no acute distress
HEENT: left nare with nasal packing and crusted blood on outer
nare
Neck: unable to assess JVP due to habitus
Lungs: Clear to auscultation bilaterally but breath sounds
muffled throughout, no wheezes, rales, rhonchi
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
GU: foley draining dark red urine without evidence of clots
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis
Skin: severe scaling and discoloration of lower extremities
below knees with ovelying clean dressing; 2+ edema
Neuro: CN ___ grossly intact, moves all extremities without
issue.
Pertinent Results:
ADMIT LABS:
___ 02:20AM BLOOD WBC-8.7 RBC-4.16* Hgb-12.7* Hct-37.3*
MCV-90 MCH-30.4 MCHC-34.0 RDW-18.2* Plt ___
___ 02:20AM BLOOD Neuts-73* Bands-0 Lymphs-16* Monos-9
Eos-1 Baso-1 ___ Myelos-0
___ 02:20AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL
___ 02:20AM BLOOD ___ PTT-44.0* ___
___ 06:42AM BLOOD Ret Aut-3.5*
___ 02:20AM BLOOD Glucose-103* UreaN-55* Creat-3.1* Na-145
K-4.4 Cl-105 HCO3-25 AnGap-19
___ 12:02PM BLOOD LD(LDH)-339* TotBili-1.7* DirBili-1.4*
IndBili-0.3
___ 12:02PM BLOOD proBNP-7740*
___ 12:02PM BLOOD Albumin-2.9* Calcium-9.0 Phos-4.7* Mg-2.4
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-8.9 RBC-3.12* Hgb-9.8* Hct-31.1*
MCV-100* MCH-31.4 MCHC-31.5* RDW-25.0* RDWSD-81.8* Plt ___
___ 06:50AM BLOOD ___ PTT-39.3* ___
___ 06:50AM BLOOD Glucose-121* UreaN-75* Creat-3.3* Na-142
K-3.9 Cl-107 HCO3-24 AnGap-15
___ 06:50AM BLOOD ALT-2 AST-19 AlkPhos-191* TotBili-2.8*
___ 06:50AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.5
PERTINENT LABS AND IMAGING:
___ 06:10AM BLOOD Hapto-10*
___ 01:38PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 01:38PM BLOOD ANCA-NEGATIVE
___ 01:38PM BLOOD ___ dsDNA-NEGATIVE
___ 01:38PM BLOOD PEP-AWAITING F IgG-1644* IgA-688* IgM-105
IFE-PND
___ 06:10AM BLOOD C3-74* C4-13
___ 01:38PM BLOOD HIV Ab-NEGATIVE
___ 01:38PM BLOOD HCV Ab-NEGATIVE
RUE US ___:
No evidence of deep vein thrombosis in the right upper
extremity.
Renal US ___:
1. No evidence of hydronephrosis.
2. Small left parapelvic cyst
CXR ___:
Congestive heart failure with mild to moderate edema and small
bilateral
pleural effusions. Standard PA and lateral the chest following
diuresis would be helpful to ensure resolution and to provide
more comprehensive assessment of the chest.
RUQ US ___:
1. Small right pleural effusion.
2. Normal hepatic echotexture with no biliary dilation.
ECHO ___:
Mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function. Moderate to
severe mitral regurgitation
MICROBIOLOGY:
Blood cultures ___ negative
C.diff ___ negative
Brief Hospital Course:
___ M with afib (CHADS2 of 6) on coumadin, recent admission for
infective endocarditis, CABG, HTN, HLD, dementia, presented from
___ for epistaxis and admitted to medicine for
___.
# Epistaxis: INR 4.8 at ___, reversed with FFP and vitamin
K. Rhino rocket placed with resolution of the bleed. ENT removed
the rhino rocket on ___ without further bleeding.
# ___: Baseline 1.4 on discharge ___ from ___. Rose to 2.2
on ___ at rehab, and was 3.2 on admission here. Renal was
consulted. There was concern for multiple intrinsic etioligies
for his ___, but he was a poor candidate for renal biopsy given
his habitus and the need to be on anticoagulation for warfarin.
Nephritic workup was done but Hep panel, ANCA, ___, dsDNA, HIV
and SPEP negative. Because AIN was on the differential, his
nafcillin was stopped and he was started on vancomycin for his
infective endocarditis. Post-staph glomerulonephritis was also
on the differential but treatment is largely supportive. It was
thought that he was volume overloaded so he was diuresed with IV
lasix; however his creatinine did not improve with diuresis. On
discharge his creatinine was 3.3.
# Afib: On rate control with dig/metop and on warfarin. CHADS2
of 6. Digoxin held due to ___ and his metoprolol was continued.
His elevated INR was initially reversed with FFP and Vitamin K
at outside hospital, and he required bridging with heparin for 1
day while subtherapeutic. His warfarin dose was decreased during
hospitalization given elevated INRs on his home dose. He was
discharged on 1mg of warfarin daily, and his INR should be
monitored every other day until he is on a stable regimen.
Stopping anticoagulation was discussed with the patient's
family, given the patient's functional status and bleeding
(epistaxis, hematuria) during hospitalization. They elected to
continue anticoagulation for now.
# Infective Endocarditis: Diagnosed previously at ___
___. Blood cultures there grew MSSA, last +BCx ___. Was on
oxacillin Q4h. No TEE done at OSH and no vegetation seen on TTE.
Plan was to treat for 6 weeks for presumed IE. Given concern for
AIN, his oxacillin was switched to vancomycin. Blood cultures
here negative. He was discharged on vancomycin, renally dosed,
to be continued for another 2 weeks for completion of his
endocarditis treatment. He will continue vancomycin until ___. He will need a vancomycin trough checked before next
administration, before 10am on ___.
# Hyperbilirubinemia: Patient with elevated direct
hyperbilirubinemia during admission. Normal AST and ALT. RUQ US
was unremarkable. Due to concern that the oxacillin may be
causing cholestasis, he was switched to vancomycin without much
improvement. His bilirubin should be checked once weekly as an
outpatient, with further investigation if uptrending. Tbili was
2.8 at discharge.
# Hematuria: patient with gross hematuria during admission,
likely due to BPH, foley placement, and supratherapeutic INR.
Urology consulted, and recommended checking urine cytology, with
further workup as an outpatient. By discharge his hematuria had
resolved and urine cytology was pending.
# Venous Stasis: Wound care consulted during admission and made
recommendations. His legs were wrapped to help with his chronic
edema.
# Dementia/Delerium: Patient with baseline dementia, getting
progressively worse over the past year. Also had waxing and
waning delirium here as well, likely due to new environment and
underlying illnesses. He was discharged on his home donepezil.
# DM: Continued SSI.
# Goals of care: Patient has multiple medical conditions,
including a progressive dementia. He is DNR/DNI per family and
per MOLST form. Had discussions with family about being less
aggressive with his care, such as not pursuing renal biopsy, and
they were in agreement with the plan. Further discussions should
be had as an outpatient in terms of how agressive to be in terms
of diagnosis of his current medical issues vs focusing on
quality of life. Given his rate of decline over the last few
months, the idea of hospice was brought up with the family on
this admission. They were in agreement with focusing on quality
of life and would be agreeable to hospice in the future if his
condition continues to decline.
TRANSITIONAL ISSUES:
- Patient with foley pulled day of discharge at 1300. Please
ensure patient has urinated by ___. If not, please bladder scan
or replace foley.
- Continue vancomycin 1250 q48 hours until ___ PICC line
can be removed at that time.
- Check vancomycin trough before next vancomycin administration,
before 10am on ___ and adjust accordingly.
-Digoxin held and not restarted due to ___. Patient without
symptoms off digoxin. Can restart digoxin renally dosed if
necessary.
- Torsemide restarted at 10mg daily (home dose 10mg BID). ___
need to uptitrate due to ___ if signs of volume overload.
- Lisinopril and Spironolactone held on this admission due to
___. Consider restarting if within goals of care and
stabilization of kidney function.
- Urine cytology pending at discharge
- Patient with intermittent hematuria during hospitalization,
with foley discontinued before discharge. If any issues with
voiding, place foley to ensure no blood clots. Can follow up
with urology with cystoscopy if within goals of care.
- Check bilirubin weekly to ensure stable (next lab draw ___
- Patient discharged on a reduced dose of warfarin (1mg) after
being supratherapeutic in-house. Please check INR every other
day while titrating warfarin to ensure within ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PNEUMOcoccal 23-valent polysaccharide vaccine 0.5 ml IM NOW
X1
2. Digoxin 0.125 mg PO DAILY
3. Donepezil 5 mg PO QHS
4. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
5. Finasteride 5 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. Oxacillin 2 g Other Q4H
9. Potassium Chloride 20 mEq PO DAILY
10. Spironolactone 25 mg PO DAILY
11. Torsemide 10 mg PO BID
12. Warfarin 2.5 mg PO DAILY16
13. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Torsemide 10 mg PO DAILY
5. Warfarin 1 mg PO DAILY16
6. Donepezil 5 mg PO QHS
7. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
8. Vancomycin 1250 mg IV Q48H
Please take until ___. Next dose due ___.
9. Oxymetazoline 1 SPRY NU BID:PRN nose bleed Duration: 3 Days
Use as needed until ___
10. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Epistaxis
___
Hematuria
Endocarditis
Delirium
SECONDARY:
AFib
Dementia
CAD
CVA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay. You were
admitted for a nosebleed and kidney injury. Your nosebleed
resolved after packing. The nephrologists consulted about your
reduced kidney function. It is unclear why your kidneys aren't
functioning well, but they stabilized during admission. You also
had blood in your urine during hospitalization. The urologists
consulted, and recommended outpatient workup if this recurs. We
sent urine cytology, which is pending at discharge. You were
kept on anticoagulation for your afib and antibiotics for your
endocarditis. We wish you the best!
Your ___ care team
Followup Instructions:
___
|
10331864-DS-21 | 10,331,864 | 21,545,162 | DS | 21 | 2193-08-28 00:00:00 | 2193-08-28 22:53:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Mesenteric arteriogram + coiling ___
History of Present Illness:
___ man w/ PMH of ___ s/p partial nephrorectomy,
HTN, HLD, T2DM, afib on Coumadin presenting from ___ with
LGIB.
Pt presented to ___ with BRBPR. He reports on the day of
admission at around 4 am he had BM which was bloody and followed
by about 3 BM with normal brown stool. Again during his ___ BM,
he noticed copious amounts of blood and presented to ___.
He states he had a colonoscopy ___ years ago with Dr. ___
showed diverticula and polyps.
At ___, his INR was 2.7, Hgb dropped to 10.0 from prior
12.9. He underwent a CTA which showed active diverticulitis and
active extravasation in the ascending colon. He was transferred
to ___ for ___ evaluation. He was given vitamin K, K centra,
and
started on cipro/flagyl. He remained HD stable. No prior history
of GI bleeds.
In the ED here,
- Initial Vitals: 97.8 85 109/63 15 98% RA
- Exam:
Gen: Elderly appearing, pale
HEENT: NC/AT. EOMI.
Neck: No swelling. Trachea is midline. No JVD
Cor: Tachycardic and irregularly irregular. No m/r/g.
Pulm: CTAB, Nonlabored respirations.
Abd: Mild tenderness to palpation in the right and left lower
quadrants bilaterally Ext: No edema, cyanosis, or clubbing.
Rectal exam: Diffuse bright red blood with mixed clots
Skin: No rashes. No skin breakdown
Neuro: AAOx3. Gross sensorimotor intact.
Psych: Normal mentation.
Heme: No petechia. No ecchymosis.
- Labs: Hgb 9.0, BUN/Cr ___, INR 1.4, lactate 2.9
- Events: While in the emergency department here, the patient
had what sounds like possible 30 seconds seizure-like episode.
He
was speaking with the senior resident. At that time he developed
a right-sided gaze deviation was not responsive. He was noted to
have some facial twitching at the time. No tonic-clonic
movements. Was confused for approximately 30 seconds after this
terminated and then was back to his baseline and oriented x 3.
- Imaging: CT head negative
- Consults: ___
- Interventions: Plan for mesenteric arteriogram +/-
embolization w/ ___
Pt underwent a mesenteric arteriogram showing pseudoaneurysm in
the ascending colon which was bleeding and coiled. He was
intubated prior to the procedure due to concern for seizures and
subsequently extubated prior to arrival to the MICU.
On arrival to the MICU, patient defers any conversation as he is
tired. No other complaints.
Past Medical History:
RCC s/p partial nephrectomy
BPH
Htn
HLD
NIDDM2
Atrial fibrillation on warfarin
Social History:
___
Family History:
Sister with hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Reviewed in Metavision
GEN: NAD, lying comfortably in bed
EYES: PERRLA, EOMI, anicteric
HENNT: MMM. No oropharyngeal lesions
CV: Irregularly irregular, normal rate. No m/r/g.
RESP: CTAB, bibasilar wheezing
GI: Mild TTP in the lower quadrants, large right-sided
abdominal hernia
NEURO: Moves all extremities w/ purpose
EXT: warm, well perfused, bilateral ___ edema to mid-shins
bilaterally
PSYCH: AAOx3
DISCHARGE PHYSICAL EXAM
VITALS: 24 HR Data (last updated ___ @ 737)
Temp: 97.9 (Tm 98.3), BP: 117/64 (108-121/58-72), HR: 65
(65-99), RR: 20 (___), O2 sat: 96% (92-97), O2 delivery: Ra,
Wt: 254.19 lb/115.3 kg
GENERAL: Alert and interactive older gentleman sitting in chair
in no acute distress.
HEENT: Sclera anicteric and without injection. MMM
NECK: no JVP elevation at 45 degrees
CARDIAC: irregularly irregular, Nl s1/s2. No m/r/g
LUNGS: Decreased breath sounds bilaterally. No wheezing/rhonchi
but very faint crackles at LLE. Breathing comfortably on RA
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: ___ ___ edema bilaterally to above the knee. Pulses
Radial 2+ bilaterally.
SKIN: Warm. No rash. Pale skin.
NEUROLOGIC: Alert, oriented, moves all extremities with purpose
Pertinent Results:
ADMISSION LABS:
___ 08:09PM TYPE-ART PH-7.36
___ 08:09PM freeCa-1.10*
___ 07:58PM WBC-12.6* RBC-3.21* HGB-10.1* HCT-30.0*
MCV-94 MCH-31.5 MCHC-33.7 RDW-15.1 RDWSD-51.9*
___ 07:58PM PLT COUNT-220
___ 05:41PM TYPE-ART PO2-337* PCO2-50* PH-7.27* TOTAL
CO2-24 BASE XS--4 INTUBATED-INTUBATED
___ 05:41PM GLUCOSE-163* LACTATE-2.2* NA+-136 K+-4.3
CL--110*
___ 05:41PM HGB-9.5* calcHCT-29
___ 05:41PM freeCa-1.16
___ 05:41PM WBC-12.8* RBC-2.92* HGB-9.2* HCT-28.1* MCV-96
MCH-31.5 MCHC-32.7 RDW-15.2 RDWSD-52.6*
___ 05:41PM PLT COUNT-260
___ 05:41PM ___ PTT-24.9* ___
___ 05:41PM ___ 02:35PM COMMENTS-GREEN TOP
___ 02:35PM LACTATE-2.9*
___ 02:30PM GLUCOSE-182* UREA N-30* CREAT-1.4* SODIUM-139
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-19* ANION GAP-11
___ 02:30PM estGFR-Using this
___ 02:30PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-58 TOT
BILI-1.3
___ 02:30PM LIPASE-21
___ 02:30PM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-3.5
MAGNESIUM-1.8
___ 02:30PM WBC-9.3 RBC-2.92* HGB-9.0* HCT-28.6* MCV-98
MCH-30.8 MCHC-31.5* RDW-14.9 RDWSD-53.7*
___ 02:30PM NEUTS-79.8* LYMPHS-12.1* MONOS-7.2 EOS-0.2*
BASOS-0.4 IM ___ AbsNeut-7.42* AbsLymp-1.13* AbsMono-0.67
AbsEos-0.02* AbsBaso-0.04
___ 02:30PM PLT COUNT-259
___ 02:30PM ___ PTT-27.2 ___
IMAGING:
CT HEAD W/O CONTRAST ___
IMPRESSION:
No acute intracranial process.
GI EMBOLIZATION ___
IMPRESSION:
Bleeding right colic artery pseudoaneurysm was identified and
successfully
embolized.
No evidence of additional active extravasation, pseudoaneurysm
or vascular
malformation.
CXR (___)
In comparison with the study of ___, there is increasing
enlargement of
the cardiac silhouette with further engorgement of ill defined
pulmonary
vessels, consistent with worsening pulmonary edema. The right
hemidiaphragmatic contour is poorly seen, consistent with
pleural fluid and
atelectatic changes at the base. Less prominent changes are
seen at the left
base.
No evidence of acute focal consolidation, though in the
appropriate clinical
setting, this would be difficult to exclude given the extensive
changes
described above and absence of a lateral view.
TTE (___)
The left atrial volume index is moderately increased. No
thrombus/mass is seen in the body of the left atrium (best
excluded by TEE). The right atrium is markedly enlarged. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. The visually estimated left ventricular
ejection fraction is >=60%. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract gradient. Mildly dilated right ventricular cavity
with normal free wall motion. The aortic sinus is mildly dilated
with normal ascending aorta diameter for gender. The aortic arch
is mildly dilated with a normal descending aorta diameter. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is trace aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is mild to moderate [___] mitral regurgitation.
The tricuspid valve leaflets appear structurally normal. There
is physiologic tricuspid regurgitation. There is mild-moderate
pulmonary artery systolic hypetension. There is a small
pericardial effusion. There are no 2D or Doppler
echocardiographic evidence of tamponade.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/ global biventricular systolic
function. Mild-moderate mitral regurgitation with normal valve
morphology. Mild-moderate pulmonary artery systolic
hypertension. Small pericardial effusion without echo evidence
for hemodynamic compromise. Mildly dilated thoracic aorta.
CLINICAL IMPLICATIONS: Based on the echocardiographic findings
and ___ ACC/AHA recommendations, antibiotic prophylaxis is NOT
recommended.
DISCHARGE LABS
___ 04:52AM BLOOD WBC-7.8 RBC-2.66* Hgb-8.2* Hct-26.6*
MCV-100* MCH-30.8 MCHC-30.8* RDW-16.5* RDWSD-57.9* Plt ___
___ 04:52AM BLOOD ___ PTT-25.0 ___
___ 04:52AM BLOOD Glucose-118* UreaN-22* Creat-1.2 Na-146
K-3.9 Cl-109* HCO3-25 AnGap-12
___ 04:52AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0
Brief Hospital Course:
SUMMARY
========
___ man w/ PMH of ___ s/p partial nephrorectomy, HTN,
HLD, T2DM, afib on Coumadin presenting from ___ with LGIB
w/ CTA showing active extravasation in the ascending colon and
mesenteric angiogram showing pseuodaneurysm of the right colic
artery s/p ___ embolization, course complicated by new O2
requirement that improved with IV Lasix and resolved by
discharge.
ACUTE ISSUES
=============
# Acute Lower GI Bleed: Patient presenting with ~10 days of
tarry stools that became bright red. He initially presented to
___ where he was found on mesenteric angiogram to have
actively bleeding pseudoaneurysm of the right colic artery
likely exacerbated by anticoagulation on Coumadin. He was given
2u pRBCs, and transferred to ___ for successful embolization
by ___ on ___ without any further evidence of bleeding.
Difficult to visualize additional sources of bleeding as per
report given large overlying abdominal hernia. Remained HD
stable with stable H/H.
#Acute Hypoxic Respiratory Failure: Patient briefly on 2LNC in
the ICU though was able to be weaned off O2. He has no hx of
lung disease and is not on O2 at home. CXR at ___ reportedly
consistent with atelectasis, although cannot view this online.
He developed a new O2 requirement and had a CXR overnight on
___ with initial concern for PNA. At that time he was started
empirically on vancomycin and cefepime (___). However,
given clinical stability discontinued PNA treatment. Patient
developed new O2 requirement again with repeat CXR in the early
AM on ___ that was consistent with significant increased
pulmonary edema. He was given IV diuresis with boluses of Lasix
40, with improvement in oxygenation. By ___, day of discharge,
he was breathing comfortably and satting high ___ on room air.
He had a TTE on ___ that showed EF >= 60% as well as mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global biventricular systolic function,
mild-moderate mitral regurgitation with normal valve morphology,
mild-moderate pulmonary artery systolic hypertension, small
pericardial effusion without echo evidence for hemodynamic
compromise, and mildly dilated thoracic aorta. Home HCTZ was
resumed on day of discharge.
#Acute diverticulitis: CTA at ___ showed acute diverticulitis
and he has a history of complicated diverticulitis. Started on
empiric cipro/flagyl though no reported history of abdominal
pain or diarrhea prior to presentation. Has had prior episodes
of complicated diverticulitis with perforation and abscess, so
unclear chronicity of this finding. Continued on cipro/flagyl
for 10 day course (___).
# # A fib # Frequent PVCs: Early in admission, patient
intermittently with HRs into the 140s, non-sustained,
hemodynamically stable, and asymptomatic. CHADS-VASc 4, so
warrants anticoagulation. Likely etiology multifactorial due to
infection, recent GI bleed. Discussed risks and benefits of
restarting warfarin with patient and family, and patient stated
he would like to restart warfarin which was done on ___.
#? Seizure: # Toxic Metabolic Encephalopathy: Episode of
impaired awareness in the ED. Reportedly had transient
right-sided gaze deviation with facial twitching and subsequent
confusion lasting about 30 seconds. CT head negative. No prior
reported history of seizures. Likely precipitated iso acute
illness. Deferred EEG/Keppra/neuro c/s given no recurrence or
underlying history.
# Deconditioning: ___ consulted, ordered for rolling walker
CHRONIC ISSUES
===============
# BPH # Urinary retention Followed by Urology as an outpatient
and planning for TURP. Continued home Tamsulosin and finasteride
# RCC s/p partial nephrectomy, CKD: Cr 1.4 on admission,
returned to baseline (1.0-1.2) by discharge.
# Afib: Natively rate-controlled. On Coumadin, held iso acute
bleed but resumed after embolization. INR 1.6 on day of
discharge; pt instructed to take 5mg warfarin daily until
___ clinic appointment on ___
# HLD: Continued atorvastatin
# HTN: Held antihypertensives iso acute bleed. Restarted HCTZ on
day of discharge given hemodynamically stable.
# T2DM: Not on any medications. briefly received sliding scale
insulin for 2 days while inpatient but insulin was discontinued
on ___. Blood glucoses have been stably < 200.
# Nutrition: Continued home MVI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Clindamycin 1% Solution 1 Appl TP BID
3. Warfarin 5 mg PO 5X/WEEK (___)
4. amLODIPine 10 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Multivitamins 1 TAB PO DAILY
7. Tamsulosin 0.8 mg PO QHS
8. Hydrochlorothiazide 25 mg PO DAILY
9. Warfarin 2.5 mg PO 2X/WEEK (___)
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*9 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*12 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Clindamycin 1% Solution 1 Appl TP BID
6. Finasteride 5 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Tamsulosin 0.8 mg PO QHS
10. Warfarin 5 mg PO 5X/WEEK (___)
Take 5mg daily until ___ then follow instructions of your
___ clinic
11. Warfarin 2.5 mg PO 2X/WEEK (___)
Please follow-up in ___ clinic for further instructions
after ___ Walker
Dx: Acute Blood Loss Anemia
ICD 10: K92.2
Px: Good
___: 13 months
Please provide rolling walker to patient.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Acute lower gastrointestinal bleeding
Pseudoaneurysm in right colic artery
SECONDARY DIAGNOSIS:
====================
Diverticulitis
Acute hypoxic respiratory failure
Pulmonary edema
Deconditioning
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You had bleeding in your gastrointestinal tract and your
blood counts dropped.
What did you receive in the hospital?
- You received blood transfusions.
- You underwent ___ guided embolization of an artery in your
colon and your bleeding was controlled.
- You had no more bloody bowel movements and your blood counts
and blood pressures were stable.
- A CAT scan of your abdomen showed evidence of diverticulitis;
you were treated with antibiotics
- You had some low oxygen saturations and shortness of breath,
a chest x-ray showed too much fluid building up in your lungs.
- You received IV Lasix, a diuretic medication, and your
breathing improved
What should you do once you leave the hospital?
- Please continue taking your medications as prescribed.
Specifically, please continue to take ciprofloxacin 500mg every
12 hours and metronidazole 500mg every 8 hours as instructed
until ___.
- Please attend any outpatient appointments you have. Please
attend your ___ clinic appointment this ___.
Please continue taking warfarin 5mg daily (starting ___
until your appointment on ___.
It was a pleasure participating in your care! We wish you the
very best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10331875-DS-11 | 10,331,875 | 25,172,619 | DS | 11 | 2168-09-07 00:00:00 | 2168-09-07 13:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
ciprofloxacin / boceprevir / carbamazepine / clarithromycin /
conivaptan / indinavir / itraconazole / ketoconazole / lopinavir
/ mibefradil / nefazodone / nelfinavir / phenytoin /
posaconazole / rifampin / ritonavir / grapefruit / ST JOHNS WORT
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
Mr. ___ is a ___ man with metastatic melanoma and
___ transferred from ___ on pressors with
presumed cellulitis for concern for necrotizing fasciitis.
Patient was on vacation in ___. Patient reports on ___
he felt generally fatigued, and fevers. On ___ morning,
patient fell injuring his lower back. Over the next few days,
had progressive weakness full body but also in his legs
bilaterally. Went to ___ for evaluation, noticed
significant cellulitis in his right leg.
Start patient on meropenem, subsequently became hypotensive to
the ___, began patient on peripheral levophed with good
response. Patient received 5 L of fluid.
On arrival, patient reports feeling generally fatigued and weak.
Patient had been followed at ___ for his oncologic
management, recently has been traveling to ___ for a
clinical trial at ___.
Surgery not concerning for ___ ___ service saw patient.
acquiring a CT currently. Patient is septic likely secondary to
cellulitis. Central line placed, receiving Levophed. Admitting
to ICU for further management.
Notably, the patient has a history of recurrent Enterobacter
cloacae bacteremia (see ___ ID note from Dr. ___.
In ED initial VS: 98.9 77 134/56 22 96% RA
Labs significant for:
- CBC: WBC 4.7, Hb 11.7, Plt 38
- LFTs: AST 41, Tbili 1.7, Alb 2.3
- Coags: ___ 16.1, PTT 41.0, INR 1.5
- BMP: Cr 1.6
= Lactate 2.8 -> 2.6
Consults: ___ surgery
VS prior to transfer: 98.7 70 113/55 18 98% RA
Past Medical History:
- Metastatic melanoma s/p chemotherapy, immune therapy,
cyberknife, and currently on a study drug through ___
___
- RLE lymphedema subsequent to RLE surgical excision of lymph
nodes, c/b recurrent cellulitis, prior antibiotic ppx with
cephalexin
- Cirrhosis, possibly secondary to NASH, complicated by varicies
- DM
- HTN
- HLD
Social History:
___
Family History:
No family history of recurrent infections or autoimmune
disorders.
Physical Exam:
Admission Physical Exam
=======================
GENERAL: Alert, oriented. In no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
LUNGS: Clear to auscultation bilaterally. No crackles, wheezes,
or rhonchi.
CV: Normal rate and rhythm. Normal S1 and S2. No murmurs, rubs,
or gallops.
ABD: Soft, non-tender. Distended, dull to percussion in flanks.
Bowel sounds present throughout. No organomegaly appreciated.
EXT: Right leg edematous and slightly erythematous. Pulses
present on Doppler. No clubbing or cyanosis.
SKIN: Chronic skin changes on right leg.
Discharge Exam:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
CV: Heart regular, no murmur, no S3, no S4. JVD difficult to
appreciate given habitus.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen softly distended, non-tender to palpation. Bowel
sounds present. No HSM. Morbid obesity.
GU: No suprapubic fullness or tenderness to palpation.
Ulcerations as previously noted
MSK: Neck supple, moves all extremities, strength grossly
symmetric
SKIN: No obvious rashes or ulcerations noted on cursory skin
exam
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
Brief Hospital Course:
___ year-old man with metastatic melanoma and ___
transferred from ___ with right lower extremity
cellulitis, septic shock and Enterobacter Cloacae bacteremia
requiring pressers.
ACTIVE ISSUES
=============
#Septic Shock:
#Cellulitis
___
Transferred from ___ on ___ with 4 days of
fatigue/fevers and progressive full body weakness and treated
with meropenem. Patient became hypotensive and was started on
pressers which were discontinued on ___. Potential sources of
infection leading to sepsis included right lower extremity
cellulitis, GNR bacteremia, SBP, and osteomyelitis. There was
initial concern for nec ___ due to cellulitis in the right
lower extremity iso of chronic lymphedema due to excision and
lymphadenectomy for metastatic melanoma. A CT scan showed
extensive right lower extremity soft tissue edema with skin and
fascial thickening more compatible with cellulitis. Due to no
subcutaneous gas or fluid collection and the surgical team was
not concerned for necrotizing fasciitis. Blood cultures from the
OSH grew Enterobacter Cloacae, resistant to cefazolin but
sensitive to CefePIME and all other tested Abx. In house blood
cultures from ___ grew pan-sensitive Enterobacter Cloacae. ID
was consulted and recommended broad antibiotic coverage with
vancomycin and cefepime. Diagnostic para on ___ without
evidence of SBP. MRI on ___ for concern of possible
osteomyelitis/discitis revealed osteo w/o e/o abscess. Pt was
stabilized, PICC was placed, and pt will be discharged for ___
course of ertapenem to be f/b OPAT, along w/ cdiff tx (as
below), and inintiation of lifelong bactrim ppx.
Antibiotic plan at time of discharge:
- Dispo abx regimen per ID recs (see note on ___
-- Erta q24 for total ___ course (day 1 = ___
-- PO vanc: 14d 125mg QID tx (d1 = ___, thus last day = ___,
then to 125mg BID to continue until 5d s/p Erta course ends
-- Lifelong ppx bactrim: PPx dosing is DS tablets (160mg/800mg)
PO once daily
-- Labs:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, AST, ALT, Total Bili,
ALK
PHOS, ESR, CRP
#Back pain: Persistent back pain with associated with weakness.
CT evidence concerning for possible osteomyelitis/discitis. Pain
managed with standing Tylenol, lidocaine patch, and oxycodone
PRNs. MRI on ___ showing osteo, as above, thus likely
explanatory etiology for his back pain.
#C diff colitis: Positive C. Differ PCR with negative toxin. Per
ID, favor treating as pre-test probability of disease in this
patient is high. Lactulose may also be contributing to the
diarrhea. Per ID recs, treated with PO vancomycin x14d and will
then convert to 125mg BID until 5d s/p his OPAT ertapenem ___
course of abx.
___: Patient with a baseline creatinine of 0.6, presented with
creatinine of 1.6, now 0.8. Most likely pre-renal due to
hypotension from sepsis and poor PO intake. BUN/Cr>20.
#Thrombocytopenia: Platelet count of 26, likely multifactorial
___ sepsis and cirrhosis. Required platelet transfusion on ___
prior to diagnostic paracentesis. Holding SC Heparin.
#Bradycardia: Sinus bradycardia to ___ with PVCs while sleeping,
rates in ___ while awake. EKG with inferior/anterior TWI and
bradycardia without blocks, QTc 530
-Watch for QT prolonging meds
-Consider ECHO at some point during hospitalization
CHRONIC ISSUES
==============
#NASH Cirrhosis: Hx of varicies without bleeding. Denies history
of HE or SBP. On nadalol ppx at home which was held in the
setting of hypotension. Asterixis consistent with decompensated
cirrhosis. Rifaxamin contraindicated with investigational
melanoma therapy study due to CYP effects. Treated with
lactulose. Diagnostic paracentesis on ___ without evidence of
SBP.
-Will need outpatient f/u with hepatology
#Metastatic Melanoma: Stage IIIC melanoma s/p chemotherapy and
cyberknife now on trial drug LOXO-101.
#Neuropathy: Peripheral neuropathy of right thigh. Gabapentin
renal dose adjusted to 100mg TID
TRANSITIONAL ISSUES
======================
[ ] F/u with hepatology upon discharge for cirrhosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Cephalexin 500 mg PO BID
3. Nadolol 20 mg PO DAILY
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
Please provide 1g IV ertapenem q24hrs for 30 days. Extension to
be provided by OPAT. Thank you.
RX *ertapenem 1 gram 1 g IV daily Disp #*30 Vial Refills:*0
2. Lactulose ___ mL PO BID
3. LOXO-101 Study Med 100 mg PO BID
4. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*3
5. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin [___] 50 mg/mL 125 mg by mouth four times a
day Refills:*0
RX *vancomycin [Firvanq] 50 mg/mL 125 mg by mouth twice a day
Refills:*5
6. Gabapentin 300 mg PO TID
7. Nadolol 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted for a severe infection. You are now stable to
go to a rehab and will need to continue to receive antibiotics
after you leave.
We wish you the best with your health.
___ Medicine
Followup Instructions:
___
|
10331875-DS-12 | 10,331,875 | 27,596,965 | DS | 12 | 2168-09-23 00:00:00 | 2168-09-23 16:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
ciprofloxacin / boceprevir / carbamazepine / clarithromycin /
conivaptan / indinavir / itraconazole / ketoconazole / lopinavir
/ mibefradil / nefazodone / nelfinavir / phenytoin /
posaconazole / rifampin / ritonavir / grapefruit / ST ___
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M h/o metastatic melanoma and recent cellulitis, enterobacter
bacteremia, and spinal osteomyelitis c/b C diff infection
presenting with failure to thrive at home and ongoing diarrhea.
The patient has had ongoing failure to thrive that has been
gradually worsening since ___ was discharged ___ following a
hospitalization for cellulitis/bacteremia and spinal
osteomyelitis. It is associated with his back pain which has not
changed at all. It was related to his prior long hospitalization
and chronic medical issues, outlined below. ___ was apparently
discharged home with ___ services despite ___ recommending
rehab as no rehab beds became available and the patient reports
___ was "antsy" to go home. ___ elected to go home with services
with help from his family. Since returning home, ___ reports that
___ has not been able to get out of bed pretty much at all, and
is limited by back pain whenever you tries to move. ___ continues
to have diarrhea ___ times daily and usually is incontinent due
to inability to get up on his own.
The patient's ___ called his ID physician ___
reported that ___ has had ongoing weakness and has remained
essentially bedbound since discharge. ___ has had ongoing
diarrhea that was identified with acute onset during last
hospitalization and got slightly better but is now slightly
worse and is related to missing a few doses of po vancomycin.
The ___ was unable to provide adequate care for him at home. Dr.
___ bringing the patient into the ED for
evaluation of the weakness and rehab placement, which the
patient agreed with.
In the ED, the patient corroborated the above. ___ reported that
the diarrhea has worsened over the past few days and due to his
back pain ___ has had difficulty getting to the bedpan in time,
leading to multiple accidents at home. ___ reported to the ED
that his back pain has not changed in nature and denies any new
weakness or neuro deficits.
I have personally reviewed his past records and to summarize:
The patient has had a long course of metastatic melanoma first
diagnosed in ___, s/p chemotherapy, immune therapy, cyberknife,
and currently on a study drug through ___.
___ has also had recurrent leg cellulitis, enterobacter
bacteremia, and spinal osteomyelitis in the setting of chronic
lymphedema. ___ has been on antibiotics as an outpatient and on
po vanc for concomitant C. Diff infection.
In the ED, The vital signs were stable. Labs were notable for
stable pancytopenia, albumin 1.9, chemistry otherwise wnl. CXR
was notable for low lung volumes and bibasilar atelectasis
without focal consolidation. ___ was given his ertapenem and
other home medications as well as 1 L of fluid.
Patient was seen by ___ who referenced ___ recommendations from
prior admission recommending rehab. Unclear why the patient had
returned home. Case management was unable to find a rehab for
the patient in the ED so decision was made to admit until
placement is confirmed.
On the floor, the patient had no new complaints. ___ was quite
comfortable at rest but with any movement or lifting his back
pain worsens.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Metastatic melanoma s/p chemotherapy, immune therapy,
cyberknife, and currently on a study drug through ___
___. Dx in ___
- RLE lymphedema subsequent to RLE surgical excision of lymph
nodes, c/b recurrent cellulitis, most recently admitted ___
for cellulitis complicated by GNR bacteremia.
- Recent C. diff infection
- Cirrhosis, possibly secondary to NASH, complicated by varicies
- DM
- HTN
- HLD
Social History:
___
Family History:
No family history of recurrent infections or autoimmune
disorders.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert, AOx3, lying flat in bed in NAD. IN visible
distress with any movement of his LLE.
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen obese, slightly 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: Multiple Telangectasias on his face. RLE w/ significant
chronic venous stasis changes and scars from previous
ulcerations but no skin breakdowns or evidence of cellulitis.
LLE slightly edematous as well with chronic venous stasis
changes not as severe as the R.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, sensation to light touch grossly intact
throughout lower extremities. Strength ___ on hip flexoion and
knee flexion on the LLE, ___ on the right
PSYCH: pleasant, appropriate affect
EXAM PRIOR TO DISCHARGE
VITALS: 98.0 121 / 64 63 18 96 RA
GENERAL: Sleeping, resting comfortably, lying flat in bed
GI: Abdomen obese, slightly distended, non-tender to palpation.
Bowel sounds present.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
EXT: Bilateral venous stasis changes fairly advanced, no
erythema, wrapped
Pertinent Results:
ADMISSION
___ 02:00AM BLOOD WBC-2.6* RBC-2.70* Hgb-8.6* Hct-26.6*
MCV-99* MCH-31.9 MCHC-32.3 RDW-16.8* RDWSD-59.3* Plt ___
___ 02:00AM BLOOD Glucose-76 UreaN-22* Creat-0.7 Na-137
K-4.7 Cl-106 HCO3-24 AnGap-7*
___ 02:00AM BLOOD ALT-13 AST-40 AlkPhos-148* TotBili-1.1
___ 02:00AM BLOOD Albumin-1.9* Calcium-7.7* Phos-2.6*
Mg-1.7
PRIOR TO DISCHARGE
___ 06:48AM BLOOD WBC-2.8* RBC-2.57* Hgb-8.3* Hct-26.2*
MCV-102* MCH-32.3* MCHC-31.7* RDW-17.1* RDWSD-63.7* Plt Ct-83*
___ 06:48AM BLOOD ___
___ 06:48AM BLOOD Glucose-132* UreaN-19 Creat-0.7 Na-140
K-4.7 Cl-108 HCO3-27 AnGap-5*
___ 06:11AM BLOOD ALT-13 AST-41* LD(LDH)-191 AlkPhos-153*
TotBili-0.6
___ 06:48AM BLOOD Calcium-7.8* Phos-2.6* Mg-1.7
___ 06:48AM BLOOD CRP-58.6*
IMAGING STUDIES
MRI L-SPINE
1. Severely limited study due to artifact likely from
combination of motion and body habitus.
2. Compression deformities of L2 and L4, likely due to Schmorl's
nodes.
3. Moderate spinal canal narrowing at L1-L2 and L3-L4.
CXR
1. Right upper extremity PICC tip terminates in the right
atrium, approximately 4 cm beyond the cavoatrial junction.
Please no redundancy in the PICC in the area of the axilla.
2. Low lung volumes. Bibasilar atelectasis without focal
consolidation.
Brief Hospital Course:
Brief summary:
This is a ___ with metastatic melanoma and recent spinal
osteomyelitis/ GNR bacteremia c/b C diff infection presenting
with failure to thrive at home and ongoing diarrhea in setting
of missed vanco doses, admitted for rehab placement and workup
of ongoing severe back pain. Workup reassuring, doing well with
nursing care and ___. Discharged to rehab facility.
By problems summary:
# Failure to thrive: Likely due to being discharged home before
___ actually was ready to be at home given his tenuous health
status, active issues, and related to ongoing back pain, chronic
illness, and recent hospitalizations. ___ unsurprisingly
recommended rehab.
# Recent osteomyelitis and leg cellulitis: Last admission ___ had
severe sepsis with septic shock, thought due to cellulitis but
then found to have Enterobacter bacteremia. In the context of
back pain, ___ was then found to have diskitis/osteo with
epidural phlegmon. ___ had some ascites and a diagnostic
paracentesis was unremarkable, though had been on antibiotics
for some time, and given the overall picture there was concern
___ could have had SBP as the primary cause.
- Ertapenem for ___ weeks (D1 ___
- No Bactrim while on other antibiotics. Can question whether
necessary thereafter as diagnosis of SBP is suspect and the
patient is actively having issues with C diff infection so there
is an atypical risk/benefit profile of this medication. Defer to
the OPAT team.
- WEEKLY CBC with diff, BMP, LFT to be faxed to OPAT team - see
their OPAT intake note from last admission for more details
# Back pain: MRI on ___ for concern of possible osteomyelitis/
discitis revealed osteo w/o e/o abscess. Continues to have
significant pain, which ___ says worsened in the context of
needing to move around more to try to take care of himself at
home. Neuro exam is confounded by generalized weakness and pain,
though ___ is able to mobilize and there is no obvious
lateralizing deficits, no sensory deficits. MRI was repeated to
assess for interval change but was unfortunately limited by
movement and habitus. ESR CRP downtrending so I think we can get
by without attempting to repeat the MRI for better images.
- Continue standing Tylenol for 2 weeks while at rehab
- Continue low dose oxycodone PRN severe pain and working with
___
- Avoid NSAIDs given comorbidities
# C. diff colitis: s/p treatment with 14 days (___) of 125
mg qid with plan to transition to 125 mg bid through end of
ertapenem course.
- Continue treatment dose at 125 mg qid for now, would do
another 2 weeks and then consider transition to BID if no
diarrhea
- Consider probiotic at rehab - none on formulary here
# Pancytopenia
# Coagulopathy
# NASH Cirrhosis: Hx of varices without bleeding. No history of
SBP per patient but does have h/o ascites. Did briefly have some
asterixis concerning for hepatic encephalopathy on last
admission treated with lactulose. S/p vitamin K for mild
coagulopathy, minimal response (but coagulopathy mild).
- Monitor for encephalopathy
- Lactulose titrated to ___ BMs per day ___ has been refusing
and having some diarrhea but this should be monitored closely
for signs of encephalopathy as C diff resolves)
# Metastatic melanoma: Stage IIIc melanoma s/p chemotherapy and
cyberknife now on trial drug LOXO-101. This drug is provided for
free by ___ in ___ picks it up but can
apparently have it shipped as well.
- Continue LOXO-101
# Neuropathy: Stable. Peripheral neuropathy of right thigh.
- Continue home Gabapentin 600 HS
# Mild dehydration in setting of diarrhea: Improved after 1L ___
NS and resolution of diarrhea.
# Mild hypophosphatemia in setting of diarrhea: Improved/stable
after 15mmol IV sodium phosphate.
# Bilateral venous stasis and some stasis dermatitis: Stable. No
signs of cellulitis. Have been providing ACE wraps to legs.
Billing: >30 minutes spent coordinating discharge to rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Lactulose ___ mL PO BID
3. LOXO-101 Study Med 100 mg PO BID
4. Vancomycin Oral Liquid ___ mg PO QID
5. Nadolol 20 mg PO DAILY
6. Ertapenem Sodium 1 g IV 1X
7. Sulfameth/Trimethoprim DS 1 TAB PO/NG DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*30
Tablet Refills:*0
3. Gabapentin 600 mg PO QHS
4. Lactulose 30 mL PO TID
5. Nadolol 40 mg PO DAILY
6. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
Every 24 hours for ___ weeks (D1 ___
7. LOXO-101 Study Med 100 mg PO BID
8. Vancomycin Oral Liquid ___ mg PO QID
Take QID for 2 weeks and then transition to BID until 2 weeks
after last dose ertapenem
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Osteomyelitis of spine
C diff infection
Cirrhosis
Melanoma on study drug
Venous stasis bilateral
Morbid obesity
Failure to thrive in adult
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with failure at home after a recent hospital
stay for sepsis, osteomyelitis of the spine, and c difficile
colitis on the background of your melanoma and cirrhosis
history.
You were admitted, given some hydration, your usual home
medications including antibiotics, and you were provided with
nursing care. You improved.
You are being discharged to rehab to get stronger so you can go
home and take good care of yourself.
Followup Instructions:
___
|
10331875-DS-13 | 10,331,875 | 23,658,552 | DS | 13 | 2168-10-26 00:00:00 | 2168-10-26 20:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
ciprofloxacin / boceprevir / carbamazepine / clarithromycin /
conivaptan / indinavir / itraconazole / ketoconazole / lopinavir
/ mibefradil / nefazodone / nelfinavir / phenytoin /
posaconazole / rifampin / ritonavir / grapefruit / ST JOHNS WORT
Attending: ___.
Chief Complaint:
Anasarca, SOB
Major Surgical or Invasive Procedure:
Diagnostic paracentesis on ___
History of Present Illness:
___ M with hx stage IIIC metastatic melanoma cancer (renal and
right-sided ilioinguinal metastasis) & cyberknife currently on
study drug LOXO-101 (TRK inhibitor), NASH cirrhosis c/b
___ (no bleeding or hx SBP), bilateral venous
stasis dermatitis, and recent admission for malnourishment in
setting of enterobacter bacteremia/cellulitis/spinal
osteomyelitis on IV ertapenam c/b cdiff on po vanc. Discharged
on ___ and had been in rehab until presentation. Now presenting
with subacute onset SOB, orthopnea, edema, and rash.
Patietn notes developing rash, swelling, and shortness of breath
about ___ days ago. ___ noticed feeling SOB with rolling over,
talking. +orthopnea but no PND. Did note a dry cough and
wheezing
associated with these new symptoms. Also with worsened bilateral
___ edema (usually R>L but now more so bilateral) as well as
worsened abdominal distension and significant scrotal edema.
Denies chest pain/pressure, palpitations, dizziness, fevers,
chills, rhinitis, congestion, dysuria, nausea, vomiting, abd
pain, jaundice, hematemesis. +sick contact with cold at rehab.
Diarrhea seems to be slowing down but still with loose stools.
Pt
with hx of CPAP but lost weight recently and did not need, but
placed back on it at rehab given SOB. Also notes pruritic rash
on
upper abdomen, upper back, and right side of face with
erythematous excoriations. Rash appeared around the same time as
SOB.
Last stress test reported to be years ago which was normal.
TTE/TEE at ___ ___ showing mild concentric LVH, nl EF
55%, no FWMA, mild AR. Of note was on pemprolizumba/ipilimumab
in
___ with progression of disease which is when T-VEC (Imlygic-
local immunotherapy) and cyberknife were initiated. No known
adverse reaction of cardiomyopathy with study drug.
In the ED, initial VS were: 97.8 70 140/90 18 96% RA
Exam notable for:
GEN: NAD, no jaundice, no asterixis
HEENT: pale conjunctiva; no scleral icterus; no lesions on
mucuous membranes
CV: normal S1 and S2; no mrg; JVD elevated to mandible at 45
degrees
Pulm: crackles bilaterally ___ of the way up; anterior lung
field
wheezes
Abd: +BS: distended; + fluid wave w/ some subcutaneous edema; no
TTP
Ext: warm, 3+ pitting edema bilaterally to the thighs
Skin: venous stasis changes bilaterally ___, no erythema;
excoriations noted on upper abdomen, upper back, and R side of
face
GU: scrotal edema, no erythema noted
ECG: NSR rate 65, no acute ST changes
Labs showed:
Imaging showed:
RUQ with Doppler
1. Cirrhotic liver, without evidence of focal lesion.
2. Splenomegaly and moderate volume ascites consistent with
portal
hypertension.
3. Patent portal vein.
CXR:
IMPRESSION:
Low lung volumes and mild vascular congestion/interstitial
edema.
Consults: None
Patient received:
Gabapentin 600 mg
IVErtapenem Sodium 1 g
PO/NGVancomycin Oral Liquid ___ mg
Transfer VS were: 65 101/54 22 94% RA
On arrival to the floor, patient reports feeling much better
with
no shortness of breath. No chest pain. Endorses the story above.
___ does not take diuretics at home.
Past Medical History:
- Metastatic melanoma s/p chemotherapy, immune therapy,
cyberknife, and currently on a study drug through ___
___. Dx in ___
- RLE lymphedema subsequent to RLE surgical excision of lymph
nodes, c/b recurrent cellulitis, most recently admitted ___
for cellulitis complicated by GNR bacteremia.
- Recent C. diff infection
- Cirrhosis, possibly secondary to NASH, complicated by varicies
- DM
- HTN
- HLD
Social History:
___
Family History:
No family history of recurrent infections or autoimmune
disorders.
Physical Exam:
ADMISSION EXAM:
===============
GENERAL: Alert, AOx3, lying flat in bed in NAD. IN visible
distress with any movement of his LLE.
EYES: Anicteric, pupils equally round
ENT: Normocephalic. Neck supple
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Crackles heard to mid lungs
GI: Abdomen obese, slightly distended, non-tender to palpation.
Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation. Scrotal
edema
MSK: moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Multiple Telangectasias on his face. RLE w/ significant
chronic venous stasis changes and scars from previous
ulcerations but no skin breakdowns or evidence of cellulitis.
3+ pitting edema bilaterally
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, sensation to light touch grossly intact
throughout lower extremities. Strength ___ on hip flexoion and
knee flexion on the LLE, ___ on the right
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
===============
PHYSICAL EXAM:
98.2 114/76 65 16 97 Ra
GENERAL: Alert, laying in bed, in NAD
HEENT: NCAT, anicteric sclera, MMM
CV: Normal rate and rhythm. Normal S1 and S2. No
murmurs/rubs/gallops
PULM: Bilateral crackles at bases. No wheezes or rhonchi.
ABDOMEN: Obese. Hyperactive bowel sounds. Soft, non-tender.
Mildly distended. non-tender to deep palpation in all four
quadrants
EXTREMITIES: His anasarca and ___ edema improved. RLE: +1 pitting
edema in ankles. LLE: larger than right leg. Improved from
admission.
NEURO: AAOx3. No asterixis
Pertinent Results:
ADMISSION LABS:
===============
___ 06:48PM BLOOD WBC-3.1* RBC-2.59* Hgb-8.4* Hct-27.0*
MCV-104* MCH-32.4* MCHC-31.1* RDW-17.4* RDWSD-66.5* Plt ___
___ 06:48PM BLOOD ___ PTT-39.6* ___
___ 06:48PM BLOOD Plt ___
___ 06:48PM BLOOD Glucose-147* UreaN-26* Creat-0.6 Na-138
K-4.9 Cl-105 HCO3-28 AnGap-5*
___ 06:48PM BLOOD ALT-13 AST-41* AlkPhos-226* TotBili-0.9
___ 06:48PM BLOOD cTropnT-<0.01 proBNP-428*
___ 06:48PM BLOOD Albumin-1.8* Calcium-7.9* Phos-3.1 Mg-1.8
___ 12:41PM BLOOD VitB12-797 Folate-10
___ 02:39PM BLOOD 25VitD-6*
___ 04:51AM BLOOD CRP-35.6*
___ 06:51PM BLOOD Lactate-1.3
DISCHARGE LABS:
===============
___ BLOOD WBC-1.5* RBC-2.27* Hgb-7.7* Hct-23.8* MCV-105*
MCH-33.9* MCHC-32.4 RDW-15.9* RDWSD-61.1* Plt Ct-78*
___ BLOOD ___ PTT-36.3 ___
___ BLOOD Glucose-97 UreaN-32* Creat-0.6 Na-139 K-4.5
Cl-105 HCO3-27 AnGap-7*
___ BLOOD ALT-15 AST-39 LD(LDH)-196 AlkPhos-146*
TotBili-0.5
___ BLOOD Albumin-2.6* Calcium-8.7 Phos-3.3 Mg-1.7
___ BLOOD CRP-32.4*
PERTINENT LABS:
================
___ 04:57AM BLOOD calTIBC-116* VitB12-744 Folate-11
___ Ferritn-302 TRF-89*
___ 02:39PM BLOOD 25VitD-6*
___ 09:48AM ASCITES TNC-133* RBC-38* Polys-7* Lymphs-14*
___ Mesothe-3* Macroph-73* Other-3*
___ 09:48AM ASCITES TotPro-0.7 Glucose-101 LD(LDH)-48
Albumin-0.2
___ 04:25PM STOOL Blood-NEG
MICROBIOLOGY
=============
-Respiratory Viral Culture (Final ___: No respiratory
viruses isolated.
-C. difficile PCR (Final ___: NEGATIVE.
- Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
- GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
-Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES:
========
___ abdominal ultrasound
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion.
2. Splenomegaly and moderate volume ascites consistent with
portal
hypertension.
3. Patent portal vein with appropriate direction of flow.
4. Cholelithiasis.
___ TTE
IMPRESSION: Mild symmetric left ventricular cavity size with
normal biventricular cavity sizes, regional/global systolic
function. Mildly elevated pulmonary artery systolic pressure.
Mild mitral regurgitation.
Brief Hospital Course:
SUMMARY:
============
Mr. ___ is a ___ year-old pleasant gentleman with history of
stage IIIC metastatic melanoma (with renal and right-sided
ilioinguinal metastases) status post chemotherapy,
immunotherapy, and cyberknife, currently on study drug LOXO-101
(TRK inhibitor), NASH cirrhosis complicated by hepatic
encephalopathy, esophageal varices, and ascites, and recent
admission for malnourishment in the setting of Enterobacter
bacteremia/spinal osteomyelitis on IV cefepime complicated by C.
difficile colitis who presents with anasarca and shortness of
breath. His anasarca and dyspnea improved with IV diuresis.
ACUTE ISSUES:
=============
#Anasarca
#Dyspnea
Patient presented on ___ with dyspnea, diffuse anasarca, and
a ~25-kg weight gain from last admission ___, which ___ notes
had been progressively accumulating over the past ___ weeks. His
BNP on ___ was slightly elevated to 428, and CXR showed
interstitial pulmonary edema. The etiology of his anasarca is
likely multifactorial in the setting of decompensated cirrhosis
and hypoalbuminemia of 1.9 secondary to malnutrition. TTE on
___ showed normal systolic function with LVEF 55-60%,
excluding a cardiac cause for his anasarca. ___ was diuresed with
IV Lasix 60mg boluses twice daily with good urine output and
resolution of his dyspnea. ___ was also given IV albumin 25% 50g
daily while being actively diuresed. Given concern that the
patient's metastatic melanoma treatment (study drug
LOXO-101/larotrectinib) was contributing to his liver
dysfunction, the medical team initially held the drug. However,
per the study's principal investigator, Dr. ___, at
___, there have been no reported cases of
liver-related side effects with this experimental medication,
and the patient has been on larotrectinib since ___. Diuretic
regimen was titrated during his hospital stay, and the patient
was discharged on 20mg furosemide daily and 12.5 spironolactone
daily. His discharge weight is 137 Kg. The patient will follow
with Dr. ___ ___ weeks after discharge.
#___ cirrhosis
#Ascites
Abdominal ultrasound on admission (___) demonstrated
ascites. Patient underwent diagnostic paracentesis, which was
negative for SBP (SAAG 1.7, WBC 133 (7 poly's), TP 0.7, glucose
101, LDH 48). (((***Of note, on a prior admission in ___ for
bacteremia/osteomyelitis, patient was evaluated for SBP in the
setting of acute decompensation; diagnostic paracentesis was
negative. Patient also has a history of paraesophageal and
perisplenic varices seen on CT abdomen in ___, though ___ has
not had an EGD noted in our system. ___ should undergo variceal
evaluation with endoscopy as an outpatient. Patient was started
on rifaximin 550mg twice daily along with nadolol. Lactulose was
held due to high frequency BMs.
#Rash
Patient presented with a pruritic, punctate, non-coalescing rash
with evidence of excoriation, mostly located on the bilateral
trunk/abdomen and upper back. ___ was seen by Dermatology, who
noted no primary lesion to suggest a drug-related reaction. The
rash was thought to be more likely secondary excoriation from
pruritus caused by decompensated cirrhosis. ___ was treated with
topical ointments and the rash resolved.
#Vitamin D deficiency
Patient was noted to have vitamin D deficiency with a
25-OH-vitamin D level of 6 on admission. ___ was started on
vitamin D supplementation.
#Myalgia
#Cervical LAD
Brief and resolved, presumed URI; viral panel negative.
CHRONIC ISSUES:
===============
#Enterobacter bacteremia complicated by osteomyelitis
Patient was recently admitted in ___ for septic shock
secondary to Enterobacter bacteremia and found to have lumbar
osteomyelitis with epidural phlegmon. ___ was transitioned to IV
cefepime while in-house and completed an 8 week course on
___.
#Back pain
MRI on ___ showed concern for osteomyelitis/discitis at the
L1-L2 and L3-L4 disc spaces, with no evidence of abscess.
Patient was continued on standing Tylenol and low-dose oxycodone
PRN for severe pain.
#C. diff colitis
#Diarrhea
Treatment for C diff colitis was initiated on admission in
___ with a 14-day course of PO vancomycin 125mg four times
daily (last day: ___ with a plan to continue PO vancomycin
125mg twice daily until 5 days after patient completes his
cefepime course (___). ___ was discharged on PO vancomycin
125mg twice daily (last day: ___. Of note, his diet was
changed to a low lactose diet due to concern for lactose
intolerance which may have exacerbated his symptoms. ___ will be
discharged on Imodium in addition to above.
#Pancytopenia
Unclear etiology, likely multifactorial secondary to iron
sequestration and cirrhosis; his immunotherapy may also be
playing a role as well. Vitamin B12 and folate levels WNL. ___
received 2u pRBCs throughout the admission.
#Metastatic melanoma
Stage IIIc melanoma s/p chemotherapy, immunotherapy, and
cyberknife now on trial drug LOXO-101 twice daily from ___
___. Study drug was briefly held but then resumed as
above.
#Neuropathy: continued home gabapentin 600 each evening
#Protein malnutrition: seen by nutrition services; started on
ENSURE clear.
TRANSITIONAL ISSUES:
====================
- Code status: full (presumed)
- Contact: ___ (wife), ___
- Discharge weight: 137 Kg
- Discharge Hb: 7.7
- Discharge Cr: 0.6
#Cirrhosis/anasarca:
[] Please obtain patient's standing weight the morning of ___.
This will be his new weight per rehab scale. Then, please
monitor DAILY STANDING WEIGHTS. If his weight increases by ___
lbs in 3 days, please increase furosemide to 40 mg daily and
contact Dr. ___ office at ___.
[] Please draw weekly BMP to monitor creatinine and potassium
[] Patient should have outpatient EGD for screening/evaluation
of esophageal and splenic varices.
[] Please monitor patient closely for signs of encephalopathy as
diarrhea resolves and continue lactulose titrated to ___ bowel
movements/day as needed.
#Pancytopenia:
[] Please follow weekly CBCs and transfuse PRN
#Diarrhea:
[] Final day of vancomycin on ___
[] Please monitor for worsening diarrhea as an outpatient
#Back pain:
[] Wean oxycodone as tolerated
#Malnutrition:
[] Ensure Enlive TID
[] High protein diet
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO QHS
2. Nadolol 40 mg PO DAILY
3. Vancomycin Oral Liquid ___ mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
5. Acetaminophen 650 mg PO Q8H
6. LOXO-101 Study Med 100 mg PO BID
7. Furosemide 20 mg PO BID
8. Lactulose 15 mL PO TID Titrate to ___ BM
9. Ertapenem Sodium 1 g IV 1X daily
Discharge Medications:
1. Betamethasone Dipro 0.05% Oint 1 Appl TP BID Duration: 2
Weeks
2. LOPERamide 2 mg PO QID:PRN diarrhea
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.rhamn
A
-
___
-
___
40-Bifido 3-S.thermop;<br>Lactobacillus
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 20 billion cell
oral DAILY
5. Rifaximin 550 mg PO BID
6. Sarna Lotion 1 Appl TP QID:PRN itching
7. Spironolactone 12.5 mg PO DAILY
8. Vitamin D 800 UNIT PO DAILY
9. Furosemide 20 mg PO DAILY
10. Acetaminophen 650 mg PO Q8H
11. Gabapentin 600 mg PO QHS
12. LOXO-101 Study Med 100 mg PO BID
13. Nadolol 40 mg PO DAILY
14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*6
Tablet Refills:*0
15. Vancomycin Oral Liquid ___ mg PO BID
16. HELD- Lactulose 15 mL PO TID Titrate to ___ BM This
medication was held. Do not restart Lactulose until your doctor
says it is safe to do so.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Anasarca
SECONDARY DIAGNOSES
===================
___ cirrhosis
Ascites
Rash
Metastatic melanoma
Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You had difficulty breathing and had gained a significant
amount of fluid weight.
- You also noticed that you had a new rash.
What did you receive in the hospital?
- You received IV medication that helped you get rid of the
extra fluid on your body.
- You underwent a procedure called a diagnostic paracentesis,
where a needle is used to sample the fluid in your abdomen. The
fluid did not show signs of infection.
- You were seen by a nutritionist, who recommended changes in
your diet to improve your protein intake.
- You were seen by our dermatologists, who thought your rash was
likely due to scratching from worsening of your liver function.
What should you do once you leave the hospital?
- Please follow up with Dr. ___ ___ weeks of leaving
the hospital in order to monitor your liver function.
- Please continue to work with physical therapy to get stronger.
- Please continue to follow up with the infectious disease
team/OPAT for management of your prior infections.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10331875-DS-14 | 10,331,875 | 25,252,109 | DS | 14 | 2168-12-03 00:00:00 | 2168-12-03 14:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
ciprofloxacin / boceprevir / carbamazepine / clarithromycin /
conivaptan / indinavir / itraconazole / ketoconazole / lopinavir
/ mibefradil / nefazodone / nelfinavir / phenytoin /
posaconazole / rifampin / ritonavir / grapefruit / ST JOHNS WORT
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
s/p Posterior laminectomies L2-L4 on ___
History of Present Illness:
Mr. ___ is a ___ with history of stage IIIC metastatic
melanoma (with renal and right-sided ilioinguinal metastases)
status post chemotherapy, immunotherapy, and cyberknife,
currently on study drug LOXO-101 (TRK inhibitor), NASH cirrhosis
complicated by hepatic encephalopathy, esophageal varices, and
ascites, with multiple recent admissions notably for
Enterobacter
bacteremia/spinal osteomyelitis requiring IV cefepime
complicated
by C. difficile colitis s/p completed treatment course who
presents w/AMS that was noted by his ___ today.
The patient was sent in by ___ for concern for altered mental
status, unable to obtain further collateral. In ED ___ reports
lower back pain. Also noted 1 week of profound bilateral lower
extremity weakness and fecal incontinence.
In the ED, initial vitals were: 95.5, 72, 140/70, 18, 96% RA
- Exam notable for: decreased interactiveness, bibasilar rales,
normal work of breathing, firm and tender abdomen suprapubically
and in the LLQ, decreased strength and sensation in UE and ___.
- ___ was noted to have markedly distended bladder on bedside
u/s
- Labs notable for: Pancytopenia with WBC 2.6 Hgb 11.5 and Plt
92. AST: 128 with AP: 171, BUN 74, Cr 1.3, Na 133, Lactate:2.1,
INR 1.4.
- Imaging was notable for:
CXR: Pulmonary vascular congestion and probable mild pulmonary
edema.
CT Head W/O Contrast: No acute intracranial process.
CT Abd & Pelvis With Contrast: Worsening discitis/osteomyelitis
at L1-2 and L3-4 levels with substantial increased vertebral
body
destruction and surrounding phlegmon, most profound
at L3-4. No drainable abscess identified. Osteolysis involving
the inferior T9 vertebral body appears similar to prior CT in
___. New pathologic fracture through the superior endplate
of the L3 vertebral body. Cirrhotic liver with sequela of portal
hypertension including massive splenomegaly and extensive
paraesophageal varices. Trace ascites, decreased from ___.
Overall stable retroperitoneal lymph nodes. Slight increased
stranding
around the origin of ___. No new lymphadenopathy or definite
metastatic
lesions.
- Code cord was called.
- MR TLS showed cauda equine compression with evidence of
diskitis and osteomyelitis at T9/10, L1/L2 and L3/L4. There is
moderate canal narrowing at L3/L4, with moderate-severe
narrowing
of the bilateral foramina may at that level. There is focal
fluid
collection
with likely contrast enhancement in the epidural space spanning
approximately 6.9 cm centered about L3/L4 (series 21, image 15).
No spinal canal involvement at T9/10. There is mild canal
narrowing at L1/L2. Comparison with prior studies is difficult
due to the poor quality of the previous MRI.
- Spine was consulted and MR imaging reviewed. They noted
significant chronic component to imaging, no critical cord
abnormality. On their exam patient with absent rectal tone.
Patient was very high risk for surgical intervention and low
chance of recovery given 1 month duration of low back pain/fecal
incontinence. After discussion with the patient and wife,
surgical decompression was opted for and patient was taken to
the
OR.
- Patient was given:
IVF NS 250 mL/hr
IV HYDROmorphone (Dilaudid) 0.5 mg
IV Vancomycin 1500 mg
PO/NG Spironolactone 25 mg
PO/NG Torsemide 20 mg
PO Nadolol 20 mg
IV Piperacillin-Tazobactam 4.5 g
In the OR, a washout of epidural phlegmon at L2-L4 was
performed.
The infection appeared old per report and no tissue was
recovered
for culture. Estimated ~300cc blood loss reported. Pt was given
1u plts preoperatively.
Upon arrival to the floor, patient reports ___ feels well.
Denies
any additional complaints. ___ is AAOx ___. Wife at beside
earlier
and seemed groggy and disoriented due to anesthesia which had
since improved. ___ was given additional 50g of albumin.
Past Medical History:
- Metastatic melanoma s/p chemotherapy, immune therapy,
cyberknife, and currently on a study drug through ___
___. Dx in ___
- RLE lymphedema subsequent to RLE surgical excision of lymph
nodes, c/b recurrent cellulitis, most recently admitted ___
for cellulitis complicated by GNR bacteremia.
- Recent C. diff infection
- Cirrhosis, possibly secondary to NASH, complicated by varicies
- DM
- HTN
- HLD
Social History:
___
Family History:
No family history of recurrent infections or autoimmune
disorders.
Physical Exam:
PHYSICAL EXAM:
VITAL SIGNS: 97.5 PO ___ 16 100 2L
GEN: NAD, no jaundice, unable to elicit asterixis
HEENT: pale conjunctiva; no scleral icterus; no lesions on
mucuous membranes, PERRLA
CV: normal S1 and S2; no mrg; JVD elevated to mandible at 45
degrees
PULM: bibasilar crackles
ABDOMEN: soft, nondistended, nontender
EXT: warm, 2+ pitting edema bilaterally to the thighs
SKIN: venous stasis changes bilaterally ___, no erythema;
excoriations noted on upper abdomen, upper back, and R side of
face
NEURO: alert, oriented to person and place, symmetric face,
moving all 4 extremities with purpose
Discharge Physical Exam:
98.1 BPPO 118 / 68 68 18 99 Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera,
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB on front, no wheezes, crackles or rhonchi. breathing
comfortably without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants
EXTREMITIES: warm well perfused. no lower extremity edema
PULSES: 2+ radial, ___ pulses bilaterall
NEURO: Alert, oriented to person and place, moving all 4
extremities with purpose, face symmetric. ___ strength in
dorsiflexion,plantarflexion bilaterally.
Skin: spinal incision without erythema, exudates, incision well
approximated with staples in place.
DERM: venous stasis changes bilaterally ___, no erythema;
excoriations noted on upper abdomen, upper back, and R side of
face
Pertinent Results:
Admission Labs:
___ 01:15PM BLOOD WBC-2.6* RBC-3.61* Hgb-11.5* Hct-36.0*
MCV-100* MCH-31.9 MCHC-31.9* RDW-14.6 RDWSD-53.1* Plt Ct-92*
___ 01:15PM BLOOD Neuts-63.7 Lymphs-14.3* Monos-16.7*
Eos-4.1 Baso-0.8 Im ___ AbsNeut-1.56* AbsLymp-0.35*
AbsMono-0.41 AbsEos-0.10 AbsBaso-0.02
___ 01:15PM BLOOD Plt Ct-92*
___ 01:15PM BLOOD Glucose-96 UreaN-74* Creat-1.3* Na-133*
K-7.6* Cl-95* HCO3-24 AnGap-14
___ 01:15PM BLOOD ALT-30 AST-128* AlkPhos-171* TotBili-1.2
___ 01:15PM BLOOD Albumin-3.1* Calcium-10.0 Phos-5.7*
Mg-2.0
___ 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:28PM BLOOD Lactate-2.1* K-7.3*
Pertinent Interval Labs:
___ 05:26AM BLOOD WBC-1.8* RBC-2.53* Hgb-8.1* Hct-25.6*
MCV-101* MCH-32.0 MCHC-31.6* RDW-14.1 RDWSD-51.8* Plt Ct-55*
___ 05:26AM BLOOD Neuts-58.0 ___ Monos-14.0*
Eos-5.6 Baso-0.6 Im ___ AbsNeut-1.04* AbsLymp-0.38*
AbsMono-0.25 AbsEos-0.10 AbsBaso-0.01
___ 05:26AM BLOOD ___
___ 05:26AM BLOOD Glucose-114* UreaN-30* Creat-0.7 Na-137
K-4.7 Cl-104 HCO3-28 AnGap-5*
___ 05:26AM BLOOD ALT-22 AST-52* AlkPhos-156* TotBili-0.6
___ 05:26AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.9
___ 06:02AM BLOOD VitB12-1052* Hapto-45
___ 01:05PM BLOOD 25VitD-12*
___ 01:05PM BLOOD CRP-57.8*
___ 07:00AM BLOOD CRP-56.6*
___:27AM BLOOD WBC-2.2* RBC-2.35* Hgb-7.5* Hct-23.7*
MCV-101* MCH-31.9 MCHC-31.6* RDW-14.5 RDWSD-52.3* Plt Ct-60*
___ 05:26AM BLOOD Neuts-58.0 ___ Monos-14.0*
Eos-5.6 Baso-0.6 Im ___ AbsNeut-1.04* AbsLymp-0.38*
AbsMono-0.25 AbsEos-0.10 AbsBaso-0.01
___ 05:27AM BLOOD Plt Ct-60*
___ 04:59AM BLOOD ___
___ 05:27AM BLOOD Glucose-106* UreaN-33* Creat-0.9 Na-135
K-4.9 Cl-103 HCO3-28 AnGap-4*
___ 04:59AM BLOOD ALT-26 AST-60* LD(LDH)-200 AlkPhos-164*
TotBili-0.7
___ 05:27AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.6
Imaging Studies:
MRI SPINE
IMPRESSION:
1. Findings consistent with L1-L 2, L3-L4 discitis
osteomyelitis, worse at
L3-L4, and worsened since ___, with worsened bone loss.
Epidural
phlegmon at these levels, with moderate to severe central canal
narrowing at
L3-L4.
2. Extensive paravertebral edema, no abscess.
3. Artifact versus enhancement of the roots cauda equina L3-L4.
4. Enhancement inferior T9 endplate, likely represent Schmorl's
node.
CT Abdomen/Pelvis:
IMPRESSION:
1. Worsening discitis/osteomyelitis at L1-2 and L3-4 levels with
substantial
increased vertebral body destruction and surrounding phlegmon,
most profound
at L3-4. No drainable abscess identified.
2. Osteolysis involving the inferior T9 vertebral body appears
similar to
prior CT in ___.
3. New pathologic fracture through the superior endplate of the
L3 vertebral
body.
4. Cirrhotic liver with sequela of portal hypertension including
massive
splenomegaly and extensive paraesophageal varices. Trace
ascites, decreased
from ___.
5. Overall stable retroperitoneal lymph nodes. Slight increased
stranding
around the origin of ___. No new lymphadenopathy or definite
metastatic
lesions.
CXR (PICC placement)
IMPRESSION:
PICC line terminating at cavoatrial junction
X-Ray L-Spine:
IMPRESSION:
Status post L2-3 and L3-4 laminectomy. Osseous destruction of
the endplates
of L3-4 and L1-2 is re-demonstrated, with interval decrease in
anterior
intervertebral disc space and mild widening of the posterior
elements at L3-4
suggesting the possibility of a degree of ligamentous
instability.
MICROBIOLOGY:
=============
___ 7:00 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 12:05 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
__________________________________________________________
___ 3:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
__________________________________________________________
___ 2:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Patient Summary Statement for Admission:
================================
Mr. ___ is a ___ with history of stage IIIC metastatic
melanoma (with renal and right-sided ilioinguinal metastases)
status post chemotherapy, immunotherapy, and cyberknife,
currently on study drug LOXO-101 (TRK inhibitor); NASH cirrhosis
complicated by hepatic encephalopathy, esophageal varices, and
ascites; with multiple recent admissions notably for
Enterobacter bacteremia/spinal osteomyelitis requiring IV
Cefepime, complicated by C. difficile colitis. ___ presented with
altered mental status and found to have worsening
osteomyelitis/diskitis with compression fractures, for which ___
underwent surgical washout and was admitted to medicine for
further management.
Acute Medical Issues Addressed:
=========================
# Acute on chronic osteomyelitis with cord compression
The patient was previously admitted ___ for septic shock
secondary to Enterobacter bacteremia with lumbar osteomyelitis
(T8-T10) & (L3-L4) with epidural phlegmon, for which ___ was
treated with IV cefepime and completed an 8 week antibiotic
course of Cefepime/ertapenem on ___. In recent weeks prior
to this admission, the patient subsequently developed worsening
weakness and fecal incontinence in the setting of C. diff, with
MRI this admission showing worsening discitis and osteomyelitis
at L1-L4 with surrounding 7cm epidural phlegmon highly
concerning for cord compression likely causing symptoms. ___
underwent surgical washout and L2-L4 laminectomy on ___. Drain
was placed and removed following resolution of output.
Intraoperatively, infection appeared chronic, however, tissue
could not be recovered for culture. The patient was consistently
afebrile, further supporting a chronic infection. Per Infectious
Disease recommendations, ___ will complete a 6 week course of
antibiotics. ___ received Cefepime while inpatient and prior to
discharge was transitioned to Ertapenem 1g q24h (end date:
___. ___ underwent PICC placement for long-term antibiotics
on ___. While on antibiotics ___ will require weekly labs: CBC
with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, CRP.
___ was fitted for TLSO Brace for out of bed movement.
# Toxic-metabolic encephalopathy: Resolved
AMS in the patient was noted by ___, and patient was poorly
interactive in ED on ___. On arrival to the floor, the patient
had slightly delayed responses and was alert and oriented to
self and only occasionally to place. Delirium in the setting of
worsening infection, recent proceduralization, and anesthesia.
No evidence of asterixis on exam. Delirium resolved ___ days
into hospitalization.
# NASH cirrhosis
# Coagulopathy
The patient has a known history of NASH cirrhosis complicated by
hepatic encephalopathy, ascites, and esophageal varices. On
admission, ___ met criteria for Child class B, MELD 15. Diuretics
were held in the setting of low pressures and infection. ___ had
no signs of bleeding, as hemoglobin and hematocrit were at
baseline throughout hospital course. Nadolol was initially held
in the setting of infection, but later restarted. The patient
initially presented with encephalopathy, which resolved, with no
signs of hepatic encephalopathy at the time of discharged. ___
was continued on rifaxamin, however ___ refused lactulose daily.
___ was offered polyethylene glycol which ___ tolerated. ___
received three days 5mg PO vitamin K repletion. Recent CT
revealed no focal hepatic lesions. Home diuretics were also held
given euvolemia.
# Pre-Renal ___: resolved
The patient is noted to have baseline Cr 0.6, Cr in ED ___. Given BUN/Cr ratio >20, in the setting of altered mental
status at home, presentation was highly concerning for prerenal
etiology. ___ was noted to have bladder dilated in the ED however
no sign of hydronephrosis on ultrasound.
#Urethral Trauma
During hospital course, the patient underwent intermittent
straight catheterization for retention. On ___, ___ was noted
to have hematuria and bleeding from penis, thought urethral
trauma secondary to intermittent straight catheterization.
Urology recommended large foley catheter insertion for five
days. Catheter should be removed on ___
#Constipation:
The patient adamantly refused lactulose throughout hospital
course. ___ received polyethylene glycol, and had a loose bowel
movement. ___ was advised of the importance of loose bowel
movements due to risk of constipation in the setting of rectal
sphincter dysfunction s/p cord compression.
# History of C. diff colitis
The patient has a history of recurrent C. diff colitis, and so
received PO vancomycin BID for prophylaxis throughout hospital
course, to be continued for the duration of antibiotic course.
# Vitamin A Deficiency:
Repleted with 7 days of ___ IU vitamin A. Last date ___ of
treatment.
Chronic Problems:
================
# Stage IIIC metastatic melanoma:
At home patient is on melanoma trial drug LOXO-101 twice daily
from ___. This was initially held in the
setting of encephalopathy and infection, however following
discussion with MSK as well as consult oncology the patient was
restarted on larotrectinib 100mg BID.
# Chronic Pancytopenia
The patient was found to have pancytopenia thought to be
multifactorial in the setting of trial drugs and underlying
cirrhosis, however was at baseline throughout course with
platelets downtrending from admission but stable. Per records
from ___, patient has been chronically
pancytopenic, believed secondary to cirrhosis. During hospital
course, CBC with differential was trended.
# Chronic macrocytic anemia
The patient presents with chronic macrocytic anemia in the
setting of cirrhosis, melanoma, and study medication. However,
___ was noted to have acute worsening following recent surgery as
well as frequent phelobtomy. His B12 level was normal, as was
haptoglobin.
CORE MEASURES:
==============
#CONTACT: ___ (spouse) - ___
#CODE: Full (presumed)
Transitional Issues:
==============
[ ]Last dose of ertapenem was given ___.
[ ]Weekly labs on antibiotics per infectious disease
recommendations : CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS, CRP ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
[ ] Chronic Osteomyelitis: Appointments: The ___ will
schedule follow up and contact the patient or discharge
facility. All questions regarding outpatient parenteral
antibiotics after discharge should be directed to the ___
___ R.N.s at ___ or to the on-call ID fellow when
the clinic is closed.
[ ] Continue Ertapenem 1g q24h (end date: ___
[ ] Home diuretics were held while inpatient and patient was
without accumulation of ascites. Please assess home diuretics
should be resumed.
[ ] Due to patient's spinal cord injury ___ may have longstanding
constipation vs fecal incontinence. After allowing time for
recovery of symptoms, please assess if patient would
desire/benefit from a colostomy.
[ ] Please consider referral to ___ s/p spinal cord injury.
[ ] Please consider if patient would benefit from outpatient
palliative care.
[ ] Remove foley catheter on ___.
[ ] Repleted with 7 days of ___ IU vitamin A. Last date ___
of treatment.
[ ] Continue PO vancomycin through duration of antibiotics
[ ] Patient must wear brace at all times while out of bed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Gabapentin 600 mg PO QHS
3. LOXO-101 Study Med 100 mg PO BID
4. Nadolol 20 mg PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Rifaximin 550 mg PO BID
8. Vitamin D 800 UNIT PO DAILY
9. Sarna Lotion 1 Appl TP QID:PRN itching
10. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
11. Vancomycin Oral Liquid ___ mg PO BID
12. LOPERamide 2 mg PO QID:PRN diarrhea
13. Spironolactone 25 mg PO DAILY
14. Torsemide 20 mg PO DAILY
Discharge Medications:
1. ertapenem 1 gram intravenous DAILY
stop date: ___. Lactulose 30 mL PO TID
3. Polyethylene Glycol 17 g PO BID
4. Vitamin A ___ UNIT PO DAILY Duration: 5 Doses
last day of treatment is ___. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild/Fever
Max 2g acetaminophen per day
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *oxycodone 5 mg ___ capsule(s) by mouth q4hr Disp #*20
Capsule Refills:*0
7. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
8. Gabapentin 600 mg PO QHS
9. LOXO-101 Study Med 100 mg PO BID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Nadolol 20 mg PO DAILY
Hold for HR <50 or SBP <90
12. Rifaximin 550 mg PO BID
13. Sarna Lotion 1 Appl TP QID:PRN itching
14. Vancomycin Oral Liquid ___ mg PO BID
Stop date ___. Vitamin D 800 UNIT PO DAILY
16. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until evaluation by
outpatient hepatology or development of ascites
17. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until evaluation by outpatient hepatology
or development of ascites
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Chronic osteomyelitis and cord compression
SECONDARY DIAGNOSOIS:
___ cirrhosis
Coagulopathy
Urethral trauma
Constipation
History of C. diff colitis
Stage IIIC metastatic melanoma
Chronic pancytopenia
Macrocytic anemia
Toxic-metabolic encephalopathy
Pre-renal ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
=================================
- You were admitted because you were not behaving as you
typically do and we noted that you were having weakness in your
legs concerning for a worsening of the infection in your spine.
What happened while I was in the hospital?
====================================
- You had an MRI scan of your spine, which showed that the
infection in your back which you received treatment for in the
past had not resolved and was likely the cause of your symptoms.
You underwent spine surgery to drain this fluid collection and
remove infected tissue.
- You were started on IV antibiotics to treat a chronic
infection in the bones of your spine.
- You resumed taking the study medication for your melanoma
- You were fitted with a brace to protect your back when
sitting up or moving.
What should I do after leaving the hospital?
====================================
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Please continue your IV antibiotics until ___
- You need weekly labs drawn and sent to the infectious disease
clinic.
- Your urinary catheter should be removed on ___
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10331875-DS-16 | 10,331,875 | 27,409,745 | DS | 16 | 2169-03-22 00:00:00 | 2169-03-22 17:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
ciprofloxacin / boceprevir / carbamazepine / clarithromycin /
conivaptan / indinavir / itraconazole / ketoconazole / lopinavir
/ mibefradil / nefazodone / nelfinavir / phenytoin /
posaconazole / rifampin / ritonavir / grapefruit / ST JOHNS WORT
Attending: ___.
Chief Complaint:
confusion/lethargy
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ man with past medical history of
vertebral osteomyelitis with cauda equina syndrome status post
debridement, metastatic melanoma status post chemotherapy,
diabetes, hypertension, hyperlipidemia, Nash cirrhosis being
sent
in by pathology for admission with concern for hepatic
encephalopathy. Per the family, ___ has been a little bit altered
for the past 24 hours with some lethargy over the past 3 days.
___
currently has no complaints. Family is able to state that ___
went
to his regular scheduled hepatology appointment where ___ was
confused and had concern for hepatic encephalopathy. ___ was then
sent to the emergency department for further evaluation.
In the ED:
Initial vital signs were notable for: T 97.1, HR 80, BP 128/77,
RR 18, 93% RA
Exam notable for:
Neuro: AOx2, speech fluent, no obvious facial asymmetry, moves
all 4 ext to command, +asterixis
Psych: confused
Labs were notable for:
- CBC: WBC 2.5 (68%n), hgb 10.8, plt 112
- Lytes:
136 / 97 / 33 AGap=7
------------- 149
4.9 \ 32 \ 1.3
- LFTS: AST: 59 ALT: 27 AP: 186 Tbili: 0.7 Alb: 2.7
- lipase 130
- lactate 2.0
- CRP 14.8
Studies performed include:
- RUQUS with:
1. Cirrhotic liver morphology without definite mass.
2. Patent portal vein without ascites. Stable splenomegaly.
3. Cholelithiasis without other findings of acute cholecystitis.
- CXR with: Low lung volumes with patchy opacities in lung bases
likely reflective of atelectasis
Patient was given: ___ 00:18 PO/NG Rifaximin 550 mg
Consults: Neurosurgery was consulted given recent MRI showing
worsening osteomyelitis. They felt that no neurosurgical
intervention was indicated at the time, and will reassess once
encephalopathy improves.
The case was also discussed with the liver fellow, who
recommended pan culture, hepatology consult, ID consult for
concern for worsening osteo, lactulose titrated to 3 BMs/day,
continue rifaximin
Vitals on transfer: T 98.5, HR 94, BP 115/79, RR 16, 95% RA
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- s/p L2-4 Laminectomies for decompression ___ in setting
of cauda equina syndrome
- vertbral osteomyelitis T9, L3/4
- Metastatic melanoma s/p chemotherapy, immune therapy,
cyberknife, and currently on a study drug through ___. Dx in ___
- RLE lymphedema subsequent to RLE surgical excision of lymph
nodes, c/b recurrent cellulitis, most recently admitted ___
for cellulitis complicated by GNR bacteremia.
- Recent C. diff infection
- Cirrhosis, possibly secondary to NASH, complicated by varices
- DM
- HTN
- HLD
Social History:
___
Family History:
No family history of recurrent infections or autoimmune
disorders.
Physical Exam:
Admission exam:
===============
VS: T 98.1, HR 80, BP 114/71, RR 18, 95% RA
Gen - sleeping comfortably in bed, NAD
Eyes - PERRLA
ENT - MMM
Heart - RRR, no r/m/g
Lungs - CTAB, slightly diminished breath sounds in bases
bilaterally
Abd - soft ntnd, no fluid wave
Ext - venous stasis changes, trace pedal edema
Skin -
Vasc - WWP
Neuro - A&O to person place and month, mild asterixis
Psych - pleasant, lethargic, calm and cooperative
.
.
Discharge exam:
================
VS:
Gen - NAD
Eyes - anicteric
HEENT - MMM, no OP lesions
Cards - RR
Chest - CTAB w/ normal WOB at rest
Abd - soft, NT, ND, BS+
Ext - +RLE swelling(chronic)
Neuro - AAOx4, conversant w/ clear speech, asterixis absent
Psych - calm, cooperative, normal judgment and insight
.
.
Pertinent Results:
Admission labs:
===============
___ 05:30PM BLOOD WBC-2.5* RBC-3.69* Hgb-10.8* Hct-33.7*
MCV-91 MCH-29.3 MCHC-32.0 RDW-16.0* RDWSD-53.6* Plt ___
___ 05:30PM BLOOD Neuts-67.9 Lymphs-15.7* Monos-12.4
Eos-2.8 Baso-0.8 Im ___ AbsNeut-1.69 AbsLymp-0.39*
AbsMono-0.31 AbsEos-0.07 AbsBaso-0.02
___ 05:30PM BLOOD ___ PTT-32.8 ___
___ 05:30PM BLOOD Glucose-149* UreaN-33* Creat-1.3* Na-136
K-4.9 Cl-97 HCO3-32 AnGap-7*
___ 05:30PM BLOOD ALT-27 AST-59* AlkPhos-186* TotBili-0.7
___ 05:30PM BLOOD Lipase-130*
___ 05:30PM BLOOD Albumin-2.7* Calcium-9.0 Phos-2.4* Mg-2.0
___ 05:30PM BLOOD CRP-14.8*
___ 05:37PM BLOOD ___ pO2-55* pCO2-49* pH-7.45
calTCO2-35* Base XS-8
___ 05:37PM BLOOD Lactate-2.0
.
.
Micro:
======
___ BCx - NGTD
___ BCx - NGTD
___ UCx - MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN AND/OR GENITAL CONTAMINATION.
.
.
Imaging:
=======
___ CXR:
Low lung volumes with patchy opacities in lung bases likely
reflective of atelectasis. Please note that infection is
difficult to exclude in the correct clinical setting. Possible
mild pulmonary vascular congestion.
___ RUQUS w/ doppler:
1. Cirrhotic liver morphology without definite mass.
2. Patent portal vein without ascites. Stable splenomegaly.
3. Cholelithiasis without other findings of acute cholecystitis
.
.
Discharge labs:
==============
___ 10:42AM BLOOD WBC-2.2* RBC-3.50* Hgb-10.2* Hct-32.9*
MCV-94 MCH-29.1 MCHC-31.0* RDW-16.8* RDWSD-57.1* Plt Ct-86*
___ 10:42AM BLOOD Neuts-59.6 ___ Monos-15.5*
Eos-4.5 Baso-0.9 AbsNeut-1.31* AbsLymp-0.43* AbsMono-0.34
AbsEos-0.10 AbsBaso-0.02
___ 10:42AM BLOOD ___ PTT-35.8 ___
___ 10:42AM BLOOD Glucose-154* UreaN-30* Creat-1.0 Na-139
K-4.0 Cl-100 HCO3-32 AnGap-7*
___ 10:42AM BLOOD ALT-25 AST-49* LD(LDH)-189 AlkPhos-159*
TotBili-0.7
___ 10:42AM BLOOD Albumin-2.6* Calcium-9.6 Phos-2.7 Mg-1.9
.
.
Brief Hospital Course:
# Hepatic encephalopathy
-presented with florid ___ (lethargy, confusion, asterixis) that
resolved with having ~4 BMs s/p initiation of lactulose
-patient at baseline mental status and mobility on day of
discharge
-Hepatology evaluated patient, felt ___ was good to go home with
re-emphasis on the importance of lactulose and follow-up as
scheduled; patient said ___ now understands the importance of
lactulose
-Counseled him re: titrating lactulose dose to goal ___ soft BMs
per day.
-If has recurrent encephalopathy despite continuing lactulose
and having goal of ___ BMs per day, this would raise suspicion
that a different medication (i.e. gabapentin) was contributing
to or causing altered mental status.
.
.
.
.
.
Time in care: >30 minutes in discharge-related activities today.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild/Fever
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
3. Gabapentin 600 mg PO TID
4. Lactulose 30 mL PO TID
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Nadolol 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO BID
8. Rifaximin 550 mg PO BID
9. Sarna Lotion 1 Appl TP QID:PRN itching
10. Spironolactone 25 mg PO DAILY
11. Torsemide 20 mg PO DAILY
12. Vitamin A ___ UNIT PO DAILY
13. Vitamin D 800 UNIT PO DAILY
14. LOXO-101 Study Med 100 mg PO BID
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. Nortriptyline 10 mg PO QHS
17. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
Discharge Medications:
1. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild/Fever
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID
3. Gabapentin 600 mg PO TID
4. Lactulose 30 mL PO TID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. LOXO-101 Study Med 100 mg PO BID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Nadolol 20 mg PO DAILY
9. Nortriptyline 10 mg PO QHS
10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
11. Polyethylene Glycol 17 g PO BID
12. Rifaximin 550 mg PO BID
13. Sarna Lotion 1 Appl TP QID:PRN itching
14. Spironolactone 25 mg PO DAILY
15. Torsemide 20 mg PO DAILY
16. Vitamin A ___ UNIT PO DAILY
17. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted to the hospital because of increasing lethargy
and severe confusion. Both improved markedly once you had
several bowel movements upon resuming lactulose. As we
discussed, you should definitely continue to take the lactulose
and adjust your daily dose to achieve a goal of ___ soft bowel
movements per day. This will help stave off lethargy and
confusion from hepatic encephalopathy. Your medication regimen
is otherwise unchanged. Please note that if you develop
lethargy and/or confusion upon returning home despite having ___
bowel movements per day, it may be possible that your gabapentin
dose (600 mg three times per day) is too high, and would need to
be decreased, as gabapentin can also cause alterations in mental
status.
Please plan to follow up with your oncologist and your
hepatologist as previously scheduled.
Wishing you the best,
The ___ Medicine Team
Followup Instructions:
___
|
10331875-DS-17 | 10,331,875 | 24,947,423 | DS | 17 | 2169-06-02 00:00:00 | 2169-06-11 16:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
ciprofloxacin / boceprevir / carbamazepine / clarithromycin /
conivaptan / indinavir / itraconazole / ketoconazole / lopinavir
/ mibefradil / nefazodone / nelfinavir / phenytoin /
posaconazole / rifampin / ritonavir / grapefruit / ST JOHNS ___
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
spine biopsy ___
History of Present Illness:
Mr. ___ is a ___ year old man with RLE lymphedema c/b
recurrent RLE cellulitis, vertebral osteomyelitis c/b cauda
equina syndrome s/p L2-L4 laminectomies (___), metastatic
melanoma currently on larotrectinib, NASH cirrhosis (c/b HE,
esophageal varices s/p banding) who presented with one day of
muscle aches, fever and malaise, found to be hypotensive in the
ED requiring pressors.
He had a recent admission to ___ (___'ed around
___ with septic shock ___ RLE cellulitis, treated with broad
spectrum antibiotics and discharged on prophylactic cefadroxil.
Patient attended routine follow appointment at Dr. ___
office on ___, c/o chills, lethargy, recurrent cellulitis.
Subsequently referred to ED. He reported one day of acute onset
chills, fatigue, malaise, in addition to worsening RLE swelling,
warmth, difficulty ambulating, and lower back pain.
In the ED,
- Initial Vitals: 99.7, 67, 105/60, 18, 98% RA
Tmax 101.8. Hypotensive to 88/38.
- Exam: dry MM. RLE edema (2+ edema).
- Labs:
2.5 10.2 74
>----<
33.0
136 99 39 87 AGap=10
------------<
4.9 27 1.4
Lactate:1.9 -> 1.7
VBG pH 7.39/ CO2 44
UA clean
- Imaging:
CXR 1: Low lung volumes with patchy opacities in lung bases,
likely atelectasis, though infection is not excluded in the
correct clinical setting.
CXR 2: Interval placement of right IJ line tip projects over
the
upper SVC. No pneumothorax. Increasing pulmonary vascular
congestion. More conspicuous left basilar opacity on the current
exam which may represent pneumonia in the proper clinical
setting.
R ___: No evidence of deep venous thrombosis in the right lower
extremity veins.
- Consults: Spine: "TLSO brace ___ when sitting- wear when
OOB. No urgent of emergent neurosurgery. would recommend
admission to medicine service for IV antibiotics. MRI reviewed
->
no severe stenosis noted that would require surgical
intervention. please reconsult neurosurgery for additional
issues"
- Interventions: Tylenol, 2L NS, cefepime 2g, vancomycin
1000mg,
levophed 0.05 -> 0.03 mcg/kg/min
He was transferred to the FICU for treatment of likely septic
shock requiring pressors.
Upon arrival to FICU, patient states he is feeling much better
than when he first arrived. Says he is still having mild pain in
his RLE, however no longer having fevers/chills. He denied any
recent respiratory sx, no SOB/DOE, cough. Denied any recent
abdominal pain, confusion, N/V/D/C. On exam he was noted to have
a pruritic rash, as documented below, which he says has been
occurring nightly for approximately 2 weeks. Had been getting
mild relief from OTC po Benadryl and topical hydrocortisone
cream. There was concern that it may have been from the
prophylactic cefadroxil, and had switched to PCN about one week
ago, but notes he has still been getting the rash.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
- s/p L2-4 Laminectomies for decompression ___ in setting
of cauda equina syndrome
- vertbral osteomyelitis T9, L3/4
- Metastatic melanoma s/p chemotherapy, immune therapy,
cyberknife, and currently on larotrectinib
- RLE lymphedema subsequent to RLE surgical excision of lymph
nodes, c/b recurrent cellulitis
- Recent C. diff infection
- Cirrhosis, possibly secondary to NASH, complicated by varices
- DM
- HTN
- HLD
- C diff
Social History:
___
Family History:
No family history of recurrent infections or autoimmune
disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T: 98.4, HR: 61, BP: 111/50 on .03 levo, RR: 14, SpO2: 98%ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
dry MM.
NECK: Unable to assess for JVD.
CARDIAC: RRR, Audible S1 and S2. systolic murmur heard best at
right second intercostal space.
LUNGS: CTAB. No w/r/r. Breathing comfortably on room air.
ABDOMEN: S, NT, ND, BS+, no fluid wave appreciated.
EXTREMITIES: RLE significantly enlarged compared to LLE, 2+
pitting edema, diffusely erythematous circumferentially from
ankle to knee, much warmer to touch compared to LLE, dry skin
and
scabbing on anterior shin. LLE with no erythema or edema.
SKIN: Upper chest has diffuse, erythematous, macular rash.
Reportedly pruritic but not urticrial in appearance. No wheals.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout with
the
exception of ___ hip flexion on R side. Normal sensation.
DISCHARGE PHYSICAL EXAM:
Temp: 97.6 PO BP: 127/68 HR: 63 RR: 18 O2 sat: 97%O2 delivery:
RA
Gen: pleasant tall man laying in bed in NAD.
HEENT: eyes anicteric, mildly anisocoria (R>L), normal hearing,
nose unremarkable, MMM without exudate
CV: RRR II/VI SEM diffusely
Resp: CTAB post
GI: obese sntnd
GU: no foley
MSK: no synovitis
Ext: wwp, 2+ RLEE w mild pink erythema diffusely
Skin: spider angiomas on chest, RLE erythema. Improving chest
rash.
Neuro: A&O grossly, DOWB intact, ___ BUE/BLE, SILT BUE,
decreased
sensation RLE compared to LLE (not atypical for pt), CN II-XII
intact, no asterixis
Psych: normal affect, pleasant
Pertinent Results:
ADMISSION LABS:
===============
___ 11:55AM BLOOD WBC-2.5* RBC-3.55* Hgb-10.2* Hct-33.0*
MCV-93 MCH-28.7 MCHC-30.9* RDW-15.6* RDWSD-53.3* Plt Ct-74*
___ 11:55AM BLOOD Neuts-84.0* Lymphs-5.2* Monos-8.4 Eos-1.6
Baso-0.4 Im ___ AbsNeut-2.09 AbsLymp-0.13* AbsMono-0.21
AbsEos-0.04 AbsBaso-0.01
___ 03:53PM BLOOD ___ PTT-33.4 ___
___ 11:55AM BLOOD Glucose-87 UreaN-39* Creat-1.4* Na-136
K-4.9 Cl-99 HCO3-27 AnGap-10
___ 12:16AM BLOOD ALT-18 AST-48* AlkPhos-153* TotBili-0.9
___ 11:55AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.6
___ 12:16AM BLOOD Cortsol-6.4
___ 07:30PM BLOOD Vanco-13.3
___ 06:00PM BLOOD Type-CENTRAL VE pO2-44* pCO2-44 pH-7.39
calTCO2-28 Base XS-0 ___
___ 12:03PM BLOOD Lactate-1.9
___ 06:00PM BLOOD O2 Sat-73
MICRO:
======
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
IMAGING/STUDIES:
================
___ NIVS:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ CXR:
Low lung volumes with patchy opacities in lung bases, likely
atelectasis,
though infection is not excluded in the correct clinical
setting.
___ CXR:
Interval placement of right IJ line tip projects over the upper
SVC. No
pneumothorax. Increasing pulmonary vascular congestion.
More conspicuous left basilar opacity on the current exam which
may represent pneumonia in the proper clinical setting.
DISCHARGE LABS:
===============
___ 05:50AM BLOOD WBC-1.4* RBC-2.98* Hgb-8.7* Hct-28.1*
MCV-94 MCH-29.2 MCHC-31.0* RDW-16.0* RDWSD-55.1* Plt Ct-45*
___ 05:50AM BLOOD Glucose-106* UreaN-28* Creat-0.9 Na-142
K-4.9 Cl-102 HCO3-33* AnGap-7*
Brief Hospital Course:
___ w metastatic melanoma, laminectomy for cauda equina ___,
T9/L3/L4 vertebral osteo, NASH cirrhosis, CDiff, pancytopenia,
RLE lymphedema ___ node removal complicated by recurrent
cellulitis admitted to ICU in septic shock secondary to presumed
RLE cellulitis.
# Septic shock, presumed secondary to:
# RLE cellulitis:
Presented with hypotension and significant RLE cellulitis
without concern for nec fasc or other complications. Initially
requiring ICU for vasopressors. Diuretics and BB held; patient
treated initially with several days of Vanc/Cefepime. Some
concern that initial hypotension may have been also in part
iatrogenic given he was significantly negative when resuming
home diuretics (~ 2L) and bradycardic with home nadolol. Thus,
torsemide decreased from 20mg to 10mg daily and nadolol held on
discharge. Patient continued to receive IV vanc/cefepime for
treatment of severe SSTI while inpatient and transitioned to
bactrim and Augmentin at discharge to complete a total 14 day
course per ID recommendations. There was some concern that
persistent vertebral osteo had been the true etiology of his
septic shock, thus he underwent a spine biopsy that was
ultimately no growth, therefore prolonged IV antibiotics was not
felt to be necessary.
# L2-4 laminectomy for cauda equina syndrome ___
# recent T9, L3-L4 vertebral osteo:
As above, concern for ongoing osteo as etiology of his septic
shock. Underwent bone biopsy with no growth of organisms.
Discharged on PO abx for SSTI. He will continue to wear his
spine brace as directed by his neurosurgery team.
# NASH cirrhosis, c/b varices, hepatic encephalopathy, ascites:
Patient presented in septic shock from presumed SSTI, however,
also suspect hemodynamic compromise from hypovolemia due to
overdiuresis and effect of nadolol (noted to be bradycardic).
Once sepsis resolved, he was initially resumed on home dose
torsemide/aldactone but was significantly negative to this
dosing, thus torsemide decreased to 10mg daily with goal of net
even. No changes made to aldactone dose. In setting of sinus
bradycardia with documented HRs in ___, his home nadolol
was held on discharge. Discharge Weight: 117.3 kg (258 lb)
Standing with orthotic brace.
# metastatic melanoma:
On TKR inhibitor as outpatient. Held in setting of infection.
Oncology team notified prior to discharge and will determine
appropriate time to resume therapy. Has follow up on ___.
# pancytopenia:
Chronic since at least ___. Slightly worsened in setting of
antibiotics. Outpatient labs to be obtained and faxed to PCP for
monitoring.
TRANSITIONAL ISSUES:
===================
[] To complete a total 14 day course of antibiotics for SSTI
with Bactrim Augmentin ending ___
[] Do NOT resume prophylactic antibiotics for future SSTIs
without consultation of ID team (refer to discharge summary for
further details)
[] Torsemide decreased to 10mg daily as he was markedly net
negative on his home 20mg.
[] Holding home nadolol on discharge due to sinus bradycardia
and borderline low BPs.
[] Discharge Weight: 117.3 kg (258 lb) Standing with orthotic
brace
[] trend volume exam and titrate diuretics as indicated
[] please obtain labs (script provided) on ___ and fax to PCP.
> 30 mins spent coordinating discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO TID
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Nadolol 20 mg PO DAILY
4. Rifaximin 550 mg PO BID
5. Spironolactone 25 mg PO DAILY
6. Torsemide 20 mg PO DAILY
7. Vitamin A ___ UNIT PO DAILY
8. Vitamin D 800 UNIT PO DAILY
9. Gabapentin 600 mg PO QHS
10. LOXO-101 Study Med 100 mg PO BID
11. Penicillin V Potassium 500 mg PO Q12H
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
twice a day Disp #*10 Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tab-cap by mouth twice a day Disp #*20 Tablet Refills:*0
3. Torsemide 10 mg PO DAILY
RX *torsemide [Demadex] 10 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Gabapentin 600 mg PO QHS
5. Lactulose 30 mL PO TID
6. Multivitamins W/minerals 1 TAB PO DAILY
7. rifAXIMin 550 mg PO BID
8. Spironolactone 25 mg PO DAILY
9. Vitamin A ___ UNIT PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. HELD- LOXO-101 Study Med 100 mg PO BID This medication was
held. Do not restart LOXO-101 until discussed with Dr. ___
___.
12. HELD- Nadolol 20 mg PO DAILY This medication was held. Do
not restart Nadolol until discussed with PCP. holding as
recovering from infection.
13.Outpatient Lab Work
please draw CBC w/ diff and chem10 ___ and fax to
PCP, ___ at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Shock, secondary to
# Sepsis, secondary to SSTI
# Hypovolemia from suspected overdiuresis
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. ___,
Why was I in the hospital?
You were having muscle pains, fevers, and malaise. The
redness/swelling in your right leg had worsened, concerning for
an infection. Your blood pressure was also found to be low.
What happened while I was in the hospital?
You required special medications to increase your blood
pressure. You were treated with antibiotics for infection.
You had some adjustments made to your water pills.
What should I do after I leave the hospital?
- Take your medicines as prescribed in this discharge packet.
Please note the following changes:
- your torsemide was reduced to 10mg daily to prevent.
dehydration.
- you will be taking two oral antibiotics that will finish
___.
- you are to HOLD your melanoma drug until further directed
by Dr. ___.
- Attend your follow up appointments as scheduled.
We wish you the very best,
- Your ___ Care Team
Followup Instructions:
___
|
10332328-DS-24 | 10,332,328 | 28,266,505 | DS | 24 | 2190-04-12 00:00:00 | 2190-04-12 20:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Male, restrictive lung disease from scoliosis from
Pott's disease on 4L home O2, chronic diastolic CHF, presents
with cough and shortness of breath. The patient reports that 10
days prior to admission he developed a cough with progressive
dyspnea; the dyspnea has progressed over the 4 days prior to
admission. He denies dietary indiscretion, medication
non-compliance, fever, chills, or worsening of his lower
extremity edema. He uses a hospital bed at home and has adjusted
his HOB upwards slightly. Of note his PCP had recently reduced
his diuretic in the outpatient setting.
In the ED, his initial vital signs were 65 160/62 22 85% 4L.
Initial labs demonstrated a WBC 6.7, HCT 34.6% (baseline ~35%),
creatinine 1.2 (baseline 1.1), and BNP 562 (baseline 50-100). A
CXR demonstrated moderate pulmonary edema and bilateral small to
moderate bilateral effusions with associated atelectasis. The
patient was given furosemide and albuterol/ipratropium
nebulizers and admitted for further management.
Upon arrival to the floor, initial vital signs were 98.3 154/60
71 24 97/6L. He was conversing in complete sentences easily
without increased respiratory effort.
Past Medical History:
-gout
-Type 2 DM
-Benign Hypertension
-restrictive pulmonary disease diagnosed ___ years agosecondary
to to Pott's disease, obesity, and sleep apnea
-Pott's disease. Crushed L1, L2, L3, L4 with severe kyphosis
-Diastolic CHF, last Echo ___ with preserved EF and no
valvular pathology but evidence of pulmonary hypertension.
-gastritis
-sleep apnea requiring BiPAP
-hyperlipidemia
-diverticulosis, colonic polyps
-hemorrhoids
Social History:
___
Family History:
States that his parents were healthy
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 98.1, 131/58, 60, 18, 93%4L
GEN: NAD, Obese
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: Bilateral feint crackles, kyphosis
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CC, 1+ edema to knees R
Pertinent Results:
___ 06:05AM BLOOD WBC-8.2 RBC-3.85* Hgb-11.1* Hct-37.0*
MCV-96 MCH-29.0 MCHC-30.1* RDW-15.3 Plt ___
___ 12:00PM BLOOD WBC-6.7 RBC-3.59* Hgb-10.1* Hct-34.6*
MCV-97 MCH-28.1# MCHC-29.1* RDW-15.1 Plt ___
___ 12:00PM BLOOD Neuts-70.0 Lymphs-16.3* Monos-9.9 Eos-3.3
Baso-0.5
___ 06:05AM BLOOD Glucose-121* UreaN-27* Creat-1.2 Na-147*
K-4.2 Cl-93* HCO3-44* AnGap-14
___ 12:00PM BLOOD Glucose-125* UreaN-26* Creat-1.2 Na-145
K-6.5* Cl-96 HCO3-38* AnGap-18
___ 12:00PM BLOOD ALT-14 AST-48* AlkPhos-78 TotBili-0.3
___ 12:00PM BLOOD Lipase-44
___ 12:00PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD CK-MB-1 proBNP-562*
___ 06:05AM BLOOD Calcium-10.0 Phos-3.1 Mg-1.7
___ 12:00PM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.5 Mg-1.7
___ 12:14PM BLOOD Lactate-1.0 K-4.6
CHEST (PORTABLE AP) Study Date of ___ 11:57 AM
IMPRESSION: Moderate cardiomegaly with mild-to-moderate
pulmonary edema,
bilateral pleural effusions and subsequent areas of atelectasis.
Brief Hospital Course:
1. Acute on Chronic Diastolic CHF Exacerbation
- Agressively diuresed overnight, and now 1.5L negative.
- This was likely due to a planned reduction in his lasix dose
at home on top of his potentially taking even less. He is back
on the full 20mg dose now and is markedly improved.
-low-sodium diet
2. Pleural Effusions
- Repeat Chest X-ray as outpatient in ___ weeks as this is most
likely due to his CHF exacerbation, and should therefore resolve
with improvement in his CHF, but if not would then work it up
outpatient
3. COPD (Restrictive Lung Disease), Pulmonary Hypertension
- Multifactorial with likely contributions from scoliosis
secondary to Pott's disease and obesity. Also known to have
pulmonary hypertension.
- Continue on home O2
4. Type 2 DM Controlled with Complications
- Continue glipizide and metformin at home with A1c 5.7% in
___.
5. Gout
- Allopurinol continued
6. Benign Hypertension
- Continue atenolol, lisinopril
7. Obstructive Sleep Apnea
- Home BiPAP continued with his personal unit
8. Hyperlipidemia
- Simvastatin continued
Full Code
PCP ___ not written as admitting resident is the PCP
___ issues:
-Patient will have follow-up CXR prior to outpatient visit to
evaluate for resolution/improvement in pleural effusions.
-Patient will have follow-up chem-7 prior to outpatient visit
given increased dose of furosemide and history of ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Lisinopril 40 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Docusate Sodium 100 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. Furosemide 10 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. potassium chloride 10 mEq oral daily
11. Aspirin 81 mg PO DAILY
12. GlipiZIDE 10 mg PO DAILY
13. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. GlipiZIDE 10 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. Simvastatin 40 mg PO QPM
12. Vitamin D 800 UNIT PO DAILY
13. Potassium Chloride 10 mEq ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
-Congestive heart failure
Secondary diagnoses:
-Restrictive lung disease
-Diabetes mellitus
-Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted with shortness of breath and found to have
fluid in your lungs, likely because of your heart failure. You
were given furosemide (Lasix) by IV and were able to get rid of
extra fluid. This improved your breathing back to your normal
levels.
I have increased your furosemide (Lasix) to 20mg daily. Please
start taking that on ___. I would also like you to get a chest
x-ray as an outpatient in ___ weeks. This can be done on the
___ building ___ floor. On the day that you go
for the x-ray, please have your blood tests checked in the lab.
Orders for both are in the computer.
Followup Instructions:
___
|
10332328-DS-26 | 10,332,328 | 26,145,251 | DS | 26 | 2194-04-09 00:00:00 | 2194-04-09 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ ___
man of ___ descent, who is followed in the Heart Failure
Clinic for longstanding heart failure with preserved ejection
fraction, hypertension, and severe pulmonary hypertension
secondary to cor pulmonale (followed by dr. ___
At baseline, that patient is on continuous home o2 at 4L 24
hours a day with BIBPA at night for OSA. His underlying lung
disease includes restrictive lung dysfunction secondary to
severe
scoliosis as well as obesity. He is known to have chronic
hypoventilation with chronic hypoxemia.
Patient states that he has been having a dry cough and "flulike
symptoms" (generalized malaise) for the past 5 days. The cough
intermittently brings up yellow sputum, but not consistently.
He
had some subjective fevers at home (did not have a thermometer
to
measure his temperature). The cough has been getting
progressively stronger, and causing more shortness of breath.
He
has been having chest pain when he coughs, but not otherwise.
His breathing began to feel progressively worse, so he presented
to the emergency department.
Interestingly, over the past several days, the patient ha been
consuming large amount of orange juice and soup In efforts to
improve his cold. This was discussed at length and the patient
seems to have consumed multiple liters a day over his typical
liquid intake.
Past Medical History:
-gout
-Type 2 DM
-Benign Hypertension
-restrictive pulmonary disease diagnosed ___ years agosecondary
to to Pott's disease, obesity, and sleep apnea
-Pott's disease. Crushed L1, L2, L3, L4 with severe kyphosis
-Diastolic CHF, last Echo ___ with preserved EF and no
valvular pathology but evidence of pulmonary hypertension.
-gastritis
-sleep apnea requiring BiPAP
-hyperlipidemia
-diverticulosis, colonic polyps
-hemorrhoids
-iron deficiency anemia
Social History:
___
Family History:
No family h/o cardiac or lung disease.
Physical Exam:
Admission Physical Exam:
========================
S: ___ 0028 Temp: 98.4 PO BP: 146/76 HR: 90 RR: 20 O2 sat:
91% O2 delivery: 5l FSBG: 201
GENERAL: ___ gentleman who appears older than stated age,
sitting up in bed. Conversing appropriately with assistance of
his son and cousin ___. In no acute distress.
HEENT: Sclerae anicteric.
NECK: JVP not appreciated above the clavicle while patient
sitting upright.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Diffusely rhonchorous breath sounds auscultated
throughout. Scant wheezing throughout.
ABDOMEN: Abdomen is soft nondistended, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or lower extremity 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
=======================
___ 0607 Temp: 97.7 PO BP: 123/66 L Sitting HR: 85 RR:
20
O2 sat: 92% O2 delivery: 4 L N C
GENERAL: AAOX3, speaking in full sentences. In no acute
distress.
HEENT: PEERLA, EOMI Sclerae anicteric.
NECK: JVP difficult to asses given body habitus.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Diffusely rhonchorous breath sounds auscultated
throughout. Scant wheezing throughout.
ABDOMEN: Abdomen is soft nondistended, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ right side lower extremity 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
=======================
___ 0607 Temp: 97.7 PO BP: 123/66 L Sitting HR: 85 RR:
20
O2 sat: 92% O2 delivery: 4 L N C
GENERAL: AAOX3, speaking in full sentences. In no acute
distress.
HEENT: PEERLA, EOMI Sclerae anicteric.
NECK: JVP difficult to asses given body habitus.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Diffusely rhonchorous breath sounds auscultated
throughout. Scant wheezing throughout.
ABDOMEN: Abdomen is soft nondistended, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ right side lower extremity 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
Pertinent Results:
Admission Labs:
===============
___ 11:30AM BLOOD WBC-9.4# RBC-3.46* Hgb-10.5* Hct-35.0*
MCV-101* MCH-30.3 MCHC-30.0* RDW-14.3 RDWSD-52.3* Plt ___
___ 11:30AM BLOOD ___ PTT-29.9 ___
___ 11:30AM BLOOD Glucose-195* UreaN-25* Creat-1.2 Na-146
K-5.3* Cl-100 HCO3-37* AnGap-9*
___ 01:37AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.2
___ 11:34AM BLOOD ___ pO2-86 pCO2-58* pH-7.42
calTCO2-39* Base XS-10
Microbiology
============
___ URINE CULTURE (Final ___ Blood Cultures X2 (negative)
___ GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
Imaging
-------
___ CXR: Moderate pulmonary edema. Underlying
consolidation is difficult to rule out.
___: Right leg US: No evidence of acute deep venous
thrombosis in the right lower extremity veins.
Notable Labs:
============
___ 02:02PM BLOOD Glucose-232* UreaN-79* Creat-2.5* Na-136
K-4.2 Cl-98 HCO3-22 AnGap-16
___ 11:30AM BLOOD proBNP-3060*
___ 05:51AM BLOOD pO2-57* pCO2-92* pH-7.29* calTCO2-46*
Base XS-13
Discharge Labs:
===============
___ 05:15AM BLOOD WBC-8.4 RBC-3.75* Hgb-11.2* Hct-36.6*
MCV-98 MCH-29.9 MCHC-30.6* RDW-14.4 RDWSD-50.7* Plt ___
___ 05:15AM BLOOD Glucose-118* UreaN-61* Creat-1.6* Na-145
K-4.1 Cl-88* HCO3-41* AnGap-14
___ 05:15AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.3
Brief Hospital Course:
Patient Summary:
Mr. ___ is a ___ gentleman with a history of
restrictive lung disease, pulmonary hypertension, diastolic
heart failure, diet-controlled diabetes who presents with a
chief complaint of ___ days of worsening cough (likely secondary
to viral URI), progressing to's acute shortness likely secondary
to CHF exacerbation in the setting of increased fluid intake.
Acute Issues:
=============
#Shortness of Breath
#Fluid Overload
#Acute on chronic HFpEF:
Patient presented with ___ days of symptoms suggestive of URI
including productive cough, fatigue and shortness of breath.
Although the patient requires 4L of o2 via NC 24 hours a day,
the patient was requiring 5L of oxygen on presentation. In the
ED he was initially treated with IV solu-medrol, Ceftriaxone,
Azithromycin, Duonebs, as well as 60mg Iv lasix. CXR
demonstrated pulmonary edema without evidence of consolidation
to suggest pneumonia. The patient reported that he felt less
short of breath after having received the lasix. He was admitted
to medicine for further workup. On the day of admission, on
further questioning, the patient was found to have been
consuming large amount of orange juice, tea, and soup on the
order for ___ liters a day on the days prior to presentation in
attempts to treat his viral symptoms. BNP was elevated to 3060,
the highest it has ever been by far. His admission weight was
181. His home furosemide was held and the patient was he placed
on 1.5L fluid restriction. He received 80mg Iv lasix for a goal
of -___ per day. Antibiotics and steroids were held and he
received cough suppressant. At time of discharge, the patient
was comfortable on 4L o2. His weight was 177 LB. BNP on
discharge was 960. He received education about fluid restriction
and will have ___ to assist with monitoring at home.
#Leg swelling
The patient was noted to have asymmetric bilateral pitting edema
(r>L) in his lower extremities. On review of his medical record
the patient has a history of leg swelling. In the setting of the
patients shortness of breath, a right tower extremity ultrasound
was preformed which showed no evidence of deep vein thrombosis.
#Hypercarbia
#OSA on home BiPAP:
The patient was found to be hypercarbic on the morning of
hospital day 1 after having not used the hospital CPAP at night
due to discomfort. The patient remained AAOX3, however his VBG
demonstrated PH 7.29 and Co2 of 98. ABG was drawn with pH 7.36,
CO2 77. The patient was instructed to bring his home BIPAP.
___
Patients baseline creatinine appears to be 1.4-1.7 since ___.
His creatinine rose to 2.5 in the setting of diuresis. On
discharge, Cr returned to baseline of 1.6. Home lisinopril and
furosemide were restarted at discharge.
#Hyperkalemia
Patient was found to be hyperkalemic up to 5.8 likely secondary
to respiratory acidosis. EKG was obtained and was unremarkable.
Hyperkalemia resolved with diuresis and use of BIPAP in the
evening. His home potassium was held on discharge.
#Hypertension
Patient's lisinopril was held in setting of diuresis, restarted
at discharge. Continued metoprolol.
#Gout:
Allopurinol ___ mg PO DAILY was held on admission due to ___. He
was restarted at renal dosing at 100mg daily at discharge.
Chronic Issues:
================
#Type 2 diabetes mellitus:
Based on most recent PCP note, generally well controlled with
diet and without medications. He received one dose of
solu-medrol in the ED. His blood sugars remained well controlled
off without use of ISS.
#History of GERD: Continued home Ranitidine
#Iron Deficiency Anemia: Patient continued daily home iron
supplementation
#Pulmonary HTN
#Restrictive lung disease (secondary to kyphoscoliosis from
Potts disease), on 4 L O2 at baseline:
Routine outpatient followup
Transitional Issues:
=====================
-Please check Creatinine ___ and adjust allopurinol dosing
accordingly
-Please check potassium at f/u ___ and consider restarting
home oral potassium.
-For ___:
*Please monitor weight daily, discharge weight 177 lbs, call
Cardiologist office if weight increases by 3 lbs in one day or 5
lbs in one week
*Please help patient monitor fluid intake (2L fluid restriction)
-Benzonatate and guaifenesin prescribed for cough
-Patient uses a cane at home, was requesting crutches to use at
home for balance, was assessed by ___ and will have home ___ for
home safety eval
#CODE: Full (confirmed)
#CONTACT: Son, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. Omeprazole 20 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
8. Klor-Con M10 (potassium chloride) 10 mEq oral DAILY
9. Torsemide 40 mg PO DAILY
10. Ranitidine 150 mg PO BID:PRN heartburn
11. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
2. GuaiFENesin ___ mL PO Q6H
RX *guaifenesin 100 mg/5 mL ___ mL mL by mouth Q6H:PRN
Refills:*0
3. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
5. Ferrous Sulfate 325 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Ranitidine 150 mg PO BID:PRN heartburn
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 40 mg PO QPM
11. Torsemide 40 mg PO DAILY
12. HELD- Klor-Con M10 (potassium chloride) 10 mEq oral DAILY
This medication was held. Do not restart Klor-Con M10 until you
meet with your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
#Shortness of Breath
___ on CKD
HFpEF
#Restrictive Lung Disease
#Pulmonary Hypertention
#Hyperkalemia
#Hypercarbia
Secondary Diagnosis
#Diabetes
#Hypertention
#Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___ ,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You were short of breath, probably because you drank too much
fluid and it pooled in your body
- You had a cough, probably because of a virus
What did you receive in the hospital?
- We gave you IV Lasix to helpe you get rid of the extra fluid
- We gave you cough medicine to help with your cough
What should you do once you leave the hospital?
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in one day for 5 LBs in one week. The visiting nurse
___ help you with this.
- Work with the physical therapist in your home.
- You should follow up with your doctor in 1 week
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10332371-DS-19 | 10,332,371 | 21,500,410 | DS | 19 | 2156-02-07 00:00:00 | 2156-02-07 22:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / amiodarone / rifampin
Attending: ___.
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with PMH bicuspid AS s/p bioAVR and AscAo graft in
___, Staph ludgenesis endocarditis/aortic root abscess s/p
Bentall #19 homograft and MVR in ___, HTN, HLD, peripheral
artery disease s/p RFA stent, presenting with 1 month of malaise
and URI sx.
She began feeling ill in ___. Had malaise, chills
without measured fevers or rigors, productive cough (white
phlegm), vomiting for a few days, mild dyspnea, sinus
congestion,
sore throat. Saw Urgent Care, was given a course of PCN for
"strep throat" (though no rapid strep test was performed) as
well
as erythromycin ointment for b/l conjunctivitis. No improvement
of sore throat and URI sx after 8 days of PCN. Went to back to
urgent care in ___ on ___, where 2x blood cultures were
drawn. Was called on ___ and told that 1 out of 2 cultures
came back with gram positive cocci and clusters, noted by OSH to
be "likely staph aureus". Went to ED again but left AMA before
significant studies could be done. Flew back on ___. Final blood
culture report on ___ states no growth at 5 days which is
inconsistent with gram positive blood infection. Pt took nyquil,
mucinex, aleeve, and tylenol with little symptomatic
improvement.
Does endorse chest heaviness and intermittent shortness of
breath
and palpitations, chills, sore throat, congestion, ear and
headache, myalgia, night sweats. Denies chest pain per se,
fevers, new skin lesions, nausea, vomiting, or abdominal pain.
Notes lower back pain (not at midline), which she attributes to
spending so much time in bed. Denies urinary sx. Appetite
stable.
In the ED:
Initial vital signs were notable for:
___ 07:31 Temp: 97 HR: 73 BP: 163/58 RR: 18 Pox: 98% RA
Exam notable for:
Gen: fatigued-appearing
HEENT: s/p tonsillectomy, prominent uvula, mildly erythematous
posterior OP. JVP < 8
Cardiac: II/VI systolic ejection murmur
Lungs: CTAB
Abd: S/NT/ND
Ext: WWP, trace b/l lower extremity edema
Derm: 1mm circular erythematous, nontender lesion on palmar
surface of left finger; nail bed in hands, feet without notable
lesions
Labs were notable for:
BUN 36, Cr 1.2
Glucose 117
CRP 9.4
Urine CastHy 3
[ ] blood culture pending
[ ] urine culture pending
Studies performed include:
Chest: Frontal and lateral views
Comparison: ___
FINDINGS:
Patient is status post median sternotomy. Cardiac and
mediastinal
silhouettes are stable. Cardiac silhouette size is mildly
enlarged. There is minimal interstitial edema. No pleural
effusion or pneumothorax is seen. No focal consolidation is
seen.
IMPRESSION:
Minimal interstitial edema. Mildly enlarged cardiac silhouette
size.
Patient was given:
___ 16:30IV Vancomycin (750 mg)
Consults:
Cardiology
Overall, patient presenting with malaise, but given prior
history
of endocarditis and bioAVR/Bentall I/s/o aortic valve
___ abscess, appropriate to keep high
concern for endocarditis. However, patient without positive
blood
cultures (although reportedly positive at urgent care in ___ ___
ago), ECG without signs of AV conduction disease (narrow PR with
stable/narrow QRS). Clinically, hemodynamically stable without
evidence of heart failure either.
Recommended that patient be worked up broadly for infection and
to have blood cultures followed. Also recommended obtaining
repeat ECG to assess for any dynamic conduction disease as well
as ID consultation. Agree with disposition decision to admit for
work-up and management of possible infection and would obtain
OSH
blood culture data. Cardiology may be consulted as inpatient if
needed (i.e. evidence of conduction disease or heart failure
assuming endocarditis is present) or TEE may be directly pursued
by inpatient medicine team as needed.
Vitals on transfer:
Temp: 97.7 BP: 150 / 74 HR: 57RR: 18 Pox: 94 on Ra
Upon arrival to the floor, patient endorses the above history.
REVIEW OF SYSTEMS:
Complete ROS obtained, positive per HPI and is otherwise
negative.
Past Medical History:
- Bicuspid AS s/p bioAVR ___ MDT) and AscAo graft (#30
Gelweave)
in ___. Staph ludgenensis endocarditis/aortic root abscess s/p
Bentall #19 homograft and MV vegetation removal in ___
- Neuropathy
- HTN
- HLD
- Peripheral arterial disease
- Hypothyroidism (post-surgical)
Social History:
___
Family History:
Father: HTN, stroke
Mother: HTN
Physical ___:
ADMISSION PHYSICAL EXAM:
VITALS: Temp: 97.7 BP: 150 / 74 HR: 57 RR: 18 Pox: 94 on Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. Erythematous posterior pharynx without exudates. TM
visualized and non-erythematous, dry cerumen present b/l.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: II/VI systolic murmur.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness. No spinal tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 20 gauge IV in L arm. No clubbing, cyanosis, or
edema. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. No rash, no new lesions. Violaceous nontender lesion
on L palm and L sole noted by pt to be from years ago.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. CN2-12
intact. Grossly normal strength throughout. Normal sensation to
vibration in upper extremities b/l. R lower extremity sensation
to vibration less than the L lower extremity. Gait normal.
DISCHARGE PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 738)
Temp: 97.8 (Tm 98.6), BP: 110/51 (108-134/51-67), HR: 55
(55-63), RR: 18 (___), O2 sat: 95% (93-95), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: MMM. Mild uvular edema.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: II/VI systolic murmur.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
SKIN: Warm. No rash, no new lesions.
NEUROLOGIC: AOx3. No gross deficits. Moving all extremities with
purpose.
Pertinent Results:
ADMISSION LABS:
___ 09:35AM BLOOD WBC-7.9 RBC-4.33 Hgb-12.9 Hct-39.4 MCV-91
MCH-29.8 MCHC-32.7 RDW-12.8 RDWSD-42.8 Plt ___
___ 09:35AM BLOOD Neuts-60.8 ___ Monos-10.6 Eos-3.2
Baso-0.5 Im ___ AbsNeut-4.83 AbsLymp-1.94 AbsMono-0.84*
AbsEos-0.25 AbsBaso-0.04
___ 09:35AM BLOOD ___ PTT-27.0 ___
___ 09:35AM BLOOD Glucose-117* UreaN-36* Creat-1.2* Na-141
K-4.6 Cl-105 HCO3-23 AnGap-13
___ 09:35AM BLOOD ALT-13 AST-14 AlkPhos-47 TotBili-0.3
___ 09:35AM BLOOD Lipase-33
___ 09:35AM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.6 Mg-2.2
___ 09:35AM BLOOD CRP-9.4*
___ 09:56AM BLOOD Lactate-1.7
INTERVAL LABS:
___ 08:25AM BLOOD Glucose-144* UreaN-30* Creat-1.0 Na-139
K-4.6 Cl-102 HCO3-23 AnGap-14
___ 09:35AM BLOOD cTropnT-<0.01
___ 04:48PM BLOOD cTropnT-<0.01
___ 07:25AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 08:25AM BLOOD WBC-6.7 RBC-4.16 Hgb-12.6 Hct-38.3 MCV-92
MCH-30.3 MCHC-32.9 RDW-13.1 RDWSD-43.7 Plt ___
___ 07:25AM BLOOD Glucose-127* UreaN-29* Creat-1.2* Na-144
K-5.3 Cl-108 HCO3-25 AnGap-11
IMAGING:
___ CHEST (PA & LAT)
FINDINGS:
Patient is status post median sternotomy. Cardiac and
mediastinal silhouettes
are stable. Cardiac silhouette size is mildly enlarged. There
is minimal
interstitial edema. No pleural effusion or pneumothorax is
seen. No focal
consolidation is seen.
IMPRESSION:
Minimal interstitial edema. Mildly enlarged cardiac silhouette
size.
___ Transthoracic Echo Report
CONCLUSION:
The left atrial volume index is moderately increased. The right
atrium is mildly enlarged. There is no evidence
for an atrial septal defect by 2D/color Doppler. The estimated
right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is mild (non-obstructive) focal basal
septal hypertrophy. There is mild regional left ventricular
systolic dysfunction with mild hypokinesis of the
apex (see schematic) and preserved/normal contractility of the
remaining segments. The visually estimated
left ventricular ejection fraction is 55-60%. Left ventricular
cardiac index is normal (>2.5 L/min/m2).
There is no resting left ventricular outflow tract gradient.
Mildly dilated right ventricular cavity with normal
free wall motion. Tricuspid annular plane systolic excursion
(TAPSE) is normal. There is abnormal septal
motion c/w conduction abnormality/paced rhythm. The aortic sinus
diameter is normal for gender with normal
ascending aorta diameter for gender. The aortic arch diameter is
normal. An aortic valve homograft prosthesis
is present. normal leaflet motion and gradient. No masses or
vegetations are seen on the aortic valve. There
is no aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve. There is
moderate mitral annular calcification. There is
mild [1+] mitral regurgitation. Due to acoustic shadowing, the
severity of mitral regurgitation could be
UNDERestimated. No masses/vegetations are seen on the pulmonic
valve. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. There is moderate [2+] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with normal
cavity size and mild hypokinesis
of the apex with preserved global biventricular systolic
function. Mild right ventricular dilation.
Normally functioning aortic valve homograft. No 2D
echocardiographic evidence for endocarditis. If
clinically suggested, the absence of a discrete vegetation on
echocardiography does not exclude
the diagnosis of endocarditis.
Compared with the prior ___ (images not available for review) of
___ , there is more tricuspid
regurgitation. Other findings similar.
___ TEST (pMIBI)
INTERPRETATION: This ___ year old woman with h/o HTN, HLD, and
PAD;
s/p AVR in ___ was referred to the lab for evaluation of chest
pain and
dyspnea. The patient was administered 0.4 mg of Regadenoson IV
bolus
over 20 seconds. No chest, neck, back, or arm discomforts were
reported
by the patient throughout the study. In the presence of baseline
NSSTTW, there was an additional 0.5-1 mm of ST segment
depression with
biphasic T waves in the inferolateral leads, returning to
baseline by
minute 15 of recovery. The rhythm was sinus with rare, isolated
APBs
throughout the study. Appropriate hemodynamic response to the
infusion.
Post-MIBI, the patient was administered 60 mg of Caffeine IV.
IMPRESSION: Non-specific EKG changes in the presence of baseline
NSSTW.
No anginal type symptoms. Nuclear report sent separately.
SUMMARY FROM THE EXERCISE LAB:
For pharmacologic stress 0.4 mg of regadenoson (0.08 mg/ml) was
infused
intravenously over 20 seconds followed by a saline flush.
FINDINGS: Left ventricular cavity size is normal
Rest and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 75%
IMPRESSION: 1. Normal myocardial perfusion study. 2. Normal left
ventricular
cavity size. Left ventricular ejection fraction is 75%.
Brief Hospital Course:
___ F with PMH bicuspid AS s/p bioAVR and AscAo graft in ___,
Staph ludgenesis endocarditis/aortic root abscess s/p Bentall
#19 homograft and MV vegetation removal in ___, HTN, HLD,
peripheral artery disease s/p RFA stent, presenting with 3 weeks
of URI sx with malaise/feeling unwell in the setting of a
reported blood
culture positive for GPC at an ___ OSH.
ACUTE ISSUES:
=============
#Malaise and URI symptoms
#Positive GPC blood culture at OSH
The reports having URI symptoms starting in an ___,
including cough productive of white phlegm, chills, sweats. More
concerning, she also expressed shortness of breath with
occasional chest discomfort. Never had any fevers. She
ultimately went to Urgent Care in ___ with these sxs on
___, and had blood cultures ___ grew GPC. The
patient was called with these findings and told to go to the ED.
She received one dose of IV vancomycin in the ED. The
microbiology lab was called on ___, and confirmed that the
culture speciated to coagulase-negative Staph aureus, and was
deemed a likely contaminant. Her other culture from ___, as well
as repeat cultures taken on ___ when she presented to an ED in
___, were all no growth to date. It does not appear as
though the patient had a true blood stream infection. Her
malaise and URI sxs are more likely attributable to a viral
prodrome. She had blood cultures drawn upon arrival to ___, all
of which were pending, but no growth to date at time of
discharge. Ultimately, given her cardiac history/risk factors,
as well as her presenting complaint of SOB, a ___ was obtained,
which showed no evidence of endocarditis and an EF of 55-60%.
Her URI symptoms were managed symptomatically, with Flonase,
guaifenesin, benzonatate, and Tylenol.
# Shortness of Breath, Chest Discomfort
Patient's presentation with roughly 1 month of intermittent SOB
was concerning for a potential cardiac etiology of her symptoms;
notably, SOB was not related to exertion. On ___, she developed
new chest discomfort, associated with nausea and SOB. EKG was
checked, no changes from prior. Troponins were trended, and were
negative. Still, given her significant cardiac history and risk
factors, she had a nuclear stress test on ___ prior to
discharge, which normal myocardial perfusion study normal, left
ventricular, and left ventricular ejection fraction is 75%.
CHRONIC ISSUES:
===============
# Bicuspid AS s/p bioAVR ___ MDT) and AscAo graft (#30
Gelweave)
in ___. Staph ludgenensis endocarditis/aortic root abscess s/p
Bentall #19 homograft and MV vegetation removal in ___
Appears euvolemic on exam. Initially concerned for possible
blood stream infection
and possibility for endocarditis given her history, although her
one blood culture was ultimately deemed a contaminant, as above.
EKG on admission showed mild 1mm ST elevation in aVR, similar to
prior EKGs, as well as evidence of early repolarization, with no
concerning ischemic changes. ___ ultimately performed, above,
which was reassuringly very similar to most recent ___.
# HTN
- Continued carvedilol
- Continued home losartan
- Held Spironolactone on ___ given Cr bump;to be restarted ___
# HLD
- Continued Ezetimibe 10 mg PO DAILY
- Has history of statin intolerance
# PAD
- Continued aspirin & ezetimibe
#HYPOTHYROIDISM
- Continued levothyroxine 50 mcg PO DAILY
#ANXIETY
- Ordered for home dose of lorazepam PRN
- Continued mirtazapine 7.5 mg PO qHS
#PAIN
- Continued oxycodone 20 mg PO BID PRN
TRANSITIONAL ISSUES
===================
[ ] Please follow-up with your cardiologist, Dr. ___,
___ your ___ and stress test findings.
[ ] Please see your primary care provider regarding your
respiratory symptoms, if they continue to persist, and do not
respond to over-the-counter symptomatic therapy.
#CODE: Full (presumed)
#CONTACT: Daughter ___, ___
Greater than 30 minutes was spent in care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CARVedilol 25 mg PO BID
2. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID Every 4
hours for 7 days as of ___
3. Ezetimibe 10 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. LORazepam 0.5 mg PO DAILY:PRN anxiety
6. Mirtazapine 7.5 mg PO ONCE NIGHTLY
7. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H PRN for pain
8. Spironolactone 25 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Losartan Potassium 100 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Benzonatate 100 mg PO TID Cough
RX *benzonatate 100 mg 1 capsule(s) by mouth up to three times
daily Disp #*30 Capsule Refills:*0
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. GuaiFENesin ___ mL PO Q6H:PRN Cough
RX *guaifenesin 100 mg/5 mL 5 mL by mouth up to 4 times daily
Refills:*0
5. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth up to 2 times daily
Disp #*8 Tablet Refills:*0
6. Simethicone 40-80 mg PO QID:PRN Gas, bloating
7. Aspirin 81 mg PO DAILY
8. CARVedilol 25 mg PO BID
9. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID Every 4
hours for 7 days as of ___
10. Ezetimibe 10 mg PO DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
12. LORazepam 0.5 mg PO DAILY:PRN anxiety
13. Losartan Potassium 100 mg PO DAILY
14. Mirtazapine 7.5 mg PO ONCE NIGHTLY
15. Multivitamins W/minerals 1 TAB PO DAILY
16. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H PRN for pain
17. Spironolactone 25 mg PO DAILY
Start taking this medication again on ___.
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Viral Upper Respiratory Tract Infection
SECONDARY DIAGNOSIS
===================
Bicuspid AS s/p bioAVR ___ MDT) and AscAo graft
HTN
HLD
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had chills, a cough, and other respiratory symptoms for
about one month.
- You had blood cultures drawn in ___ that grew some
bacteria
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We got labwork and a chest X-ray, which was all reassuringly
normal, and did not show any evidence of infection.
- You got one dose of IV antibiotics in the ED, given the
concern for your positive blood culture in ___.
- We drew additional blood cultures in the ED.
- We got EKGs to examine your heart function, and they
reassuringly showed no evidence of new heart
dysfunction/ischemic (were very similar to prior).
- We discussed your blood cultures with the microbiology
facility in ___ that processed them, and they reported that
the cultures were likely a contaminant.
- We got an echocardiogram of your heart, which did not show any
evidence of endocarditis, and was overall similar to your prior
echo.
- We got a stress test of your heart, which was reassuringly
normal.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow-up with your cardiologist, Dr. ___, to discuss the
findings in your echo.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10332580-DS-10 | 10,332,580 | 23,070,235 | DS | 10 | 2124-11-21 00:00:00 | 2124-11-21 14:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
___: Revision hip fixation with removal of protruding
screw with protruding spiral blade replacing with shorter lag
screw and supplementary cannulated screw anterior to the
implant.
History of Present Illness:
___ female presenting to the emergency department
for evaluation of left hip pain. Approximately 2 weeks ago the
patient had a mechanical fall resulting in a left hip fracture.
The patient had operative intervention at ___
___.
The patient was doing well at rehabilitation until she developed
rather acutely increased pain and difficulty with ambulation.
She
had x-ray showing likely hardware migration. The patient was
sent
in for evaluation. There is no known fall since the time of her
operative repair.
Past Medical History:
Alzheimer's disease
spinal stenosis
thalassemia
hearing loss
right eye blindness since youth
arthritis
"borderline cholesterol"
T11-L1 compression fracture
HTN
HLD
Social History:
___
Family History:
Father died in ___ of stroke; mother died in ___ w/dementia;
sister died in ___ of MI; brother died in ___ of cancer. Brother
in ___ is healthy; daughter around ___ is also healthy.
Physical Exam:
Left hip incision clean, dry, and intact
Thighs and leg compartments soft
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ FHS ___ TA Peroneals Fire
1+ ___ and DP pulses
Pertinent Results:
___ 05:34AM BLOOD WBC-8.2 RBC-4.36 Hgb-10.7* Hct-34.7*
MCV-80* MCH-24.6* MCHC-30.8* RDW-16.0* Plt ___
___ 06:00AM BLOOD Glucose-113* UreaN-8 Creat-0.6 Na-139
K-3.8 Cl-101 HCO3-29 AnGap-13
___ 06:00AM BLOOD Calcium-9.0 Phos-3.5
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left hip hardware failure and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for revision left hip fracture open
reduction internal fixation, which the patient tolerated well
(for full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is touch down weight bearing in the
left lower extremity, and will be discharged on Lovenox 40 mg SC
daily for 2 weeks for DVT prophylaxis. The patient will follow
up in two weeks per routine. A thorough discussion was had with
the patient's daughter regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. CeleBREX *NF* (celecoxib) 400 mg Oral QD
3. Donepezil 20 mg PO DAILY
4. Gabapentin 500 mg PO TID
5. Lorazepam 0.5 mg PO Q4H:PRN anxiety
6. Memantine 10 mg PO DAILY
7. Quetiapine Fumarate 12.5 mg PO QAM
8. Quetiapine Fumarate 25 mg PO QHS
9. Sertraline 75 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. CeleBREX *NF* (celecoxib) 400 mg Oral QD
3. Donepezil 20 mg PO DAILY
4. Gabapentin 500 mg PO TID
5. Lorazepam 0.5 mg PO Q4H:PRN anxiety
6. Memantine 10 mg PO DAILY
7. Quetiapine Fumarate 12.5 mg PO QAM
8. Quetiapine Fumarate 25 mg PO QHS
9. Sertraline 75 mg PO DAILY
10. Acetaminophen 650 mg PO Q6H
11. Calcium Carbonate 500 mg PO TID
12. Multivitamins 1 TAB PO DAILY
13. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days
RX *enoxaparin 40 mg/0.4 mL 40 mg SC once a day Disp #*14
Syringe Refills:*0
14. Senna 2 TAB PO HS
15. Vitamin D 800 UNIT PO DAILY
16. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Failed left hip trochanteric fixation nail with migration of the
screw into the acetabulum.
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:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- 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:
- Left lower extremity touch down weight bearing
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Touchdown weight bearing
Encourage turning, deep breathing and coughing qhour when awake.
Treatment Frequency:
WOUND CARE:
- You can get the wound wet/take a shower starting 3 days after
your surgery. You may wash gently with soap and water, and pat
the incision dry after showering.
- 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.
- Daily dry gauze dressing changes. No dressing is needed if
wound continues to be non-draining.
Followup Instructions:
___
|
10332792-DS-11 | 10,332,792 | 28,230,179 | DS | 11 | 2192-03-25 00:00:00 | 2192-03-26 21:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ibuprofen / Aspirin
Attending: ___.
Chief Complaint:
Nausea/Vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ w/ hx of eosinophilic gastritis and
iliohypogastric neuralgia who presents with abdominal pain and
inability to tolerate POs x 3 days. Patient states that on
___ morning he developed terrible RLQ abdominal pain in the
same place as his chronic pain. He said that the pain was sharp,
stabbing. Pain is worse with bowel movements and better with
pain meds and rest. He has had persistent n/v and inability to
tolerate po. He had a formed stool on ___ and diarrhea x 1 on
___. No BM today but has been passing gas. No black or
bloody stools. Denies any fevers but + chills. No urinary
symptoms. Denies sick contacts or recent travel. He spoke with
the on call gastroenterology fellow who recommended he come to
the ED for evaluation.
In the ED intial vitals were: 99.0 76 125/80 18 96%
Labs significant for WBC count of 12 and H/H of ___, Na 146,
Cr 1.4, ALT and AST in the 100s with normal tbili
Patient was given: 2L IVF, 1 mg of dilaudid x3, zofran, ativan
x1 and sent to the floor
Vitals on transfer: 98.6 58 137/73 16 99% RA
Review of Systems:
(+) per HPI
(-) fever, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Ileohypogastric neuralgia with h/o right iliohypogastric nerve
block and steroid injection and RF ablation of right
iliohypogastric nerve
- Meckel's diverticulum ___ s/p resection in ___
- Appy ___
- Eosinophilic gastroenteritis (no eosinophils found in ___
biopsy, though was noted originally in esophagus, ileocecal
valve, and colon in ___
- s/p R knee surgery x 4
Social History:
___
Family History:
Brother with lupus.
Sister with thyroid problem.
Mother s/p triple A repair.
Father died of cerebral aneurysm in his ___
Physical Exam:
Exam on Admission:
Vitals- 98.7 120/72 58 18 99% RA
General- Alert, oriented, appears uncomfortable
HEENT- Sclera anicteric, dry MM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- +BS. soft, tender to palpation in right
periumbilical/lower quadrant, non-distended. voluntary guarding
with no rebound tenderness. no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Skin - multiple tattoos
Exam on Discharge:
Vitals- 98.1-98.7 121/68 (107-147/57-72) 60 ___ 99-100% RA
General- Alert, oriented, resting comfortably
HEENT- Sclera anicteric, MM slightly dry, oropharynx clear
Neck- supple, JVP not elevated
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- +NABS. soft, mildly tender to palpation in right
periumbilical/lower quadrant, non-distended. No rebound or
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 tattoos
Pertinent Results:
ADMISSION LABS:
___ 11:20PM GLUCOSE-125* UREA N-43* CREAT-1.1 SODIUM-146*
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-32 ANION GAP-15
___ 07:58PM WBC-12.0*# RBC-5.97 HGB-17.5 HCT-52.3*#
MCV-88 MCH-29.3 MCHC-33.5 RDW-12.1
___ 07:58PM NEUTS-73* BANDS-0 LYMPHS-14* MONOS-13* EOS-0
BASOS-0 ___ MYELOS-0
___ 07:58PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 07:58PM PLT SMR-NORMAL PLT COUNT-209
___ 07:58PM ALBUMIN-5.7* CALCIUM-10.1 PHOSPHATE-3.5
MAGNESIUM-2.8*
___ 07:58PM LIPASE-10
___ 07:58PM ALT(SGPT)-126* AST(SGOT)-163* CK(CPK)-721*
ALK PHOS-81 TOT BILI-0.9
___ 08:05PM LACTATE-1.4
___ 07:58PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 11:20PM ___ PTT-27.6 ___
___ 12:00AM URINE MUCOUS-RARE
___ 12:00AM URINE HYALINE-1*
___ 12:00AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 12:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
INTERVAL LABS:
___ 06:30AM BLOOD WBC-15.2* RBC-4.98 Hgb-15.1 Hct-45.5
MCV-91 MCH-30.2 MCHC-33.2 RDW-12.4 Plt ___
___ 11:20PM BLOOD ___ PTT-27.6 ___
___ 06:30AM BLOOD Glucose-113* UreaN-31* Creat-0.8 Na-145
K-4.1 Cl-104 HCO3-32 AnGap-13
___ 06:30AM BLOOD ALT-80* AST-65* AlkPhos-61 TotBili-0.7
___ 06:30AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.5 Iron-107
___ 06:30AM BLOOD calTIBC-317 Ferritn-294 TRF-244
___ 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:58PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
IMAGING:
RUQ U/S/ ___
UNDERLYING MEDICAL CONDITION:
___ year old man with abdominal pain, n/v, and new
transaminitis
REASON FOR THIS EXAMINATION:
eval for obstruction, lesion
Final Report
HISTORY: Abdominal pain with nausea, vomiting and new
transaminitis. Assess for obstruction or lesion.
COMPARISON: CT abdomen pelvis ___.
FINDINGS: The liver is normal in echotexture without focal
lesion. Mild central biliary prominence is seen with the common
hepatic duct measuring 7 mm and top-normal common bile duct of
5-6 mm. No obstructing lesion/stone is seen. The gallbladder
is mildly distended but without gallstones or other secondary
signs of cholecystitis; sludge may be present within the
gallbladder. The main portal vein is patent with hepatopetal
flow. The pancreas is unremarkable though the distal tail is
not well seen due to overlying bowel gas. No free fluid is
seen. The imaged aorta and IVC are unremarkable.
IMPRESSION: Minimal extrahepatic and central biliary prominence
as seen on the prior CT from over ___ year ago. This is of
uncertain significance particularly in the absence of elevated
bilirubin, alkaline phosphatase or obstructing stone/lesion
identified. As suggested on the previous examination, this
could be assessed with MRCP if clinically indicated.
___ KUB:
ABDOMEN (SUPINE & ERECT) Clip # ___
Reason: rule out obstruction
UNDERLYING MEDICAL CONDITION:
___ year old man with hx of abdominal surgeries presenting
with abdominal pain,
n/v
REASON FOR THIS EXAMINATION:
rule out obstruction
Final Report
HISTORY: ___ male with history of abdominal surgeries
presenting with abdominal pain, nausea, and vomiting, assess for
obstruction.
COMPARISON: Abdominal radiograph ___.
FINDINGS:
Two frontal views of the abdomen show a normal bowel gas
pattern. There are no dilated loops of large or small bowel to
suggest obstruction or ileus. There is no evidence of free air
or pneumatosis. The visualized osseous structures are
unremarkable.
IMPRESSION:
Normal bowel gas pattern without evidence of obstruction or
ileus.
Brief Hospital Course:
Mr. ___ is a ___ yo M with hx of eosinophilic gastritis,
iliohypogastric neuralgia who presents with abdominal pain and
N/V x3 days.
# Nausea/Vomiting: Began early ___ morning, on presentation
patient had been unable to take PO for several days and was
significantly dehydrated. Patient was hydrated with IVF and was
initially kept NPO. His nausea and vomiting was treated with
Zofran and Ativan. SBO or partial SBO was considered given
patient's surgical history, but abdominal exam was fairly benign
and KUB showed no signs of obstruction. The nausea and vomiting
eventually resolved and patient's diet was advanced. It was
thought that this presentation may be related to sphincter of
Oddi dysfunction (see below). Patient did persist in asking for
Ativan for anxiety and ultimately this medication was
discontinued as he is not prescribed as outpatient.
# Acute on chronic abdominal pain - predominant in the
periumbilical region and RLQ in the same spot as his known
chronic pain. Per patient the pain was worse than his baseline
since starting the N/V. Patient did have transaminitis on
admission, RUQ u/s relatively unchanged from what was seen on CT
scan from one year prior, but he does not seem to have had any
imaging when he was painfree. With hydration, transaminases
downtrended. Pain service was asked to see the patient and
recommendation was to continue symptomatic pain control, restart
Gabapentin as patient tolerated PO and to add Lidoderm patch
just superior and medial to his right ASIS in the RLQ. Also
recommended starting Nortriptyline 25mg qhs for chronic pain.
The GI service was additionally consulted for concern of
elevated transaminases, acute on chronic abdominal pain. They
were concerned about possible sphincter of oddi dysfunction
contributing to this acute episode with N/V. Plan was to do
MRCP that patient requested be performed as an outpatient.
Initially patient was requiring dilaudid IV for pain control but
this was discontinued as he clinically improved. He did well
without the Dilaudid, using the Gabapentin and Lidoderm patch
for pain control prior to discharge. He continued to take
Dronabinol this admission when tolerating PO. On day of
discharge, his pain was back to his baseline chronic pain.
Chronic Issues:
# History of eosinophilic gastritis - not recently active. last
EGD with biopsies negative for eosinophils in ___. Patient
does not report taking H2 blocker for this currently.
# Iliohypogastric Neuralgia: Will follow up in pain clinic for
evaluation of RFA, nerve block. Patient is starting
Nortriptyline on discharge for further control of chronic pain,
continued Gabapentin and Lidoderm patches.
Transitional Issues:
- Patient needs to have MRCP as outpatient, will then follow up
with Dr. ___ in GI clinic for ? sphincter of oddi
dysfunction
- Patient started Nortriptyline this admission at 25mg qhs and
given 30 day supply. Can be uptitrated if tolerating medication
well.
- Patient also reported significant anxiety this admission which
he felt was contributing to his nausea/vomiting. Would be worth
reassessing in less acute setting to see if symptoms are
persistent. He requested Ativan frequently this admission.
- If seen in ED for acute on chronic abdominal pain, Pain
Service strongly recommends against providing this patient with
narcotics. He at many points throughout admission described
pain out of proportion to his exam, appeared quite comfortable
with very normal vital signs and continued to request Dilaudid
frequently.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dronabinol 5 mg PO BID
2. Ranitidine 300 mg PO BID
3. Gabapentin 800 mg PO TID
4. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Gabapentin 800 mg PO TID
2. Dronabinol 5 mg PO BID
3. Ranitidine 300 mg PO BID
4. Nortriptyline 25 mg PO HS
RX *nortriptyline 25 mg 1 capsule by mouth at bedtime Disp #*30
Capsule Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD DAILY pain
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) apply to right lower
abdomen at site of pain for 12 hours on, 12 hours off as needed
for pain Disp #*30 Transdermal Patch Refills:*0
6. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Possible Gastroenteritis
Secondary: Iliohypogastric Neuralgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted with abdominal pain, nausea and vomiting. You were
started on intravenous fluids because you were quite dehydrated
on arrival to the hospital. It is still unclear the initial
cause of your nausea/vomiting and abdominal pain but it is
possible that this was caused by an infectious gastroenteritis.
Your liver enzymes were elevated during this admission and the
Gastroenterologists strongly recommend that you follow up with
imaging called an MRCP. The number to schedule this appointment
is listed below. You will be started on an additional
medication which may help with your pain called Nortriptyline
(Pamelor). Please follow up with the appointments as listed
below. We wish you the best.
Followup Instructions:
___
|
10333122-DS-5 | 10,333,122 | 25,650,366 | DS | 5 | 2153-03-10 00:00:00 | 2153-03-11 06:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with a history of A. fib (not currently on
anticoagulation), hypertension, osteopenia, CVA, IBS and recent
intracerebral hemorrhage who presents with fall found to have
compression fracture.
Patient is unable to provide history regarding fall, but from
records appears to have had a mechanical fall this morning
without a head strike. She is supposed to use a walker but did
not use one when walking this morning.
I discussed her history with her son and daughter-in-law
(daughter-in-law is an ___ at ___ who reports that she
is been having progressive cognitive decline over the last
several months. Earlier this year she was admitted to hospital
in ___ with aspiration pneumonia and severe hypoxemia. At
that time her systolic blood pressures were noted to be in the
230s. She was discharged and returned to ___ where
she
was admitted to ___ for ESBL E. coli UTI treated with
ertapenem. During her hospitalizations she suffered an
unwitnessed fall with imaging showing an intracerebral
hemorrhage
in the left putamen. Since then her family reports a
progressive
worsening in her executive function and short-term memory. She
has had a MoCA done one week ago with a score of 19. Her family
reports that there has also been evidence of suspicion and
paranoia from the patient regarding her 24-hour caretakers.
Since discharge she has been off her Eliquis and has neurology
follow-up in 2 weeks.
The patient initially presented to ___ where a CT scan was
concerning for osteolytic lesions. The patient was transferred
to the ___ for neurosurgery evaluation and work-up of
these lytic lesions. In the emergency department oncology was
consulted and recommended sending a work-up for multiple myeloma
given her history of MGUS.
- In the ED, initial vitals were: T 97.5 HR 78 BP 196/68 RR 16
O2
Sat 96% RA
- Exam was notable for:
Well-appearing, no complaints
NR, RR. Nl S1, S2. No m/r/g.
Lungs CTAB
Strength ___ BLE; Sensation intact
- Labs were notable for: ___ (normal CBC, BMP) Alk phos 119,
Protein 5.7
- Studies were notable for:
1. When compared to the prior CT, there is no significant change
of the severe superior endplate compression deformity of T11 and
the acute T12 vertebral body fracture, likely osteoporotic in
etiology.
2. No significant change of the moderate superior endplate
compression deformity of L1 without associated bone marrow
edema,
suggestive of a chronic compression deformity.
3. No significant change of the mild acute L5 superior endplate
compression fracture with diffuse increased T2/STIR signal
throughout the L5 vertebral body and posterior elements, most
likely osteoporotic in etiology.
4. Overall, no significant change in sagittal alignment along
the
lower thoracic and lumbar spine without evidence of epidural
collection, cord compression or severe spinal canal stenosis.
5. Cervical, thoracic and lumbar spondylosis as detailed above
with flattening of the ventral cord along the cervical levels
but
without cord signal abnormality.
6. Multilevel cervical and lumbar neural foraminal narrowing as
described above.
7. Moderate left pleural effusion, unchanged.
- Neurosurgery was consulted:
"No acute neurosurgical intervention, patient needs follow-up in
6W with T and L spine xrays, AP and lateral, with Dr. ___ final ___ read, likely osteoporotic lesions at T12
and
L5, however the fx appear stable
-please call the clinic during office hours at ___
- Recommend Oncology/Medicine consult for workup/staging
- NO Logroll precautions
- TLSO brace needed, use when out of bed, ___ at the edge of
the bed to work with ___
- Patient was given: losartan 25mg, amlodipine 2.5mg oxycodone
5mg iv Zofran 4mg
On arrival to the floor the patient reports she is in no pain.
She is otherwise unwilling to cooperate with a full neuro exam
reporting that she does not feel like she needs to.
Past Medical History:
HTN
Osteopenia
MGUS
TIA
A fib
IBS
Intracerebral hemorrhage ___
OA s/p R hip TKA ___
endometrial thickening s/p biopsy (recommended d+C but patient
declined)
Social History:
___
Family History:
Father- glaucoma
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 2120)
Temp: 98.6 (Tm 98.6), BP: 146/68, HR: 80, RR: 18, O2 sat:
93%
(93-97), O2 delivery: RA, Wt: 201 lb/91.17 kg
GENERAL: Alert and interactive, flat affect
HEENT: PERRL, EOMI. Sclera anicteric .
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. soft
systolic murmur at RUSB
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: Unable to assess due to patient cooperation
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm.
NEUROLOGIC: Alert, oriented to ___, hospital in ___ and
self. CN ___ intact. Moving all 4 limbs spontaneously when
unaware examiner is watching. Unwilling to participate in
strength exam, when asked why reports "I don't feel like it and
I
only do things I feel like doing". Within these confines she is
at least antigravity in four extremities. Flat affect. Unable to
remember events from this morning but long term memory intact.
DISCHARGE PHYSICAL EXAM:
=======================
VS: 24 HR Data (last updated ___ @ 2314)
Temp: 98.0 (Tm 98.3), BP: 125/77 (125-153/63-77), HR: 73
(60-83), RR: 20 (___), O2 sat: 94% (94-96), O2 delivery: Ra
GEN: alert/conversant elderly woman resting comfortably lying
in
bed, breathing without difficulty.
HEART: RRR, no m/r/g.
LUNGS: CTAB, no w/r/r.
ABDOMEN: S, NT, ND, BS+
EXTREMITIES: legs WWP, no ___ edema.
Pertinent Results:
ADMISSION LABS:
___ 01:33PM PEP-NO SPECIFI Free K-16.7 Free ___ Fr
K/L-0.99 IgG-827 IgA-113 IgM-96
___ 01:33PM TOT PROT-6.1*
___ 05:44AM BLOOD WBC-8.2 RBC-4.43 Hgb-11.8 Hct-38.6 MCV-87
MCH-26.6 MCHC-30.6* RDW-14.6 RDWSD-46.5* Plt ___
___ 05:44AM BLOOD ___ PTT-26.5 ___
___ 05:44AM BLOOD Glucose-107* UreaN-17 Creat-0.9 Na-141
K-4.7 Cl-102 HCO3-28 AnGap-11
MICRO:
___ 5:54 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
___ MRI C/T/L Spine
IMPRESSION:
1. When compared to the prior CT, there is no significant change
of the severe
superior endplate compression deformity of T11 and the acute T12
vertebral
body fracture, likely osteoporotic in etiology.
2. No significant change of the moderate superior endplate
compression
deformity of L1 without associated bone marrow edema, suggestive
of a chronic
compression deformity.
3. No significant change of the mild acute L5 superior endplate
compression
fracture with diffuse increased T2/STIR signal throughout the L5
vertebral
body and posterior elements, most likely osteoporotic in
etiology.
4. Overall, no significant change in sagittal alignment along
the lower
thoracic and lumbar spine without evidence of epidural
collection, cord
compression or severe spinal canal stenosis.
5. Cervical, thoracic and lumbar spondylosis as detailed above
with flattening
of the ventral cord along the cervical levels but without cord
signal
abnormality.
6. Multilevel cervical and lumbar neural foraminal narrowing as
described
above.
7. Moderate left pleural effusion, unchanged.
___ CT T/L Spine
IMPRESSION:
1. Fracture through the T12 vertebral body which is distracted,
similar
appearance compared to recent exams. Paraspinal soft tissue
stranding
suggesting that this is recent.
2. Acute L5 superior endplate compression fracture, also similar
to prior.
3. T11 vertebral body compression deformity with 50% vertebral
body height
loss similar compared to prior exams.
4. No new fracture since prior imaging.
5. Right thyroid nodule for which nonurgent, thyroid ultrasound
is suggested
if not previously performed.
___ CT Head WO Contrast
IMPRESSION: No acute intracranial abnormality, specifically, no
evidence of hemorrhage or
large territorial infarction.
DISCHARGE LABS:
None obtained on day of discharge.
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY:
=====================
___ female with a history of A. fib not currently on
anticoagulation, hypertension, osteopenia, CVA, IBS and recent
intracerebral hemorrhage who presents with fall found to have
compression fractures likely secondary to OA.
TRANSITIONAL ISSUES:
==================
[ ] Patient should wear TLSO brace when out of bed until
neurosurgery follow up appointment ___.
[ ] Started on once weekly alendronate 70mg for osteoporosis
(D1: ___. Also discharged on calcium and vitamin D.
[ ] Metoprolol dose was changed to 12.5mg metoprolol succinate
(on metoprolol tartrate 12.5 mg BID in outpatient setting) in
setting of relative hypotension. Should be uptitrated in
outpatient setting as needed.
[ ] Briefly on amlodipine due to difficulty obtaining updated
outpatient medication list. Reinitated on home losartan 50 mg on
discharge. Blood pressures should be checked BID with titration
of medication as needed if any evidence of hypotension.
[ ] Held home dicyclomine for IBS in setting of significant
anti-cholinergic effects. Should be reassessed in outpatient
setting.
[ ] Monitor pain level.
[ ] Would repeat UA to assess for resolution of hematuria.
ACUTE/ACTIVE ISSUES:
==================
#compression fractures of T12 and L5
#OA
Patient presented s/p fall with acute compression fractures of
T12 and L5. Initially concerned for lytic lesions on CT, however
on MRI appeared more consistent with OA. Oncology was consulted
in the ED and recommended work up for multiple myeloma given
patient's history of MGUS, including quantitative IgGs, free
light chains, SPEP and UPEP, all of which were normal. Patient
received Tylenol for pain control. She received vitamin D and
calcium supplementation, and was started on once weekly
alendronate 70mg (D1: ___. Patient was seen by
neurosurgery who recommended TLSO brace when out of bed and
follow up with neurosurgery in 6 weeks. ___ recommended discharge
to rehab.
#Somnolence, resolved: Patient triggered for acute change in
consciousness that self-resolved. Neurologic exam was stable.
Non-contrast CT head was negative. No new medications to explain
sedation. Unlikely cardiac etiology given no symptoms. Although
she has a history of Afib not on AC, unlikely CVA given rapid
improvement. No evidence of infection other than U/A as
discussed below. Metoprolol was dose reduced in the setting of
slight hypotension during episode (108/67).
#H/o UTI:
#Hematuria
Patient had urinary retention during hospitalization, with
stable CT T/L spine ruling out cord compression. UA demonstrated
large leuk esterase, few bacteria, 13 RBC and >182 WBC. While
concerning for infection, patient denied any hematuria, dysuria,
urgency or frequency, and urinary retention self-resolved. Given
patient has history of ESBL UTI treated with ertapenem in
___, antibiotics were deferred while awaiting culture. Urine
culture demonstrated mixed bacterial flora. No treatment was
pursued. She denied dysuria or other symptoms. Would repeat UA
to assess for resolution of hematuria.
CHRONIC ISSUES:
=============
# Afib: CHADSVASC ~6. AC held in outpatient due to recent
intracerebral hemorrhage. Metoprolol dose was reduced to 12.5 qd
as above.
#HTN: Briefly on amlodipine due to difficulty obtaining
outpatient medication list. Home losartan initially held due to
uncertainty in dosing, started 50 mg at discharge
#HLD: continued home statin
#IBS: Held dicyclomine given anti-cholinergic effects
#H/o MGUS: Labs here not concerning for progression to myeloma.
# CODE: DNR/DNI confirmed (has MOLST)
# CONTACT: ___
Relationship: SON
Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. DICYCLOMine 20 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Albuterol Inhaler 2 PUFF IH Q6H
7. Cyanocobalamin 1000 mcg PO DAILY
8. Lactobacillus rhamnosus GG 10 billion cell oral DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Alendronate Sodium 70 mg PO QTUES
3. Calcium Carbonate 500 mg PO TID
4. Lidocaine 5% Patch 1 PTCH TD QPM
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H
7. Atorvastatin 80 mg PO QPM
8. Cyanocobalamin 1000 mcg PO DAILY
9. Lactobacillus rhamnosus GG 10 billion cell oral DAILY
10. Losartan Potassium 50 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- DICYCLOMine 20 mg PO DAILY This medication was held.
Do not restart DICYCLOMine until your primary care provider says
you can re-start this.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Compression fractures of T12 and L5
Osteoarthritis
Secondary Diagnoses:
Afib
HTN
HLD
IBS
H/o MGUS
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 privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because you fell and
fractured your spine.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You were seen by neurosurgery who recommended that you wear
the back brace whenever you are up and out of bed.
- Physical therapy worked with you and recommended that you go
to rehab after discharge.
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.
We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10333190-DS-17 | 10,333,190 | 22,536,678 | DS | 17 | 2196-04-09 00:00:00 | 2196-04-10 16:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Called back from ___ ED for blood cultures with resistant E.
coli
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
This is a ___ year old ___ woman with no PMHX who
was seen at the ___ ED on ___ with pyelonephritis and was
given ceftriaxone x2 and discharged with a prescription for
ciprofloxacin. Blood cultures drawn on ___ grew out E. coli
resistant to ciprofloxacin.
She reports having had LBP x1 month with dysuria - had seen been
to a clinic twice and diagnosed with UTI, treated unsuccessfully
with antibiotics prior to coming to ___ ED on ___.
In the ED today, she is complaining of shaking chills with a
tender abdomen, +/- CVA tenderness and suprapubic tenderness.
She also reports fever, chills, dyspnea x1 month, with LBP,
dysuria, frequency and nausea.
In the ED, her vitals were T 98.8F, HR 83 BP 145/98 R 16 Spo2
100% on RA. In the ED, she received cefepime 2g x1, ondansetron
and 1L IV NS. Labs were significant for WBC of 9.2, N 77.2% and
a grossly positive UA, with negative UCG. Urine and blood
cultures were also drawn.
On the floor she was febrile to T 102.3F.
Past Medical History:
None
Social History:
___
Family History:
Non contributory
Physical Exam:
EXAM ON ADMISSION
VITALS - T 102.3F, BP 118/78, HR 90, R 16, Spo2 97% on RA
GENERAL - lying in bed, in NAD
HEENT - MMM, PERRL, EOMI
LUNGS - CTAB without crackles, wheezes
COR - regular rate, normal S1 and S2 with presence of S4,
without murmurs or rubs
ABDOMEN - soft, non-tender, tympanic, normoactive bowel sounds;
minimal R sided CVA tenderness
EXTREMITIES - trace pitting edema of the feet bilaterally ___ up
the shin; warm, well perfused, DP pulses 2+ bilaterally
NEURO - CN II-XII intact, A&O x3, conversing mostly in
___, some in ___
SKIN - warm, without petechiae, rash or excoriations
EXAM ON DISCHARGE
VITALS - 98.3 117/69-135/88 ___ 100% on RA
GENERAL - lying in bed, in NAD
HEENT - MMM, PERRL, EOMI
LUNGS - CTAB without crackles, wheezes
COR - regular rate, normal S1 and S2, without murmurs, rubs, S3
or S4
ABDOMEN - soft, non-tender, tympanic, normoactive bowel sounds;
no suprapubic tenderness, no CVA tenderness
EXTREMITIES - trace edema of the feet bilaterally to the ankle;
warm, well perfused, DP pulses 2+ bilaterally
NEURO - CN II-XII intact, A&O x3, conversing mostly in
___, some in ___
SKIN - warm, without petechiae, rash or excoriations
Pertinent Results:
LABS ON ADMISSION
___ 05:10PM BLOOD WBC-9.2 RBC-4.19* Hgb-13.1 Hct-40.1
MCV-96 MCH-31.3 MCHC-32.6 RDW-14.0 Plt ___
___ 05:10PM BLOOD Neuts-77.2* Lymphs-12.1* Monos-9.3
Eos-1.1 Baso-0.3
___ 05:10PM BLOOD Glucose-84 UreaN-10 Creat-0.7 Na-138
K-3.4 Cl-105 HCO3-23 AnGap-13
___ 05:47PM URINE RBC->182* WBC-50* Bacteri-FEW Yeast-NONE
Epi-7
___ 05:47PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
LABS ON DISCHARGE
___ 07:41AM BLOOD WBC-7.4 RBC-3.69* Hgb-11.7* Hct-35.4*
MCV-96 MCH-31.7 MCHC-33.0 RDW-13.9 Plt ___
___ 07:41AM BLOOD Neuts-70 Bands-0 Lymphs-15* Monos-14*
Eos-1 Baso-0 ___ Myelos-0
___ 07:41AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 07:41AM BLOOD Plt Smr-NORMAL Plt ___
___ 07:41AM BLOOD Glucose-95 UreaN-9 Creat-0.7 Na-139 K-3.5
Cl-105 HCO3-23 AnGap-15
___ 07:41AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.8 Mg-2.1
IMAGING
Renal US:
Right sided collecting system fullness, otherwise unremarkable.
CXR:
Heart size and mediastinum are stable in appearance. Interval
increase in left pleural effusion is demonstrated as well as
presence of small right pleural effusion. Right PICC line tip is
at the level of mid to lower SVC.
Brief Hospital Course:
This is a ___ year old ___ woman who was recenty
in the ___ ED (___) with pyelonephritis, discharged with
ciprofloxacin after receiving ceftriaxone x2, whose blood
cultures grew E. coli resistant to ciprofloxacin. She was called
to come back to the hospital for appropriate antibiotic
treatment.
## PYELONEPHRITIS/E. COLI BACTEREMIA. The patient was started
on cefepime 2g bid for E. coli bacteremia. Received APAP and
ibuprofen, as needed for pain/fever. She was febrile at the time
of admission to 102.7F but quickly responded to antibiotics and
antipyretics. She had a PICC line placed to continue a 14 day
course of cefepime with ___ at home. Upon discharge, pt had been
afebrile for >24 hours and was tolerating POs well.
## PERIPHERAL EDEMA: There was minimal pitting edema of the
lower extremities bilaterally in the setting of having received
4L NS 2 days prior to admission and pyelonephritis. This edema
slowly resolved on its own.
TRANSITIONAL ISSUES
[] Blood cultures fromo ___ and ___ pending at discharge
[] Complete 14 day total course of antibiotics (last day ___
[] hypoalbuminemia: the pt had low albumin levels (2.5 mg/dl)
but no known history of liver disease. Her last LFTs were from
___ but were not abnormal. She has no clincial signs of liver
dysfunction (sclera anicteric, not grossly volume overloaded, no
spider angiomas etc). A work up for liver disease was
subsequently defered to outpatient management.
Medications on Admission:
None
Discharge Medications:
1. CefePIME 2 g IV Q12H
RX *cefepime [Maxipime] 2 gram 2 g IV every 12 hours Disp #*24
Vial Refills:*0
2. Acetaminophen 650 mg PO Q4H:PRN fever, pain
3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
RX *heparin lock flush (porcine) 10 unit/mL 10 cc IV daily Disp
#*12 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___ after blood cultures that were taken
when ___ came to the ___ emergency room grew E. coli bacteria
that was resistant to the antibiotics ___ were taking. ___
required IV antibiotics to treat your infection. ___ had a PICC
line placed to infuse the appropriate antibiotics at home. ___
had excellent response to the antibiotics and began getting
better quickly.
Thank ___ for allowing us to take part in your care! It was a
pleasure caring for ___.
- Your team at ___
Followup Instructions:
___
|
10334189-DS-4 | 10,334,189 | 23,784,349 | DS | 4 | 2152-03-27 00:00:00 | 2152-03-29 11:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
alendronic acid / Amoxicillin / Calcitonin / colchicine /
digoxin / lactose / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug) / pravastatin / risedronate sodium / simvastatin / Sulfa
(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal Pain, fevers, n/v
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and stent placement ___
___ placement ___
History of Present Illness:
Ms. ___ is a ___ with a history of HTN, HL, CAD, MI s/p
7-vessel CABG, afib on coumadin, and cholecystitis s/p
cholecystectomy x ___ years ago presents from OSH with
pancreatitis and concern for common bile duct inflammation. She
presented to ___ with severe RUQ pain radiating to
the shoulder associated with nausea. Labs there were
significant for WBC 18, AST 740, ALT 536, alk phos 475, lipase >
15,000, amylase 2988, lactate 2.1, Ca ___. RUQ US was
significant for intrahepatic bile duct dilatation with a CBD
measuring 8mm in diameter w/o evidence of choledocolithiasis.
Blood cultures were taken, now growing Gram + cocci in pairs in
chains, and she was started on Zosyn 4.5g. She also received 1L
NS, Pantoprazole 40mg IV, Mag Sulfate 2g. She was transferred
to ___ for emergent ERCP.
Patient's recent history per patient's daughter. The daughter
reports a history of abdominal pain for the past year. About
one year ago the patient prsented to the ___ with abdominal
pain found to have elevated LFTs and ? of gallstones/sand on
abdominal US. She was followed without intervention and had
another episode of similar RUQ pain in ___. Since that time
the family reports abdominal pain with spicy/greasy food. Since
about 1 month ago, patient has been having abdominal pain 1 time
per week. Associated with nausea, ? related to food with normal
PO intake and denies fevers/chills. Patient saw PCP ___ 2
weeks ago and he started omeprazole for ? of GERD. Patient
herself reports a history of pale stools x 1 week. Patient
denies SOB, chest pain, fevers/chills, vomiting, dysuria,
hematuria, blood in the stool, melena. She deneis angina and
SOB on exertion. No history of stroke, renal disease, CHF, and
valvular heart disease.
In the ED, initial VS were: T 98.3 HR 94 BP 109/66 RR 22 O2 sat
96% on RA . Labs were remarkable for WBC 39 (90% PMNs, 3%
lymphs), INR 3.0, K 2.4, ALT 414, AST 523, Alk phos 321, Tbili
5.8, lipase 3528. UA was unremarkable and a urine culutre was
taken. Vitals on Transfer: HR 74 BP 140/77 RR 25 O2 sat 96% on
RA.
Vitals on the floor: T: 97.6 BP: 138/80 P: 77 R: 18 O2: 96% RA.
Past Medical History:
HTN
CAD
MI s/p 7 vessel CABG ___ years ago
Afib on coumadin
HL
Tophaceous gout
DM2-diet controlled
PAST SURGICAL HISTORY:
7 vessel CABG x ___ years ago
choleystecomy x ___ years ago
C-section and hysterectomy
suspended kidney relocation
Social History:
___
Family History:
Father - died of MI in late ___
Brother - died of urogenital/liver cancer in ___
Brother - died of brain tumor in late ___
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 97.6 BP: 138/80 P: 77 R: 18 O2: 96% RA
General: Frail appearing older woman in no acute distress.
HEENT: dry MM, EOMI,
Neck: Supple
CV: Irregularly irregular rhythm, normal S1/S2, no m/r/g,
Lungs: CTAB
Abdomen: Soft, non-distended, RUQ and LUQ tenderness to
palpation, ? rebound tenderness, +BS, no HSM
Skin: Flushed cheeks.
DISCHARGE PHYSICAL EXAM
Vitals: T: 98.1 BP: 171/89 P: 76 R: 20 O2: 98% RA
General: Frail appearing older woman in no acute distress.
HEENT: moist MM, EOMI, PERRLA
Neck: Supple
CV: Irregularly irregular rhythm, normal S1/S2, no m/r/g,
Lungs: CTAB
Abdomen: Soft, non-distended, non-tender, +BS, no HSM
Skin: Flushed cheeks.
Pertinent Results:
ADMISSION LABS
___ 01:21AM BLOOD WBC-39.0* RBC-4.52 Hgb-14.1 Hct-41.3
MCV-91 MCH-31.3 MCHC-34.3 RDW-16.2* Plt ___
___ 01:21AM BLOOD Neuts-90* Bands-4 Lymphs-3* Monos-2 Eos-0
Baso-0 ___ Metas-1* Myelos-0
___ 01:21AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 09:08AM BLOOD ___ PTT-47.0* ___
___ 01:21AM BLOOD Glucose-156* UreaN-19 Creat-0.8 Na-142
K-2.4* Cl-100 HCO3-25 AnGap-19
___ 01:21AM BLOOD ALT-414* AST-523* AlkPhos-321*
TotBili-5.8*
___ 01:21AM BLOOD Lipase-3528*
___ 01:21AM BLOOD Albumin-4.1
___ 10:20AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1
___ 02:42AM BLOOD Lactate-1.6
INTERVAL LABS
___ 10:20AM BLOOD WBC-25.8* RBC-4.16* Hgb-13.3 Hct-38.4
MCV-92 MCH-31.9 MCHC-34.6 RDW-16.7* Plt ___
___ 07:00AM BLOOD WBC-19.7* RBC-4.04* Hgb-13.0 Hct-37.6
MCV-93 MCH-32.2* MCHC-34.7 RDW-16.4* Plt ___
___ 07:35AM BLOOD WBC-12.6* RBC-3.96* Hgb-12.6 Hct-37.3
MCV-94 MCH-31.7 MCHC-33.7 RDW-16.5* Plt ___
___ 10:20AM BLOOD ___ PTT-44.6* ___
___ 07:00AM BLOOD ___ PTT-47.7* ___
___ 07:35AM BLOOD ___ PTT-50.4* ___
___ 10:20AM BLOOD ALT-346* AST-343* LD(LDH)-315*
AlkPhos-289* TotBili-5.9*
___ 07:00AM BLOOD ALT-241* AST-157* AlkPhos-254*
TotBili-3.3*
DISCHARGE LABS
___ 08:00AM BLOOD WBC-7.4 RBC-4.06* Hgb-12.7 Hct-37.2
MCV-92 MCH-31.3 MCHC-34.1 RDW-16.6* Plt ___
___ 06:04AM BLOOD ___
___ 06:04AM BLOOD Glucose-122* UreaN-8 Creat-0.6 Na-139
K-3.2* Cl-104 HCO3-28 AnGap-10
___ 06:04AM BLOOD ALT-51* AST-25 AlkPhos-169* TotBili-1.1
___ 06:04AM BLOOD Calcium-9.3 Phos-2.6* Mg-1.6
MICRO
Urine Culture ___: No Growth
Blood Culture x2 ___: No growth
C. diff Stool DNA amplification ___: negative
Blood culture x1 ___: No Growth
OSH Blood Culture ___: Streptococcus bovus
IMAGING
CXR ___
FINDINGS: AP single view of the chest has been obtained with
patient in
semi-upright position. Since the next preceding examination of
___ the patient has received a right-sided PICC line,
which terminates overlying the right-sided mediastinal
structures at a level 5 cm below the carina. This is very close
to the expected entrance into the right atrium and withdrawal by
2 cm is recommended so to terminate safely in the lower third of
the SVC.
TTE ___
FINDINGS: The left atrium is dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
The right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with borderline normal free
wall function. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] The aortic root is mildly dilated at the sinus
level. There are focal calcifications in the aortic arch. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Severe [4+]
tricuspid regurgitation is seen (prominent systolic flow
reversal seen in the hepatic veins). 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.] Significant pulmonic
regurgitation is seen. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No vegetations seen (best
excluded by TEE); severe tricuspid regurgitation and
moderate-to-severe pulmonary hypertension present
ERCP ___ IMPRESSION:
A single diverticulum with medium opening was seen in the
cricopharyngeus.
There was an impacted stone stone in the major papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome
A mild diffuse dilation was seen at the biliary tree with the
CBD measuring 12 mm.
There were several round filling defects compatible with stones
in the distal CBD at the biliary tree.
Normal intrahepatics. Clips of previous cholecystectomy were
noted.
Limited pancreatogram was normal.
Given the patient's elevated INR, a 7cm by ___ Cotton ___
biliary stent was placed successfully. Excellent flow of bile
and pus was noted.
CXR ___ FINDINGS:
Single portable frontal view of the chest. A vague opacity is
seen at the left lung base. It is difficult to determine is
this is an actual consolidation or atelectasis as the patient is
rotated and there are no priors for comparison. Short term
follow up with frontal and lateral views is recommended. There
is mild prominence of the right pulmonary artery. The cardiac
silhouette is mildly enlarged.
There is a tortuous and calcified aorta. There is no pleural
effusion or pneumothorax. Vascular calcifications are noted.
Brief Hospital Course:
Ms. ___ is a ___ with a history of HTN, HL, CAD, MI s/p
7-vessel CABG, afib on coumadin, and cholecystitis s/p
cholecystectomy x ___ years ago presents from OSH with
pancreatitis and concern for common bile duct infection.
ACTIVE ISSUES
# PANCREATITIS/CHOLANGITIS/Strep Bovis Septicemia/ presumed
endocarditis
She was transferred from ___ for RUQ pain and an
abodminal US showing CBD dilatation, leukocytosis, and an
elevated lipase concering for pancreatitis and cholangitis. She
was continued on Zosyn and Vancomycin upon arrival to ___. She
underwent an ERCP on ___ which showed a stone in the common
bile duct as well as frank pus and a stent was placed.
Folllowing this procedure her abdominal pain improved
significantly and her LFTs trended down. Her ___
blood cultures came back and were positive for Strep bovus and
Vancomycin was discontinued. She had a TTE to evaluate for
endocarditis which showed 4+ TR without evidence of
endocarditis. We discussed with the ID team and her family in
regards to further testing of a TEE and colonoscopy (given
concern for infective endocarditis and colon cancer in the
setting of strep bovis), and we determined at this time to not
pursue further studies due to her advanced age and increase risk
with anesthesia and the procedures themselves. We instead plan
to empirically treat her with 4 weeks of IV antibiotics for
presumed endocarditis. After the antibiotic sensitivities of
her blood cultures from the OSH returned, we switched her
antibiotic from zosyn to ceftriaxone and she remained stable and
her leukocytosis normalized. A PICC line was placed ___ for
long term IV antibiotic andministration. She was discharged
home in stable condition with a plan for ___ nursing, 24 hour
family monitoring, and antiobiotic infusion pumps. She will
continue to take the IV ceftriaxone at home for a total of 4
weeks of treatment (last day ___. She was also need a
repeat ERCP for stent pull and stone extraction in 4 weeks and
will need to be off anticoagulation at this time.
CHRONIC ISSUES
# HTN
She was continued on her home dose of metoprolol and ramipril.
Her Lasix was held initially and restarted on ___. Her
blood pressures were well-controlled during her hospitalization.
# CAD
Aspirin 81mg was continued.
# HL
Her lipitor was held due to elevated LFTs. Please evaluate for
restarting statin.
# Atrial Fibrillation on Coumadin
Her INR was 3.0 on admission. It trended up during admission
and was monitored so her coumadin was held. She received
Vitamin K for placement of a PICC line. Her home dose of
coumadin was restarted on ___. Her metoprolol was restarted
after her ERCP and she remained hemodynamically stable. Her
heart rate was well-controlled during her hospitalization.
# Gout
Her home dose of allopurinol was continued.
TRANSITIONAL ISSUES
- Repeat ERCP in 4 weeks for stent pull, reevaluation,
sphincterotomy and stone extraction. The patient needs to be off
anticoagulation for the appointment. Will need coordinate with
her PCP ___ Cardiologist for management of anticoagulation
before the procedure.
- Patients statin was put on hold secondary to elevated LFTs.
LFTs are trended down. Can consider restarting statin therapy.
- Please follow-up ___ lab draws for BMP, Ca, Mg, Phos, INR, and
LFTs for IV Abx monitoring
- Please monitor INR (next check on ___, to be followed by PCP)
- continue IV Ceftriaxone via ___ for total 4 week course, f/u
with ___
- CBC to assess for stability / improvement of plt count
- repeat CXR imaging with full PA/lateral film to assess for
possible left lung base opacity seen on CXR (See CXR report from
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
3. Lumigan *NF* (bimatoprost) .03 % ___ 1 drop daily
4. Vitamin D 1000 UNIT PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Warfarin 1.25 mg PO QSUN
8. Ramipril 10 mg PO DAILY
9. Furosemide 40 mg PO BID
10. Metoprolol Tartrate 12.5 mg PO BID
11. Paroxetine 10 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
thin layer to the affected areas.
14. Warfarin 2.5 mg PO EVERY ___, TH, F, SAT
15. Calcium Carbonate 500 mg PO DAILY
16. Ocuvite *NF* (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg Oral Daily
17. Potassium Chloride 15 mEq PO DAILY
Hold for K > 5
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 grams IV Q 24 hours Disp #*22 Each
Refills:*0
2. Outpatient Lab Work
Please check BMP, Ca, Mg, Phos, and AST/ALT, alk phos, INR on
___. Please fax results to Dr. ___ at
___.
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
7. Furosemide 40 mg PO DAILY
8. Metoprolol Tartrate 12.5 mg PO BID
9. Omeprazole 40 mg PO DAILY
10. Paroxetine 10 mg PO DAILY
11. Potassium Chloride 15 mEq PO DAILY
12. Ramipril 10 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Warfarin 2.5 mg PO DAILY16
15. Lumigan *NF* (bimatoprost) .03 % ___ 1 drop daily
16. Ocuvite *NF* (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg Oral Daily
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gallstone Pancreatitis
Cholangitis
Strep bovis Bacteremia
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 ___
___. You were admitted to the hospital for
abdominal pain with concern for an bile duct stone and
inflmmation of your pancrease. You had a procedure which found
a stone in your bile duct and a stent was placed. In addition,
blood taken at ___ was found to be infected with
Strep bovis bacteria. You were continued on antibiotics that
treat this type of infection. You also had an ultrasound of
your heart that did not show any infection on your heart valves.
You will cotinue taking IV antibiotcs at home for a total of 4
weeks. You should also continue taking your coumadin as
directed by your primary care doctor.
Followup Instructions:
___
|
10334371-DS-7 | 10,334,371 | 21,512,685 | DS | 7 | 2181-02-28 00:00:00 | 2181-02-28 15:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness, falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a history of cervical and lumbar
surgeries, CAD, with recent 1 mo increased gait difficulty and
freuqent falls, who is transferred from ___ for spine
evaluation, admitted for rehab placement, now tx to MICu with
symptomatic hypocalcemia and hypomagnesemia.
Mr. ___ has had progressively more frequent falls over the
past few months, which he further describes as being due to
difficulties with balance. No lightheadedness, dizziness,
syncope. His falls have been being attributed to his known
spinal stenosis for which he is due for surgery with Dr ___
in one month. Falls have progressed to 10 falls in 1 week.
Reportedly fell 3 times on the morning of admission and his
girlfriend insisted that he come to the ___ for
evaluation.At ___: Imaging of the UE were negative for
fractures or DVT; CT head was negative (of note pt is on
clopidogrel for vascular disease). He was transferred to ___
for further evaluation as his spine doctor is here.
In ___ initial VS: 97.8 104 122/65 16 99% RA
Exam: bilateral UE tremor, sensory deficits in b/l LEs and UEs
rectal w/normal tone and sensation, guiaic negative. bladder
scanned for >500 cc.
Patient was given: oxycodone, NS, KCl
Imaging notable for: CT C spine and abd/pelvis with multilevel
degenerative changes
Consults: Ortho spine - Exam is at baseline. CT scan shows no
acute fractures. Per the family they most concerned that he is
unsafe to be at home and would like him to be in a rehab until
surgery. We will have the patient admitted to ___ observation and
evaluated by ___ and case management.
He was admitted to medicine for placement. Upon arrival to the
floor, his labs were reviewed and his Ca was found to be 4.6,
Mag 0.4, and pt was tremulous. He received 2 g calcium gluconate
x2 and endocrine was consulted and recommended calcium infusion
for which hhe was transferred to the MICU.
Upon arrival to the MICU, he reiterates the history above. He
describes his falls as due to being off balance, particularly
when he gets up at night. He reports b/l hand pain (which is a
pins-and-needles quality) that has been going on for months, is
similar to pain he had before his C spine surgery, and is
sometimes accompanied by hand numbness. He denies numbness in
his feet but sometimes gets foot pain. He has been progressively
shaky recently (though has had tremor for years).
Denies perioral numbness/tingling, CP, shortness of breath.
Drinsk 2 drinks per day, denies any h/o withdrawal. Denies
bowel/bladder changes though as above was retaining in the ___.
Last drink ___ night.
Past Medical History:
HTN
Cervical spine surgery ___ years ago in ___
Lumbar fusion in ___ approx. ___ years ago
peripheral vascular disease
HLD
CAD
Social History:
___
Family History:
no hx of thyroid disease. No known history of hypocalcemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Afebrile HR 110s BP 135/62 97% RA
GENERAL: Alert, oriented, no acute distress, able to tell recent
history, very tremulous/jerky in his movements
HEENT: Sclera anicteric, MMM, oropharynx slightly dry, +tongue
fasciculations
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Pitting edema to knee bilaterally and to forearm bilaterally
(R>L in upper extremity)
SKIN: no rash
NEURO: Neg Trousseau's sign. Positive Chvostek's sign
bilaterally (twitching of lateral lip). Full strength in upper
and lower extremities. B/l hand tremor. Endorse normal sensation
b/l hands.
DISCHARGE PHYSICAL EXAM:
VITALS: Tm 98.3, HR 83-98, BP 106-134/65-80, RR ___
on RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, PERRL
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: CTAx2, no increased work of breathing
Abd: soft, non-tender, non-distended
EXT: warm and well-perfused with no edema
NEURO: lower extremity hip flexion, knee flexion/extension ___
bilaterally, ankle plantar flexion ___ bilaterally, ankle
dorsiflexion ___ on R and ___ on L, L ankle plantar flexed and
everted at baseline, sensation to light touch intact in distal
lower extremities, decreased vibration sense in distal lower
extremities L>R, proprioception of great toes intact bilaterally
Pertinent Results:
ADMISSION LABS
___ 04:42PM PLT COUNT-289
___ 04:42PM NEUTS-76.7* LYMPHS-13.9* MONOS-7.8 EOS-0.9*
BASOS-0.4 IM ___ AbsNeut-9.57* AbsLymp-1.73 AbsMono-0.97*
AbsEos-0.11 AbsBaso-0.05
___ 04:42PM WBC-12.5* RBC-3.60* HGB-10.0* HCT-28.3*
MCV-79* MCH-27.8 MCHC-35.3 RDW-13.2 RDWSD-37.9
___ 04:42PM CK(CPK)-5217*
___ 04:42PM estGFR-Using this
___ 04:42PM GLUCOSE-83 UREA N-16 CREAT-0.8 SODIUM-138
POTASSIUM-3.0* CHLORIDE-95* TOTAL CO2-25 ANION GAP-21*
___ 05:05PM URINE RBC-5* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG
___ 05:05PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:05PM URINE UHOLD-HOLD
___ 05:05PM URINE HOURS-RANDOM
___ 05:05PM URINE HOURS-RANDOM
___ 05:23PM ___ PTT-32.1 ___
___ 04:24AM K+-3.3
___ 09:30AM CK(CPK)-4763*
___ 12:35PM WBC-14.7* RBC-3.45* HGB-9.6* HCT-28.0*
MCV-81* MCH-27.8 MCHC-34.3 RDW-13.6 RDWSD-40.1
___ 12:35PM WBC-14.7* RBC-3.45* HGB-9.6* HCT-28.0*
MCV-81* MCH-27.8 MCHC-34.3 RDW-13.6 RDWSD-40.1
___ 12:35PM ALBUMIN-2.8* CALCIUM-4.6* PHOSPHATE-3.1
MAGNESIUM-0.4*
___ 12:35PM GLUCOSE-113* UREA N-12 CREAT-0.9 SODIUM-138
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-23 ANION GAP-19
___ 03:00PM 25OH VitD-12*
___ 03:00PM CALCIUM-4.7* PHOSPHATE-3.0 MAGNESIUM-0.4*
___ 07:19PM 25OH VitD-11*
___ 07:19PM TSH-3.9
___ 07:19PM ALBUMIN-2.8* CALCIUM-5.5* PHOSPHATE-3.5
MAGNESIUM-1.5*
___ 07:19PM ALT(SGPT)-34 AST(SGOT)-64* LD(LDH)-754* ALK
PHOS-58 TOT BILI-0.7
___ 07:19PM GLUCOSE-96 UREA N-12 CREAT-0.9 SODIUM-139
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-21* ANION GAP-20
___ 07:29PM freeCa-0.78*
___ 07:29PM GLUCOSE-94 LACTATE-0.9 NA+-134 K+-3.1*
___ 07:29PM ___ TEMP-35.9 PO2-48* PCO2-31* PH-7.47*
TOTAL CO2-23 BASE XS-0
___ 08:45PM URINE HOURS-RANDOM UREA N-596 CREAT-116
SODIUM-124 TOT PROT-56 CALCIUM-<0.8 MAGNESIUM-2.0 PROT/CREA-0.5*
___ 09:45PM ALBUMIN-2.9* CALCIUM-5.9* PHOSPHATE-3.3
MAGNESIUM-2.0
___ 09:45PM GLUCOSE-163* UREA N-11 CREAT-0.9 SODIUM-139
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-21* ANION GAP-19
___ 09:52PM freeCa-0.85*
___ 09:52PM ___ PO2-62* PCO2-34* PH-7.46* TOTAL
CO2-25 BASE XS-0
DISCHARGE LABS
___ 05:50AM BLOOD WBC-8.0 RBC-3.84* Hgb-11.7* Hct-36.0*
MCV-94# MCH-30.5# MCHC-32.5 RDW-12.7 RDWSD-43.5 Plt ___
___ 05:50AM BLOOD Glucose-108* UreaN-18 Creat-0.8 Na-140
K-3.9 Cl-103 HCO3-28 AnGap-13
___ 05:50AM BLOOD ALT-34 AST-22 LD(LDH)-122 CK(CPK)-46*
AlkPhos-68 TotBili-0.2
___ 05:50AM BLOOD Albumin-3.5 Calcium-8.9 Phos-3.0 Mg-2.1
___ 05:50AM BLOOD calTIBC-156* VitB12-364 Hapto-196
Ferritn-542* TRF-120*
___ 02:02AM BLOOD PTH-113*
___ 07:19PM BLOOD 25VitD-11*
___ 07:19PM BLOOD TSH-3.9
IMAGING AND DIAGNOSTICS
MRI ___:
IMPRESSION:
1. Severe lumbar spondylosis as described above with L3-L4 and
L4-L5 severe spinal canal and left neural foraminal narrowing.
2. Prominent paraspinal muscles STIR hyperintense signal, which
is nonspecific and may represent edema/inflammation from
degenerative changes or myositis. Clinical correlation for
infectious process should also be considered, although there is
no evidence of disc hyperintense signal or large joint
effusions.
3. T2 hyperintense foci within the right psoas muscle as
described above, with very minimal cyst associated right psoas
muscle edema pattern. Of note, these do not appear to enhance
on prior CT abdomen and pelvis of ___ and may represent
sequela of prior infection or trauma. However clinical
correlation for infectious process is recommended.
4. The marrow signal is mildly T1 heterogeneous and hypointense
without focal suspicious lesion. This could represent sequela
of marrow reconversion in the setting of anemia or other
systemic process. Clinical correlation is recommended.
CT Torso ___:
IMPRESSION:
1. Fat stranding with an ill-defined fluid collection overlying
the right
greater trochanter measuring up to 4.5 cm, which may be
traumatic, or may
represent greater trochanteric bursitis.
2. No other acute traumatic injuries within the chest, abdomen,
or pelvis.
3. Large hiatal hernia with a patulous and fluid-filled distal
esophagus.
4. Either a short-segment intimal flap or ulcerated plaque
within the
infrarenal abdominal aorta, likely chronic.
5. Grade 1 anterolisthesis of L4 on L5, likely chronic and
degenerative in
nature.
CT C-Spine ___:
1. Status post anterior fusion of C4 through the C7 with
straightening of the normal cervical lordosis.
2. Grade 1 anterolisthesis of C2 on C3, C3 on C4, and C7 on T1,
likely
degenerative in nature, however there are no priors for
comparison. No
evidence of acute fracture.
3. Multilevel multifactorial degenerative changes without
high-grade spinal canal stenosis.
Brief Hospital Course:
Mr. ___ is a ___ man with a history of cervical and
lumbar surgeries secondary to spinal stenosis, with one month of
increased gait difficulty and freuqent falls, who was
transferred from ___ for spine evaluation, found to
have severe hypocalcemia and hypomagnesemia on admission.
#Hypocalcemia:
#Hypomagenesemia:
Presented with severe symptomatic hypocalcemia (Ca 4.7) and QTc
in 500s, requiring ICU transfer for a calcium drip.
Endocrinology was consulted, and his hypocalcemia thought to be
secondary to hypomagenesemia (see below) possibly due to chronic
alcohol use (though states only 2 drinks/day), low vitamin D
(PTH 113 and Vit D 12) and at home chronic Nexium use for GERD.
In addition, he presented with labs consistent with mild
rhabdomyolysis (elevated CK) likely from falls, and this may
have precipitated the calcium drop. Per endocrinology, after the
calcium drip he was transitioned to oral calcium carbonate
supplementation once on the floor. He was given four days of IV
magnesium 4 g, and then transitioned to 800 mg magnesium daily.
He was also started on Vit D supplementation: 50,000 U weekly
for 12 weeks ___, last day ___, with plan to check
level then after initial repletion and adjust repletion dose at
that time. He will continue oral calcium carbonate, magnesium
and vitamin D as an outpatient, with endocrinology follow up.
#Falls:
#Cervical and lumbar spinal stenosis:
Patient has had one month of increased falls and feeling
unsteady on his feet. Gait instability did not improve with
electrolyte repletion so ___ was consulted and was concerned for
weakness of left ankle dorsiflexion and decreased range of
motion that could be contributing to his instability. He
complained of bilateral hand tingling, but did share that this
is associated with his known cervical stenosis. He was started
on gabapentin 100 mg at night, and this can be uptitrated post
discharge. An MRI spine was performed on ___ which showed
chronic, severe narrowing of the spinal canal at the L3-L4 and
L4-L5 levels, which is thought to contributing to his gait
unsteadiness and foot drop. The MRI also showed edema of the
paraspinal muscles that could represent degenerative change
versus myositis and foci in the right psoas that could represent
infection versus trauma (with clinical correlation recommended).
Given no current clinical signs of infection, outpatient follow
up is recommended to asses changes in exam. He should also
follow up with spine surgeon, Dr. ___ further spinal
stenosis treatment. Of note, patient also reported use of Ambien
at night, and that he would feel foggy the next morning and felt
this could contribute to his falls. The team strongly
discouraged use of Ambien in the future.
#EtOH use disorder:
Given his profound electrolyte disturbances there was concern
for alcohol use disorder. He reported drinking only two drinks
per day, but per admitting nursing team he may have reported
drinking more of this. While in the ICU he was loaded with
phenobarbital to prevent alcohol withdrawal and continued on a
taper. He notably did not have any stigmata of chronic liver
disease or chronic alcohol use (no cirrhosis on CT
abdomen/pelvis, normal CBC, normal coagulation studies). Social
work was counseled, and he reported that he wants to cut down on
drinking to prevent future events like this.
#Elevated CK:
Elevated to 5000 on admission, this could have been due to
neuromuscular excitability from hypomagnesemia and hypocalcemia
or from mild rhabdomyolysis from falls as above. This
downtrended to normal with IVF, electrolyte normalization and
good oral intake. Atorvastatin was held while hospitalized and
can be restarted as an outpatient if CK remains stable.
#CAD:
Continued home aspirin, clopidogrel, metoprolol. Atorvastatin
held in the setting of elevated CK as above.
#Mild transaminitis:
On ___, AST/ALT were mildly elevated compared to admission
values (Tbili remained normal throughout) but repeat LFTs on ___
were normal. AST had been elevated on admission, but presumed
secondary to potential rhabdomyolysis or neuromuscular
excitability as above. CT abd/pelvis on admission showed no
clear evidence of cirrhosis. Given only mild elevation and
subsequent normalization, decided to defer further work-up to
the outpatient setting. Recommend re-checking LFTs as an
outpatient.
#GERD: Intially discontinued Nexium due to hypomagnesemia during
admission. However a PPI was restarted on ___ due to persistent
heartburn symptoms. Endocrinology confirmed this is OK to
continue, as long as he is taking magnesium.
#Frequent urination:
Patient shares that he urinates often and has had this problem
for many months. He says he has had a workup for this but is
unclear of results. He had no signs of diabetes on labs (normal
sugars) and no findings on UA consistent with a UTI. He was
started on tamsulosin.
TRANSITIONAL ISSUES
===================
- Please recheck labs on ___: Chem-10 including calcium,
magnesium, phosphate, also check AST/ALT/Alk Phos/T bili/CK and
Albumin. Please discuss results with MD.
- Continue vitamin D repletion with 50,000 U weekly for 12
weeks, given on ___. Last dose ___ then should have
repeat Vit D level drawn and repletion adjusted as such
- Atorvastin held at discharge given elevated CK
- Patient discharged with OK to continue Nexium as long as
continues to take Magnesium, would recommend EGD in the future
if has never had one for evaluation of longstanding GERD.
- Follow up with spine surgeon Dr. ___ severe
spinal stenosis leading to left foot drop
- In one month, ___, repeat back and lower extremity exam to
follow up MRI findings of paraspinal edema and right psoas
cysts. No clinical signs of infection at time of discharge.
- Ambien discontinued at discharge and would avoid use of
benzodiazepines or sedating medications given increased risk of
falls
- He was started on gabapentin 100 mg at night for hand tingling
from cervical stenosis, and this can be uptitrated post
discharge as patient tolerates.
- Follow up of potential BPH as cause of frequent urination,
started on tamsulosin.
- CONTACT: ___, GF/HCP, ___
- CODE STATUS: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO BID
3. Clopidogrel 75 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Nexium 40 mg Other DAILY
6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Calcium Carbonate 1250 mg PO TID Duration: 4 Days
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 100 mg PO QHS
4. Multivitamins 1 TAB PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Thiamine 100 mg PO DAILY
7. Vitamin D ___ UNIT PO 1X/WEEK (___) Duration: 12 Weeks
Weekly on ___, last dose ___, then should have repeat
Vit D check.
8. Aspirin 325 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Esomeprazole 40 mg Other DAILY
11. Metoprolol Succinate XL 50 mg PO BID
12. HELD- Atorvastatin 80 mg PO QPM This medication was held.
Do not restart Atorvastatin until your doctor tells you to.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypocalcemia, Hypomagnesemia, Spinal stenosis
Discharge Condition:
Mental Status: clear and coherent
Ambulatory status: transfers from bed to chair with assistance
and ambulation with assistance
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at the ___. You were
hospitalized at ___ because of very low levels of calcium and
magnesium in your blood. This may have been caused by daily
consumption of alcohol, which can lead to decreased levels of
calcium and magnesium in the blood over time. We also found that
your vitamin D level was very low and that you were taking
Nexium (Esomeprazole), both of which could contribute to your
low calcium level.
During this admission, your calcium and magnesium levels were
brought back to normal levels. We would like you to continue
taking oral calcium, magnesium and vitamin D. Decreasing alcohol
consumption will also help maintain normal levels of calcium and
magnesium. You can continue to take your Nexium for your
comfort, but you MUST take magnesium as well. You will follow up
with the endocrinology team (the doctors who manage ___ calcium
and low magnesium) once you leave the hospital.
In addition, we are concerned about the increasing number of
falls you have had recently. You had an MRI of your spine which
showed severe, chronic narrowing of the lower spinal canal. This
narrowing or "stenosis" is likely contributing to your
unsteadiness with walking. We would like you to follow up with
your spine surgeon, Dr. ___, to address this. We also
recommend that you discontinue taking Ambien for sleep since it
is possible that this medication is causing you to feel more
"foggy" in the morning, making you more prone to falls.
We also started Gabapentin, a pain medication, that is very good
for treating the type of pain you are experiencing in your
hands, which we think is also related to your back problems.
Because this medication can lead to sedation as a side effect,
we would like you to stop taking Ambien and tramadol, which can
also cause sedation.
If you have fevers, chills, confusion, worsening tingling in
your hands or legs, or are falling again, please seek medical
attention.
If you have questions, please contact your outpatient providers.
Follow up with your PCP ___ be important to make sure your
calcium and magnesium remain at normal levels.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10334880-DS-17 | 10,334,880 | 25,067,628 | DS | 17 | 2115-04-18 00:00:00 | 2115-04-19 20:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ year old lady with a history of
polycystic kidney disease on ___ transferred from ___ because
of syncope and hypotension.
She had her regular dialysis session at ___
yesterday afternoon around ___ pm, and then after that went up
to ___ adjacent clinic to have her PD catheter evaluated (she is
in the process of switching from HD to PD). In the clinic, she
was sitting in a chair and her head began to drift from side to
side as well as her eyes. She could not answer questions well
and could not recall her daughter's name. She then slumped over,
lost consciousness, and EMS was called. EMS initial vitals were
144/65 - 70 - 99 on RA, no glucose documented. There was no
noted convulsive activity, no tongue biting and no incontinence.
Her daughter gives much of the history.
She was then taken to the ED at ___ where her initial BP 170/93.
There per her daughter she kept her eyes closed, was not talking
normally or answering questions lucidly, and not moving her arms
and legs much. There she then had a blood pressure reading of
68/38 and reportedly was hypoglycemic as well, after treatment
it was in the ___ though the exact treatment was not recorded.
He had a non con head CT which showed only mild global atrophy.
There was concern about CVA and a neurologist was contacted who
said no TPA given that her PTT was supra therapeutic from
getting heparin at dialysis. Her TSH was checked and was 95, so
she got 100mcg of IV levothyroxine, IV hydrocortisone, ativan,
phenytoin, and morphine. She also got 1750 cc NS with
appropriate improvement in her BP.
Given that there were no ___ ICU beds and patient had been in ED
for ___ hours, she was transferred to ___ ED for ICU
admission. Her daughter notes that she started becoming more
normal once she arrived at ___, around 1 am. She was able to
answer yes or no questions and was able to move her arms and
legs.
In the ED, initial vs were: temp 98.1 60 90/60 16 100% 2L FSBS
64. No further studies were pursued and she was transferred to
the care of the MICU team.
On examination in the TSICU, she is easily arousable, pleasant,
and interactive, and her daughter is at the bedside who provides
transaltion. Her daughter notes she has only had one episode of
hypoglycemia once about ___ years ago. She denies pain except for
chronic pain in her left knee, does not feel confused, feels
improved over all from yesterday but quite tired.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, headache, cough, shortness of breath,
abdominal pain, chest pain, weakness, n/v/d.
Past Medical History:
ESRD on ___ dialysis since ___ - about to start getting PD,
goes to ___
Hypothyroidism
Polycystic kidney disease
Hypertension
Chronic L knee pain/arthritis
L wrist fracture s/p fall
Social History:
___
Family History:
son passed from intracranial hemorrhage (unknown if he had PKD)
Physical Exam:
ON ADMISSION:
Vitals: 98.4 - 103/63 - hr 64 rr 13 100% RA
General: Alert, easily arousable, oriented x3 including date, no
resp distress
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
heard throughout precordium
Abdomen: soft, non-tender, non-distended, PD catheter in place
w/o surroudning erythema or purulence
GU: foley in place w/ no urine output (pt does not make urine)
Ext: warm, well perfused,chronic non-tender deformity of left
wrist, 2 clotted non pulsatile fistulas one on each bilateral
arm
R HD catheter in place c/d/i no surroundig erythema
ON DISCHARGE:
Vitals: 98.0 ___ ___ 16 96-100%RA
General: Alert, oriented to "hospital", person and ___ (but
could not give date, year or president). No distress.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
heard best at LUSB.
Abdomen: soft, non-tender, non-distended, PD catheter in place
w/o surrounding erythema or purulence.
Ext: warm, well perfused, chronic non-tender deformity of left
wrist, 2 clotted non pulsatile fistulas one on each bilateral
arm,
R femoral HD catheter in place c/d/i, no surrounding erythema
Pertinent Results:
ON ADMISSION:
=============
___ 03:34AM BLOOD WBC-4.1 RBC-3.16* Hgb-9.4* Hct-30.8*
MCV-98 MCH-29.9 MCHC-30.7* RDW-15.5 Plt ___
___ 03:34AM BLOOD Neuts-79.8* Lymphs-13.7* Monos-3.0
Eos-3.3 Baso-0.1
___ 03:34AM BLOOD Glucose-89 UreaN-25* Creat-5.3* Na-140
K-4.1 Cl-102 HCO3-27 AnGap-15
___ 03:34AM BLOOD ALT-6 AST-21 LD(LDH)-266* AlkPhos-263*
TotBili-0.2
___ 03:34AM BLOOD CK-MB-3 cTropnT-0.10* proBNP-1359*
___ 03:34AM BLOOD Albumin-3.5 Calcium-8.6 Mg-1.8
___ 03:34AM BLOOD D-Dimer-3074*
___ 03:34AM BLOOD TSH-60*
___ 03:34AM BLOOD Free T4-0.41*
ON DISCHARGE:
==============
___ 06:00AM BLOOD WBC-4.2 RBC-4.15* Hgb-12.1 Hct-40.3
MCV-97 MCH-29.1 MCHC-29.9* RDW-15.7* Plt ___
___ 06:00AM BLOOD Glucose-83 UreaN-19 Creat-4.9*# Na-137
K-4.2 Cl-98 HCO3-25 AnGap-18
___ 06:00AM BLOOD CK-MB-4 cTropnT-0.10*
___ 06:00AM BLOOD Calcium-8.6 Phos-3.7# Mg-2.0
___ 06:00AM BLOOD T4-3.5* just before po levothyroxine dose
___ 11:10AM BLOOD T4-6.7 ~4 hours after po levothyroxine
dose
___ 06:00AM BLOOD antiTPO-12
STUDIES:
=========
___ MRI Brain: Unremarkable study without evidence of
hypoperfusion or acute infarct.
___ TTE: Normal biventricular regional/global systolic
function. Mild symmetric left ventricular hypertrophy. Left
atrial volume is severely dilated. Mild mitral and tricuspid
regurgitation.
___ EEG: Some slowing, but non-focal. No epileptiform
activity.
___ CXR: Mild interstitial edema has substantially cleared,
now collected at the base of the right lung. Heart size top
normal, with a configuration suggesting left atrial enlargement.
Pleural effusions small if any. No pneumothorax.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with polycystic kidney disease
on HD MWF, admitted with hypotension, hypoglycemia (both
transient) and syncope/altered mental status, all of which have
improved since admission/transfer.
# Syncope / altered mental status: Mental status now at
baseline. Likely ___ either brief episode hypoglycemia (and
confusion afterwards is c/w this) or post-dialysis hypotension,
perhaps exacerbated by severe hypothyroidism. Low suspicion for
primary neuro cause or arrhythmia. MRI Brain was normal. EEG
showed some slowing that may suggest a metabolic encephalopathy,
but no epileptiform activity.
# Hypotension: Afebrile without focal infectious signs
currently, s/p HD session - likely hypovolemia vs arrhythmia.
Initial EKG with irregular rate and low voltage, making
differentiation of atrial fibrillation from atrial ectopy
difficult. NSR on tele and repeat EKG. Echo unrevealing.
# Profound hypothyroidism: TSH elevation confirmed here at 60,
with low T4. PCP reports TSH from ___ over the last year,
despite the patient and her daughter's adamant claims of
compliance. Endocrinology was consulted and recommended a trial
of measuring total T4 before and after oral levothyroxine
administration to evaluation for absorption. Her total T4 did
appropriately rise. It may be that her sevelamer is interfering
with absorption, although the patient's daughter says she
usually takes it on an empty stomach. Advised the patient to
take her levothyroxine at night, six hours after her evening
sevelamer. She will follow up with Endocrinology. She received
200mcg iv levothyroxine before discharge.
# ESRD: Continued to receive HD on MWF during her
hospitalization.
TRANSITIONAL ISSUES:
# Follow-up with PCP and ___.
# Communication: daughter/HCP, ___, ___
# Code status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 12.5 mg PO BID
2. Levothyroxine Sodium 200 mcg PO HS
3. Cinacalcet 60 mg PO BID
4. sevelamer CARBONATE 2400 mg PO TID W/MEALS
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. Cinacalcet 60 mg PO BID
3. Levothyroxine Sodium 200 mcg PO HS
4. sevelamer CARBONATE 2400 mg PO TID W/MEALS
5. walker 1 rolling walker miscellaneous continuous
Needs a rolling walker due to balance issues, for lifetime use.
RX *walker Continuous Disp #*1 Unit Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Hypotension
Hypothyroidism
Secondary:
End-Stage Renal Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted for fainting. After a normal work-up including MRI,
EEG, and EKG, it was determined that your fainting was most
likely due to low blood pressure. Your thyroid hormone level was
also very low. You should continue to take your levothyroxine on
an empty stomach at least ___ hours after taking your sevelamer.
Followup Instructions:
___
|
10335293-DS-23 | 10,335,293 | 21,416,357 | DS | 23 | 2201-04-02 00:00:00 | 2201-04-02 23:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Digoxin / Shellfish / Fish derived / Augmentin / aspirin
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ yo F with PMH as noted, s/p fall earlier in
the day on ___. Pt was sitting on a stool in her kitchen &
slipped off, landing on her coccyx/low back. She reports not
feeling well after starting pramipexole for restless leg
syndrome on ___. Since that time, she reports a four day h/o
fatigue, loss of appetite, urinary retention and dysuria, which
she attributed to the new medication.
Pt seen in ED and found to have fever to 103, cloudy urine,
sodium 129 and creatinine 1.2. Received CTX x1 dose,
acetaminophen and IVF.
Admitted to medical service for further care.
She reports generalized abdominal discomfort but no frank pain.
She also has recent chills (resolved). She reports chronic low
back pain and right hip pain, both unchanged from her baseline.
Her daughter is at her bedside.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: As per HPI
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
Chronic back pain, followed by pain clinic
Dyspepsia
GERD
HTNB/Afib (not anticoagulated due to h/o ICH)
h/o CVA
Restless leg syndrome
h/o L hydronephrosis
Anemia (hct 32%), iron deficiency
GIB (___)
Internal hemorrhoids
IBS
Diverticulosis
Lactose intolerance
Depression
s/p TAH
s/p R knee replacement
s/p bladder suspension
Social History:
___
Family History:
No neoplasm.
Physical Exam:
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: Tm = 103 (rectal) P = 72 BP: 161/80 RR = 12 SaO2 = 99% on
RA
GENERAL: NAD.
Mentation: Alert, speaks in full sentences
Eyes: NC/AT, EOMI.
Oral: Dry mucus membranes.
Neck: Supple
Resp: Bibasilar crackles
CV: RRR, normal S1S2
GI: Soft, NT/ND, normoactive bowel sounds
GU: + foley with cloudy urine
Skin: No rashes or lesions noted
Extremities: No edema. R hip tenderness; old per patient.
Back: + diffuse mild tenderness over lumbar spine/paraspinal;
old per patient
Lymph/Heme/Immun: No cervical ___ noted
Neuro:
- Mental Status: A+O. Able to relate history without
difficulty
-Motor: Normal bulk, strength and tone throughout. Distal ___
strength ___ bilaterally.
Psych: WNL
DISCHARGE PHYSICAL EXAM
GEN: No acute distress, comfortable appearing
HEENT: NCAT, sclera anicteric
CV: Normal S1, S2 no murmurs, rubs, gallops
RESP: Good air entry, no rales or wheezes
ABD: Normal bowel sounds, soft, non-tender, non-distended, no
rebound/guarding
BACK: Kyphoscoliosis
GU: No foley.
EXTR: No edema, intact pulses
DERM: No rash
NEURO: Face symmetric, speech fluent, non-focal
Pertinent Results:
ADMISSION LABS:
___ 03:30PM BLOOD WBC-12.6* RBC-3.50* Hgb-9.8* Hct-30.7*
MCV-88 MCH-28.0 MCHC-31.9* RDW-13.7 RDWSD-43.4 Plt ___
___ 03:30PM BLOOD Neuts-80.3* Lymphs-7.4* Monos-11.5
Eos-0.1* Baso-0.2 Im ___ AbsNeut-10.16* AbsLymp-0.93*
AbsMono-1.45* AbsEos-0.01* AbsBaso-0.03
___ 03:30PM BLOOD Glucose-86 UreaN-18 Creat-1.2* Na-129*
K-4.6 Cl-92* HCO3-28 AnGap-14
___ 07:55AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.8
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-9.8 RBC-3.05* Hgb-8.7* Hct-27.1*
MCV-89 MCH-28.5 MCHC-32.1 RDW-14.0 RDWSD-45.6 Plt ___
___ 06:00AM BLOOD Glucose-86 UreaN-13 Creat-0.9 Na-141
K-4.4 Cl-108 HCO3-26 AnGap-11
___ 06:00AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.2
MICROBIOLOGY:
___ 8:40 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
CITROBACTER ___. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
CITROBACTER ___. >100,000 ORGANISMS/ML.. ___
MORPHOLOGY.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER ___
| CITROBACTER KOSERI
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
IMAGING:
___ CT PELVIS / L-SPINE:
1. No evidence of acute fracture or malalignment in the lumbar
spine or pelvis.
2. Multilevel degenerative changes and chronic mild compression
deformity of T12, unchanged since at least ___.
3. Left renal pelviectasis has increased since the prior CT.
4. Diverticulosis, with no evidence of diverticulitis.
5. Atherosclerotic vascular disease.
6. Moderate hiatal hernia.
Brief Hospital Course:
___ woman with chronic back pain, AF (not on OAT
secondary to ICH), prior stroke, admitted for generalized
weakness resulting in a fall, found to have a UTI/pyelonephritis
with retention and hyponatremia and acute kidney injury.
# CITROBACTER URINARY TRACT INFECTION / PYELONEPHRITIS / w/
SEPSIS and RETENTION: Patient met septic criteria based on
fever and leukcotysis. She also had right CVA tenderness on
exam. She was initially treated with ceftriaxone, then
transitioned to ciprofloxacin for a planned 10 day course to end
___. On admission, a Foley catheter was placed due to
urinary retention and she was able to void successfully upon
removal.
# FALL / WEAKNESS: No evidence of trauma. She attributes her
generalized weakness to pramipexole, which was stopped due to
ineffectiveness. Urinary tract infection with sepsis was more
likely a significant contributor. She is generally weak and
deconditioned, but exam is non-focal. ___ recommended home with
home ___ but patient declined.
# ACUTE KIDNEY INJURY: Improved after 2.5L IVF. Suspect
hypovolemic / pre-renal.
# HYPONATREMIA: Improved with IV fluid resuscitation. Urine Na
and Osm consistent with low solute intake vs hypovolemic
etiology
# RESTLESS LEGS: Reports intolerance to pramipexole and no
relief, so this medication was stopped.
# CHRONIC BACK PAIN: Continued tramadol and tylenol
# ATRIAL FIBRILLATION: Not on anticoagulation due to prior ICH,
also had recent admission for diverticular bleed. Continued
atenolol.
# PRIOR DIVERTICULAR BLEED with IRON DEFICIENCY ANEMIA:
Continued iron supplementation.
TRANSITIONAL ISSUES
- Continue antibiotics until ___ to complete a 10 day
course
- Consider repeating urinalysis and culture to ensure resolution
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Atenolol 50 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
6. Docusate Sodium 100 mg PO DAILY
7. Psyllium Powder 1 PKT PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Pramipexole Dose is Unknown PO Frequency is Unknown
10. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Atenolol 50 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
8. Ciprofloxacin HCl 250 mg PO Q12H Duration: 5 Days
Take at least 4 hours apart from iron and calcium.
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*10 Tablet Refills:*0
9. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*10 Tablet Refills:*0
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
11. Psyllium Powder 1 PKT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: CITROBACTER URINARY TRACT INFECTION / PYELONEPHRITIS /
w/ SEPSIS and RETENTION
SECONDARY: ACUTE KIDNEY INJURY, HYPONATREMIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized after a fall at home. You had no
significant injuries from the fall but you were found to have a
urinary tract infection due to a bacteria called Citrobacter.
You were treated with antibiotics and this infection improved.
Please keep follow-up appointments and take all medications as
described below.
Followup Instructions:
___
|
10335293-DS-26 | 10,335,293 | 28,748,299 | DS | 26 | 2201-08-06 00:00:00 | 2201-08-06 16:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Digoxin / Shellfish / Fish derived / Augmentin / aspirin /
Penicillins
Attending: ___.
Chief Complaint:
Left Hip Fracture
Major Surgical or Invasive Procedure:
___ L hip hemiarthroplasty
History of Present Illness:
Mrs. ___ is an ___ w/ AF c/b CVA (not currently
anticoagulated ___ Hx of intracranial bleed), HTN, Hx of
diverticular bleeding, admitted to the orthopedic service with a
L hip fracture ___t home. Per
patient, she was sitting in a chair made of slippery material
and when she tried to get up, she tripped, falling on her left
side. She denies any antecedent lightheadedness, SOB,
palpitations, dizziness, or other symptoms. She denies any head
strike or LOC.
Regarding her functional capacity, she lives at home alone and
does the majority of her own housework. She manages all of her
iADLs (she has a cleaning service come once a month for heavy
work like cleaning floors and the bathroom). She does light
dishes and cooking herself. She ambulates without a walker or
cane and experiences limitation due to back pain. She is able to
climb 28 stairs daily to get into her apartment without any
associated shortness of breath or chest pain with this. She does
not sleep flat on her back due to her scoliosis but denies
orthopnea. She does endorse new lower extremity edema over the
past month. This was attributed to venous stasis by her PCP and
she was started on Furosemide 40 mg PO QD PRN, which she has
been taking daily for the past week and a half. She has not had
a recent echocardiogram (Last TTE in ___ showing mild LVH). She
denies episodes of presyncope, syncope, angina, or palpitations.
In the ED, she was noted to have shortening of the L leg with VS
notable or BP 173/73 and 100% RA. Labs at the time were notable
for WBC 15.0 w/ 83% PMNs, Hgb 10.3 (most recent Hgb 11.5), coags
WNL, and Cr 1.3 (baseline 1.1). ECG showed NSR @ 68 bpm w/o no
ischemic changes, CXR was unremarkable, and hip XR showed a L
femoral neck fracture. The patient received a total of
Acetaminophen 1g, Morphine 5 mg IV x4, and Dilaudid 0.5 mg IV
x2, and was admitted to the orthopedic surgery service.
She underwent Left hip hemiarthroplasty with Ortho on ___
and has had an uncomplicated post-op course. However, on
___, she triggered for persistent O2 requirement with sats
of 93% on 4LNC and hypotension (___ systolic). She has never
been on O2 at home in the past. During this period, she had what
appeared on tele to be a 9s sinus pause and coarse a-fib. She
denies any symptoms throughout the episode, such as LH,
dizziness, h/a, chest pain/pressure, SOB, abd pain, N/V, or
increased ___ swelling. She also has not had any coughing,
wheezing, or recent fevers/chills. Her BP recovered following
bolus of 500cc IVF and she self-converted to sinus rhythm.
Past Medical History:
CARDIAC HISTORY:
-HTN
-Afib (not anticoagulated due to h/o ICH in ___
-h/o CVA
-HLD
OTHER PAST MEDICAL HISTORY:
-Chronic back pain, followed by pain clinic
-Dyspepsia/GERD
-Osteoporosis
-Restless leg syndrome
-h/o L hydronephrosis
-Anemia (hct 32%), iron deficiency
-GIB (___) - diverticular bleed
-Internal hemorrhoids
-IBS
-Diverticulosis
-Lactose intolerance
-Depression
PAST SURGICAL HISTORY:
-s/p TAH
-s/p R knee replacement
-s/p bladder suspension
Social History:
___
Family History:
No cancer or heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM (Per Initial Orthopedics Note):
VS: 97.4 187/81 64 18 98% RA
Gen: in mild distress
HEENT NCAT
Pulm: CTAB
CV: RRR
Abd: NDNT
Back: NTTP
Bilateral upper extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender arm and forearm
- Full, painless ROM at shoulder, elbow, wrist, and digits
- Fires EPL/FPL/DIO
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, WWP
Right lower extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender thigh and leg
- Full, painless ROM at hip, knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Left lower extremity:
- Skin intact
- foreshortened compared to right, marked proximal pain with
passive ROM at hip
- Soft, non-tender thigh and leg
- Full, painless ROM at knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS:
98.2 130-150s/60-70s 110s 18 99RA
I/O: 60/200 since MN; 1020/1050 over 24H
GENERAL: NAD, semi-reclined in bed
HEENT: NCAT
CARDIAC: RRR, +S4 no m/r
LUNGS: very kyphotic back, LLL with coarse crackles, diminished
RLL breath sounds
ABDOMEN: Soft, NT/ND +BS; no suprapubic tenderness
EXTREMITIES: BLEs propped up on pillow; palpable DP/PTs; L
surgical site c/d/I with staples, mild erythema surrounding
staples; preserved sensation to light touch
SKIN: No rash
NEURO: Moving all extremities
PSYCH: AOx3
Pertinent Results:
ADMISSION LABS:
___ 05:21PM BLOOD WBC-15.0*# RBC-3.68* Hgb-10.3* Hct-31.7*
MCV-86 MCH-28.0 MCHC-32.5 RDW-14.1 RDWSD-44.1 Plt ___
___ 05:21PM BLOOD Neuts-83.2* Lymphs-8.2* Monos-7.5
Eos-0.3* Baso-0.3 Im ___ AbsNeut-12.46*# AbsLymp-1.23
AbsMono-1.12* AbsEos-0.04 AbsBaso-0.04
___ 09:30PM BLOOD ___ PTT-26.5 ___
___ 05:21PM BLOOD Glucose-124* UreaN-35* Creat-1.3* Na-134
K-4.1 Cl-98 HCO3-24 AnGap-16
___ 05:21PM BLOOD CK(CPK)-58
___ 05:21PM BLOOD Calcium-9.9 Phos-2.4* Mg-2.1
OTHER IMPORTANT LABS:
None
MICROBIOLOGY:
___ 4:50 pm URINE Source: Catheter.
URINE CULTURE (Pending):
___ Blood Culture: Negative
IMAGING AND OTHER STUDIES:
___ CXR: Resolved opacity at the right hilum, therefore
likely positional.
___ Left Hip X-ray: Left mid cervical femoral neck
fracture.
___ Left Hip X-ray: Interval left total hip replacement
with anatomic alignment on this single projection.
___ CXR: Interval increase in heart size, pulmonary
vascular congestion, and small to
moderate bilateral pleural effusions since ___. New
bibasilar consolidation, could be de dependent edema and
atelectasis, though pneumonia, vertically aspiration, is a
possibility. Probable interval increase in size of hiatus
hernia could also be a source of distress.
___ TTE: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF = 75%). 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. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
___ CXR: In comparison with the study of ___, the
enlargement of cardiac silhouette appears less prominent and the
pulmonary vascularity is essentially within normal limits.
Opacification at the left base suggests volume loss in the lower
lobe and possible effusion. On the right, however, there is a
more coalescent area with possible air bronchograms. Although
some of this could represent merely atelectatic changes,
especially in view of the clinical history the possibility of
superimposed pneumonia should be seriously considered.
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-16.4* RBC-3.20* Hgb-8.8* Hct-28.3*
MCV-88 MCH-27.5 MCHC-31.1* RDW-14.4 RDWSD-46.3 Plt ___
___ 06:00AM BLOOD Glucose-92 UreaN-29* Creat-1.1 Na-136
K-4.6 Cl-97 HCO3-31 AnGap-13
___ 06:00AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.3
___ 04:50PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 04:50PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 04:50PM URINE RBC-26* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
___ 04:50PM URINE CastHy-4*
___ 04:50PM URINE WBC Clm-FEW Mucous-RARE
Brief Hospital Course:
Mrs. ___ is an ___ w/ AF c/b CVA (not currently
anticoagulated ___ Hx of intracranial bleed), HTN, CKD III, Hx
of diverticular bleeding, admitted for L hip fracture ___
mechanical fall, now s/p left hip hemiarthroplasty on ___.
Transferred to medicine for persistent O2 requirement and
prolonged conversion pause. Triggering multiple times for afib
with RVR.
# paroxysmal atrial fibrillation: The patient has a history of
pAfib not on anticoagulation due to prior intracranial bleeding.
Due to Sinus pauses on telemetry, felt to be conversion pauses
(converting from afib to sinus), the patient's home atenolol was
initially held. Thereafter, she triggered multiple times for RVR
with rates sustained in 160's (all asymptomatic), requiring
multiple doses of IV metop and uptitration of beta blockade. She
was finally stabilized on metop XL 250mg PO daily with manage of
her conversion pauses as below. Regarding anticoagulation, per
discussion with the patient's son, her prior intracranial bleed
was a small occipital lobe bleed/stroke. With this in mind and
her CHADS2VASC of at least 6, stroke prophylaxis was felt to
have more benefit than risk. This discussion was initiated
during the inpatient stay and should be continued with her PCP
following discharge. Prior to being sent to rehab, she was
without further episodes of RVR.
# Sinus/Conversion Pauses: Following her operation, the patient
was noted to have 2 episodes of 8-second sinus pauses on
telemetry. As above, her beta blockade was initially held per EP
guidance and the patient was recommended to have a pacemaker
placed as an inpatient. The patient and her family, however,
despite being explained the severe risks of not having a
pacemaker, opted to defer pacemaker placement. As such, she was
restarted on her beta blockade (with continued shorter
conversion pauses, ___ seconds) out of necessity due to frequent
afib with RVR. She was also arranged for ___ monitor on
discharge and outpatient follow-up with EP. She was discharged
on Metoprolol XL 250mg PO daily given risk for variable renal
function in older patient with CHF and predominant renal
clearance of Atenolol (home medication).
# Acute Diastolic Congestive Heart Failure: Patient has no
history of oxygen use at home but in the hospital (post-op) had
a persistent O2 requirement saturating only 93% on ___ by NC.
DDX included HF, COPD, infection, aspiration, or
splinting/atelectasis post-op. The patient had no smoking
history, use of inhalers at home, or known hx of heart failure.
She also had no fevers, chills, or constitutional signs of
infection. Per last TTE in ___, she had mild LVH and was
recently started as an outpatient on lasix 40mg po daily for ___
swelling, so CHF was felt to be most likely diagnosis. She was
diuresed effectively with IV lasix with rapid improvement in her
breathing and O2 requirements. She also had a repeat TTE showing
mild symmetric LVH with EF of 75%, which in the setting of
active afib with RVR suggested combination of chronic diastolic
CHF exacerbated acutely by impaired ventricular filling. She was
transitioned to her home lasix 40mg PO daily and was on RA prior
to being sent to rehab.
# Displaced Left Femoral Neck Fracture: The patient suffered a
displaced left femoral neck fracture from her fall. She
underwent L hip hemiarthroplasty on ___ with orthopedics
and recovered well. She worked with ___ and received lovenox for
DVT prophylaxis. Pain management was difficult during this
admission and the patient unfortunately required treatment with
naloxone due to overadministration of narcotic pain medications.
As such, she was carefully managed on acetaminophen and low dose
oxycodone for pain. She was discharged to rehab with
instructions to continue working with ___.
# Iron deficiency anemia: The patient was admitted with known
history of anemia (baseline hgb ___, ranging anywhere from
8.5-12). She was continued on her home MVI and monitored
clinically, with no signs of bleeding, especially given her
history of diverticular disease. Her hgb was stable throughout
this admission.
# Constipation: The patient has multiple prior admission for
constipation requiring manual disimpaction. She did go for 8
days without a BM during this admission, most likely ___ pain.
She was treated with an aggressive bowel regimen and ultimately
responded to PR bisacodyl. She should be continued on aggressive
bowel regimen at rehab, especially while on narcotic pain
medications.
CHORNIC/RESOLVED/STABLE PROBLEMS:
# HTN: Her blood pressures were normal during this admission.
Management of her beta blockers are detailed as above.
# Chronic back pain: The patient's pain was managed as above.
# IBS: The patient was treated with an aggressive bowel regimen
as above.
# GERD: She was continued on her home calcium carbonate.
# Diverticulosis: She was maintained on an aggressive bowel
regimen as above.
TRANSITIONAL ISSUES:
-LABS: Repeat CBC in ___ days to assess WBC trend.
-Urine culture from ___ pending at discharge; please follow
up if antibiotics are initiated for UTI.
-Leukocytosis to 16 at discharge; no focal infectious symptoms.
CXR with RLL opacity (no cough, no fevers) and c/o dysuria x1
___ ___ with UA suggestive of possible UTI. Elected not to
treat. If febrile or with persistent leukocytosis, would
consider treating PNA or UTI based on symptoms.
-TTE this admission showed mild symmetric LVH with preserved EF
(75%)
-Patient discharged with ___ monitor with outpatient cardiology
follow-up. Pt declined ___.
-atrial fibrillation (CHADS2VASC of 6) not on anticoagulation;
prior h/o ICH, pt elected not to be anticoagulated; consider
continued discussion with family/pt re: anticoagulation
NEW MEDICATIONS:
Calcium Carbonate 500 mg PO QID:PRN indigestion
Enoxaparin Sodium 40 mg SC Q24H
HydrOXYzine 25 mg PO/NG Q6H:PRN itching
Loratadine 10 mg PO DAILY:PRN itch
Metoprolol Succinate XL 250 mg PO DAILY
OxycoDONE (Immediate Release) 2.5-5 mg PO/NG Q4H:PRN pain
CHANGED MEDICATIONS:
Acetaminophen 1000 mg PO Q8H
STOPPED MEDICATIONS:
Atenolol 50 mg PO DAILY
Betamethasone Valerate 0.1% Ointment 1 Appl TP BID
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (Daughter/HCP ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN back pain
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY
9. Betamethasone Valerate 0.1% Ointment 1 Appl TP BID
10. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 600-400
mg-units oral DAILY
11. hydrocortisone-pramoxine ___ % rectal BID:PRN hemorrhoids
12. Furosemide 40 mg PO DAILY
13. Acetaminophen 500 mg PO Q6H:PRN pain/fever
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR QHS
3. Docusate Sodium 100 mg PO BID
4. Furosemide 40 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Calcium Carbonate 500 mg PO QID:PRN indigestion
9. HydrOXYzine 25 mg PO Q6H:PRN itching
10. Loratadine 10 mg PO DAILY:PRN itch
11. Metoprolol Succinate XL 250 mg PO DAILY
12. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
13. Sarna Lotion 1 Appl TP QID:PRN itch
14. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY
15. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 600-400
mg-units oral DAILY
16. hydrocortisone-pramoxine ___ % rectal BID:PRN hemorrhoids
17. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
4 weeks post-op. STOP ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
-Left Femoral Neck Fracture
-Atrial Fibrillation complicated by Conversion Pauses
SECONDARY DIAGNOSIS/ES:
-Acute on Chronic Diastolic Congestive Heart Failure
-Constipation
-Chronic Back Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you fell at home and
suffered a left hip fracture. In the hospital, you underwent a
surgery to replace your left hip and were initially care for on
the orthopedic surgery team. Shortly after your surgery, you
were found to have low blood pressures and oxygen levels. You
were also found on the heart monitor to have 2 8-second episodes
where the electrical activity of your heart stopped (conversion
pauses). You were transferred to the medicine team for further
care.
You were given medications to remove the extra fluid from your
body (lasix) and improve your breathing. You also were evaluated
by the Cardiology Team, who felt these conversion pauses to be
very dangerous. They recommended that you receive a pacemaker
immediately. However, you did not want one to be placed, even
after being explained the high risk for future falls and
possibly even sudden death. You were ultimately sent home with a
heart monitor ___ ___) to be worn at rehab. You should
follow up with Cardiology for further recommendations.
On discharge, you were doing better and no longer requiring
additional oxygen. You were sent to rehab to continue working
with physical therapy and improve your strength. Please note the
changes in your home medications and follow up with your
outpatient doctors ___ below). Please also note the detailed
instructions from your surgeons (as below).
Thank you for allowing us to be a part of your care,
Your ___ Team
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:
- WBAT LLE
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Followup Instructions:
___
|
10335293-DS-28 | 10,335,293 | 23,577,897 | DS | 28 | 2204-02-18 00:00:00 | 2204-02-19 21:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Digoxin / Shellfish / Fish derived / Augmentin / aspirin /
Penicillins
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ woman
with a history of a fib/sick sinus syndrom s/p PPM placement in
___, chronic pain, hypertension, hyperlipidemia, GERD,
diastolic
heart failure, chronic iron deficiency anemia, OSA, and
osteoporosis, who presents with acute onset shortness of breath
this morning.
The patient states that she started feeling unwell last night
and
had an episode of vomiting. This morning she awoke and had a few
more episodes of non-bloody emesis, and then became short of
breath. Does not report fevers, abdominal pain, diarrhea, and
blood in the stool. Does not report chest pain or cough. Does
not
use oxygen at home and states she has never had these symptoms
before. Does not report lower extremity edema.
Per EMS report, patient initially seemed to have a normal sinus
rhythm, and on repeat rhythm check appeared to have a rapid wide
rhythm with concern for V. tach, and at that time had a mild
drop
in her blood pressure from prior, but was still maintaining a
normal blood pressure and mentating normally.
On arrival in the emergency department, patient continues to
complain of mild dyspnea and nausea. Does not report chest pain.
Normotensive.
In the ED initial vitals were: HR 87, BP 142/84, RR18, O2 sat
100% NC
EKG: Heart rate ___. Intermittently wide complex and narrow
complex, paced rhythm.
Labs/studies notable for: Hgb 7.9, Cr 1.8, BNP 2421, trop <0.01,
lactate 1.7
CXR- Low lung volumes with possible mild pulmonary vascular
congestion but no frank pulmonary edema. Large hiatal hernia
and
bibasilar streaky atelectasis.
Patient was given: No medications given.
Vitals on transfer: T 98.0, HR 76, BP 156/62, RR18, O2 sat 100%
2L NC
On the floor, the patient confirmed the above history. She
states
that other than having nausea and vomiting this morning, she had
been feeling well. Currently states that her shortness of breath
has improved. Does not report fevers, chills, chest pain,
nausea,
vomiting, abdominal pain, and lower extremity swelling.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. 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 exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes: No
- Hypertension: Yes
- Dyslipidemia: Yes
2. CARDIAC HISTORY
- No prior cath
- TTE ___- Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Moderate mitral regurgitation. Mild pulmonary artery systolic
hypertension. Mild aortic regurgitation. Increased PCWP.
- Atrial fibrillation and sick sinus syndrome s/p PPM ___
3.OTHER PAST MEDICAL HISTORY
GERD
Osteoarthritis
OSA
Osteoporosis
Chronic back pain
Chronic iron deficiency anemia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION EXAM
======================
VS: T98.1 PO, BP 152 / 69, HR 85, RR 18, O2 sat 97% 2L
GENERAL: Well developed, well nourished, irritated, pale, in
NAD.
Oriented x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Pale conjunctivae. No pallor or cyanosis of the oral mucosa. No
xanthelasma.
NECK: Supple. Non-elevated JVP.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes, or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. Trace
peripheral edema to the mid-shins.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
======================
24 HR Data (last updated ___ @ 349)
Temp: 98.5 (Tm 98.9), BP: 113/54 (86-122/37-71), HR: 77
(75-80), RR: 18 (___), O2 sat: 91% (89-96), O2 delivery: ra
GENERAL: Oriented x3. NAD, answering questions mostly with eyes
closed
NECK: Supple. Non-elevated JVP.
CARDIAC: Regular rate and rhythm. no m/r/g
LUNGS: no wheezes or rhonchi on anterior fields, unable to
tolerate exam on back
ABDOMEN: +BS, Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing or cyanosis. Trace
peripheral edema to the mid-shins. Left shoulder with tenderness
to palpation intermittently, patent refusing further examination
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS
=========================
___ 02:22PM URINE HOURS-RANDOM
___ 02:22PM URINE UHOLD-HOLD
___ 02:22PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:13AM LACTATE-1.7
___ 11:05AM GLUCOSE-86 UREA N-25* CREAT-1.8* SODIUM-143
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 11:05AM estGFR-Using this
___ 11:05AM ALT(SGPT)-15 AST(SGOT)-28 ALK PHOS-105 TOT
BILI-<0.2
___ 11:05AM cTropnT-<0.01 proBNP-2421*
___ 11:05AM ALBUMIN-3.6
___ 11:05AM WBC-8.1 RBC-3.51* HGB-7.9* HCT-28.4* MCV-81*
MCH-22.5* MCHC-27.8* RDW-16.3* RDWSD-48.4*
___ 11:05AM NEUTS-66.2 LYMPHS-16.6* MONOS-12.5 EOS-3.6
BASOS-0.7 IM ___ AbsNeut-5.35 AbsLymp-1.34 AbsMono-1.01*
AbsEos-0.29 AbsBaso-0.06
___ 11:05AM PLT COUNT-235
IMAGING
=========================
CXR ___
IMPRESSION:
Low lung volumes with possible mild pulmonary vascular
congestion but no frank
pulmonary edema. Large hiatal hernia and bibasilar streaky
atelectasis.
TTE ___
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global
biventricular systolic function. Mild aortic regurgitation.
Mild-moderate mitral regurgitation. Pulmonary hypertension
suggested.
CXR ___
Increased small right pleural effusion and bibasilar
atelectasis.
Renal u/s ___
1. No hydronephrosis.
2. 15 mm hyperechoic lesion (vs, pseudolesion) is noted in the
right upper
pole of indeterminate significance. Short-term ___
ultrasound can be performed for reassessment. Alternatively,
consider contrast enhanced CT for further evaluation after
improvement of renal function.
Discharge labs:
=====================
___ 07:35AM BLOOD WBC-10.3* RBC-3.41* Hgb-7.8* Hct-26.4*
MCV-77* MCH-22.9* MCHC-29.5* RDW-17.4* RDWSD-45.1 Plt ___
___ 07:00AM BLOOD Neuts-67.4 Lymphs-11.7* Monos-16.2*
Eos-3.7 Baso-0.5 Im ___ AbsNeut-6.95* AbsLymp-1.21
AbsMono-1.67* AbsEos-0.38 AbsBaso-0.05
___ 07:35AM BLOOD Glucose-89 UreaN-37* Creat-1.9* Na-138
K-3.9 Cl-98 HCO3-28 AnGap-12
___ 07:00AM BLOOD ALT-7 AST-15 LD(LDH)-172 AlkPhos-94
TotBili-0.3
___ 07:35AM BLOOD Calcium-9.0 Phos-2.4* Mg-2.4
Brief Hospital Course:
Ms. ___ is an ___ woman with a history of a fib/sick
sinus syndrom s/p PPM placement in ___, chronic pain,
hypertension, hyperlipidemia, GERD, diastolic heart failure,
chronic iron deficiency anemia, OSA, and osteoporosis, who
presents with acute onset shortness of breath, found to have ECG
with features consistent with possible atrial fibrillation w/
aberrancy vs. VT.
====================
ACUTE ISSUES:
====================
# Atrial fibrillation
# Sick sinus syndrome s/p PPM
On pacemaker interrogation she was found to have a 10 minute
episode of atrial fibrillation one day prior to admission and no
evidence of VT. Unclear etiology of atrial fibrillation and
whether it correlated to her dyspnea. She was continued on
flecainide and metoprolol. Flecanide dose was reduced in the
setting ___ to 50mg q12hr.
# Dyspnea/Hypoxia:
# Atelectasis:
# HFpEF:
On arrival to the hospital her subjective dyspnea had resolved
but she required ___ O2 to maintain her oxygenation. Her CXR
was notable for mild pulmonary congestion with streaky
atelectasis. Her BNP was not significantly up from baseline. She
was thought to be slightly volume up and was diuresed with IV
Lasix which was discontinued once patient appeared euvolemic and
Cr increased. Her hypoxia was also thought to be related to
kyphosis and atelectasis and she was treated with chest ___ and
incentive spirometry. Sating 91-94% on RA on discharge.
# ___: Patient has an elevated Cr to 1.8 from a baseline ~1.2.
Appears the rise was subacute as Cr was also 1.8 in ___, in
the setting of diuresis. Most likely ___ is pre-renal etiology
given vomiting and poor PO intake. Renal ultrasound without
evidence of hydronephrosis. Improved with holding diuresis and
minimal IVF.
# Anemia: Patient has severe chronic iron deficiency anemia and
has been as low as the 7s for a hemoglobin in the past. No
evidence of occult GI bleeding at this time. Started IV iron
while in hospital. started on oral iron supplementation on
discharge.
#Leukocytosis: to 12.5, downtrending to 10.3 at discharge. Pt
with low grade temp to 100 overnight on ___, no other fever.
Urine culture negative. CXR w/o PNA. No N/V, dysuria, cough or
any additional localizing symptoms.
====================
CHRONIC ISSUES:
====================
# Hypothyroidism: continued home levothyroxine
# Overactive bladder: continued home oxybutynin
# Depression: continued home quetiapine with second dose changed
to QHS rather than mid-afternoon to help regulate sleep cycle
and increase daytime energy
====================
TRANSITIONAL ISSUES:
====================
- Obtain repeat Cr in ___ days to evaluate for interval
improvement off diuresis
- repeat CBC at PCP ___ to evaluate for resolution of
leukocytosis
- Flecanide dose decreased to 50mg q12hr due to impaired renal
function. Consider increase back to 100mg q12 once renal
function improves
- 15 mm hyperechoic lesion (vs, pseudolesion) noted in the right
upper pole of indeterminate significance on renal ultrasound.
Please obtain repeat renal u/s to evaluate for resolution vs
better characterization
- Given poor PO intake please supplement diet with Ensure TID
- Encourage daily use of incentive spirometry to help with
atelectasis
- daily weights recommended for volume status once patient
strong enough to determine need for re-starting diuresis
- Discharge weight: unable to stand for weights
- Discharge creatinine: 37/1.9
# CODE STATUS: FULL CODE (presumed)
# CONTACT: Name of health care proxy: ___
Relationship: daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Cetirizine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Psyllium Powder 1 PKT PO QHS
8. QUEtiapine Fumarate 12.5 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Vitamin D 1000 UNIT PO DAILY
11. Flecainide Acetate 100 mg PO Q12H
12. Bisacodyl ___AILY:PRN constipation
13. camphor-menthol 0.5%-0.5% topical DAILY:PRN
14. Floranex (Lactobacillus acidoph-L.bulgar) 100 million cell
oral DAILY
15. Melatin (melatonin) ___ mg PO QHS:PRN
16. calcium citrate 250 mg calcium oral DAILY
17. Polyethylene Glycol 17 g PO QHS
18. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
19. Betamethasone Valerate 0.1% Cream 1 Appl TP BID
20. Oxybutynin 5 mg PO QHS
21. Furosemide 20 mg PO DAILY:PRN weight gain
22. QUEtiapine Fumarate 12.5 mg PO BID:PRN agitation
Discharge Medications:
1. Lidocaine 5% Patch 2 PTCH TD QAM L shoulder
2. Metoprolol Tartrate 25 mg PO ONCE Duration: 1 Dose
please give at 1800 on ___. Flecainide Acetate 50 mg PO Q12H
4. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
6. Betamethasone Valerate 0.1% Cream 1 Appl TP BID
7. Bisacodyl ___AILY:PRN constipation
8. calcium citrate 250 mg calcium oral DAILY
give at least 2 hours before or after levothyroxine
9. camphor-menthol 0.5%-0.5% topical DAILY:PRN
10. Cetirizine 10 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Floranex (Lactobacillus acidoph-L.bulgar) 100 million cell
oral DAILY
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Melatin (melatonin) ___ mg PO QHS:PRN
15. Metoprolol Succinate XL 100 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Oxybutynin 5 mg PO QHS
18. Polyethylene Glycol 17 g PO QHS
19. Psyllium Powder 1 PKT PO QHS
20. QUEtiapine Fumarate 12.5 mg PO BID:PRN agitation
Give second dose before bed
21. QUEtiapine Fumarate 12.5 mg PO BID
give second dose before bed
22. Senna 8.6 mg PO BID:PRN constipation
23. Vitamin D 1000 UNIT PO DAILY
24. HELD- Furosemide 20 mg PO DAILY:PRN weight gain This
medication was held. Do not restart Furosemide until you meet
with your cardiologist
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Atrial Fibrillation
Sick Sinus Syndrome
SECONDARY DIAGNOSIS
====================
Chronic Diastolic Heart Failure
Hypertension
Hypothyroidism
Overactive Bladder
Depression
Acute Kidney Injury
Iron Deficiency Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms ___,
You came to ___ because you were short of breath. You were
found to have some collapse of your lungs and possibly increase
in fluids in your lungs that cause your shortness of breath.
Please see more details listed below about what happened while
you were in the hospital and your instructions for what to do
after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- You were treated with IV lasix to remove excess fluid from
your lungs
- You had imaging of your kidneys as the function
- You improved considerably and were ready to leave the hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have chest pain, shortness of
breath, or other symptoms of concern.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10335334-DS-15 | 10,335,334 | 27,572,974 | DS | 15 | 2133-05-17 00:00:00 | 2133-05-17 17:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Amoxicillin / vancomycin
Attending: ___.
Chief Complaint:
Transferred from ___ following breakthrough seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o man with history of HTN, hypothyroidism,
seizure disorder s/p TBI, behavioral changes (mostly aggression)
following TBI, and ESRD of unknown etiology s/p recent renal
transplant who was at ___ following
his transplant surgery (___). He is followed by Dr.
___, ___ for several years and he was well
maintained on levetiracetam monotherapy. As his renal function
started to deteriorate, he was switched over to include dilantin
as well. Ultimately, prior to his transplantation, he was
switched over to a regimen of zonegran and depakote as dilantin
was thought to be a culprit interactor with several post
transplant immunosuppressants. He was started on depakote 500 mg
qAM and 750 mg qPM with an ativan bridge and now at 1g BID
(depakote). He had no seizures during this hospitalization, and
during his rehab stint was doing well and he was about to be
discharged back to his group home. Outside hospital records show
that the patient had his depakote level checked on approximately
___ which showed a level of 117. The VPA was brought down
to a total daily dose of 1500mg. On the afternoon of ___,
he was found unresponsive in his room to verbal and tactile
stimulation. He was noted to have right gaze deviation, and was
tachycardic and diaphoretic. He quickly returned to his baseline
neurologic status. He was given an extra 250mg dose of VPA and
remained seizure free for 24 hours following which he was once
again found unresponsive in his room, with mucus and blood
emanating from his mouth. He had experienced both urinary and
bowel incontinence. Given the possibility of seizure, he was
given IV lorazepam and transported to ___ for
evaluation. We don't have an examination from that visit, but he
received a CXR (negative for infiltrative process) as well as
NCHCT which showed expected posttraumatic changes and
encephalomalacia following his known traumatic brain injury.
By written report he was at ___ and
rehab.
He was found yesterday not responsive with right eye deviation,
tachycardic and diaphoretic. Within ___ minutes he was
becoming
more responsive and finally back to baseline. Ativan was not
given at that time. Today he was found on the floor with a head
laceration over his right brow. He was also incontinent of urine
and stool. The thought was that he had an unwitnessed seizure
and
therefore was given 2mg IV ativan and taken to ___.
At ___ he was given 250mg IV depakote and transferred to ___
after a CXR and CT head was done.
he states that he is not having HD currently and that he is
urinating adequately.
On ROS: he denies headache, changes to vision, fever or chills,
nausea or vomiting, abdominal pain, weakness, extremity pain,
and
no rashes. He does state that his nose hurts and that his tongue
hurts.
With regards to his past sz/neurologic history:
The patient sustained head injury in ___. While working as a
___ in a ___, a metal blade from a lawn mower
flew up and penetrated his L frontal lobe. He then began having
seizures 6 to 12 months later. He has 2 types of seizures-
generalized tonic clonic, and partial complex characterized by
speech arrest, staring, following by yell, with L arm elevation
and head turn to R, followed by ___ minutes of confusion. He was
initially treated with Keppra and remained stable for several
years with few seizures. In ___, he had an increase in
seizure frequency, from 0 to 3 seizures per month, attributed to
worsening renal failure and needing to start on HD. Since Keppra
was not the ideal medication given renal failure, he was
admitted
to the EMU for monitored medication changes. He was tapered off
Keppra and started on Dilantin and zonisamide. He has remained
on
these 2 medications. He had also been tried on gabapentin and
Depakote in the past but the details of this are not clear.
The patient had been seizure free for about ___ years, prior to
his
most recent hospitalization. He lives in a group home for the
past several years because his behavior became difficult to
control after the head injury (aggression). He is independent in
his ADLs at baseline, oriented, and alert, able to hold
conversations. Works at the group home administer his
medications.
Past Medical History:
- ESRD of unclear etiology, on HD for several years, now s/p
transplant
- penetrating head trauma with metal blade ___, s/p L frontal
injury
- Epilepsy secondary to TBI
- HTN
- hypothyroid
Social History:
___
Family History:
His father had arthritis and died of an MI at age ___. His
mother has hypertension, breast cancer, and a tumor in her back.
Physical Exam:
On admission:
Vitals;97.9 74 141/79 20 98% 2L Nasal Cannula
Rectal temp 99.8
General: Lethargic, cooperative, NAD.
HEENT: Right laceration 3 stitches. Old skull trauma evident
(frontal)
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, has well healed RLQ scar.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person. place and time except
that he initially said it was ___. He is inattentive as he
required frequent tactile stimuli to awaken. Language is fluent.
Speech was
not dysarthric. Able to follow both midline and appendicular
commands. The pt. able to identify the current president by
name.
He was sable to name stethoscope. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: R pupil 3.5mm Left 3mm Reactive, brisk.
III, IV, VI: EOMI. Horizontal endgaze physiologic nystagmus. No
diplopia. Normal saccades.
V: Facial sensation intact to light touch.
VII: Right NL fold flat on smile.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. +asterixis bilaterally
Delt Bic Tri WrE FFl FE IO IP Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch , pinprick. No extinction
to
DSS.
Vibration not tested given his lethargy.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 1 0
R 3 3 3 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
- Gait deferred
Pertinent Results:
Admission labs:
___ 07:15PM BLOOD WBC-7.2# RBC-3.09* Hgb-10.4* Hct-30.6*
MCV-99* MCH-33.6* MCHC-34.0 RDW-13.9 Plt ___
___ 07:15PM BLOOD Neuts-88* Bands-0 Lymphs-7* Monos-5 Eos-0
Baso-0 ___ Myelos-0
___ 07:15PM BLOOD Glucose-120* UreaN-43* Creat-3.3*# Na-142
K-5.0 Cl-112* HCO3-19* AnGap-16
___ 02:15AM BLOOD Calcium-8.3* Phos-1.4*# Mg-1.5*
___ 09:00PM BLOOD Ammonia-15
___ 02:15AM BLOOD TSH-0.066*
___ 03:41AM BLOOD TSH-0.064*
___ 07:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:30AM BLOOD tacroFK-7.0
___ 03:41AM BLOOD tacroFK-4.8*
___ 08:10PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 08:10PM URINE Color-Straw Appear-Clear Sp ___
___ 08:10PM URINE RBC-5* WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
Microbiology:
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ URINE URINE CULTURE-PENDING INPATIENT
Reports:
CXR ___: Compared to the previous radiograph, there is no
relevant change. The right central venous access line has been
removed. Tubes of an oxygen mask are visible at the superior
part of the image. Atelectasis at the left lung base but no
evidence of pneumonia. Normal size of the cardiac silhouette. No
pulmonary edema.
Tacrolimus ___ 4.5
Brief Hospital Course:
Refer to brief H/P described above. Given his recent
breakthrough seizures while on depakote and zonegran and his
history of being well controlled on keppra, he received a 750mg
IV keppra IV load (his renal function is poor, with a creatinine
that is currently a 3.2/3.3) and was started on keppra 750mg
BID. He was initially admitted to the Neurology floor, but later
in the ED, he was noted to have another GTC lasting 3 minutes
(description is not available) and was given ativan out of
concern for ongoing subclinical seizures. He was then noted to
be quite lethargic, "not protecting airway and on
nonrebreather". The decision was made to admit the patient to
the ICU. Labs at the time of ICU admission showed a stable
macrocytic anemia, uremia (BUN 43, Cr 3.3), normal LFTs and
ammonia, normal UA and a normal VPA level (63), normal tox
panels and a prominent lack of leukocytosis.
Overnight in the ICU, he remained afebrile and hemodynamically
stable. He was breathing in a nonlabored fashion and oxygenating
well without tachypnea. His keppra was downgraded to 500mg BID
(renally dosed) and zonegran was continued. I spoke personally
with the radiologist at ___ who reviewed his NCHCT
once again and did not find any evidence for a contusion or
small hemorrhage following his "being found down". We also
discussed the possibility of checking MRI C-spine, but OSH notes
report that his C-spine had been cleared while he was awake and
able to deny tenderness and display a normal ROM. We repeated a
CXR which showed no infiltrate or effusion. Given his overall
hemodynamic and neurologic stability, he was transferred to the
floor under the care of Epilepsy Attending, Dr. ___
and team.
The renal transplant team was consulted to clarify several
issues, a) does he continue to need dialysis (the patient
reported that he was last dialyzed one week prior), b) is
zonegran safe for him given it's known propensity towards
nephrolithiasis), and c) to clarify the issue of
immunosuppression, as the patient is on both sirolimus,
tacrolimus and Cellcept. He will likely no longer require
hemodialysis, but if he does he can take an extra 250 mg of
Keppra after each round. Zonisamide is not contraindicated at
this time. He will continue on his immunosuppressive medications
at the doses specified below.
He had no further seizures. He was discharged on the new regimen
of Keppra and Zonisamide.
PENDING STUDIES: None
TRANSITIONAL CARE ISSUES:
[ ] Please f/u the patient's seizure control on Levetiracetam
and Zonisamide as his renal function continues to improve. He
may require higher doses of these anticonvulsants as his renal
function from his transplant improves.
[ ] Please check his PTH level as an outpatient and change his
cinacalcet dose as needed.
[ ] Please check his electrolytes and monitor his phosphorous.
We repleted his phosphorous with Neutra-Phos for a few doses.
This may change as his diet is altered.
[ ] Please make sure that his group home is able to obtain the
immunosuppressive/transplant rejection and antiseizure
medications (they get the medications filled in a blister pack
from his pharmacy).
Medications on Admission:
1. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: then stop.
3. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO twice a day: am and pm.
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): swish and swallow after meals and HS.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: no more than 3000mg per day.
10. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY HS.
11. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
12. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(___).
13. Sirolimus 8mg daily
14. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
16. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
17. tacrolimus 5 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
18. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
Discharge Medications:
1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day): for the kidney.
4. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours): for the kidney.
5. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): to prevent infection.
7. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. sirolimus 1 mg Tablet Sig: Nine (9) Tablet PO DAILY (Daily):
for the kidney.
Disp:*270 Tablet(s)* Refills:*2*
9. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain or temp >100.4.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO every
other day: to prevent infection.
Disp:*15 Tablet(s)* Refills:*2*
13. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day: for seizure prevention.
Disp:*60 Tablet(s)* Refills:*2*
14. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day: for hypothyroidism.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Seizures
Secondary Diagnosis: Posttraumatic epilepsy, Posttraumatic
behavioral changes, Hypertension, Renal failure s/p transplant,
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic: Awake, alert, oriented, speech fluent, follows
commands, full strength, stable gait.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Neurology Intensive Care Unit and the
Neurology wards of the ___
following two seizures that you sustained at your rehabilitation
facility. Through a series of physical examinations,
neuroimaging studies and laboratory tests, we were able to
determine that the likely reason for these seizures was the fact
that one of your seizure medications (valproic acid or depakote)
was recently reduced in dose. It is also possible that your
fluctuating kidney function may have played a role. We were able
to rule out the presence of any new brain hemorrhage, infection
or other metabolic abnormality. We consulted the Renal
Transplant service who helped make adjustments to your
medications given the changing of your kidney function (which is
improving and changing the way your body handles the
medications).
In order to better control your seizures at this time, we have
made the following changes:
1. We switched you from DEPAKOTE to KEPPRA/levetiracetam, which
is a medication you have tolerated well in the past. It is
important that you take this medication as prescribed. You will
take KEPPRA 750 MG TWICE DAILY.
2. Please continue to take ZONEGRAN/zonisamide at the prior
prescribed dose for seizure prevention.
3. The Renal specialists would like you to take SIROLIMUS at 9
MG DAILY.
4. The Renal specialists would like you to discontinue CALCIUM
ACETATE at this time.
5. The Renal specialists would like you to take VALGANCYCLOVIR
every other day (instead of your prior twice weekly dosing
schedule).
6. The Renal specialists would like you to reduce the dose of
LEVOTHYROXINE to 100 MCG each day.
Please take your other medications as previously prescribed and
listed on this handout.
Please be sure to follow up with your primary care physician,
your neurologist (Dr. ___ as well your nephrologist (Dr.
___.
If you experience any of the following symptoms, please seek
medical attention.
It was a pleasure providing you with medical care during this
hospitalization.
Followup Instructions:
___
|
10335334-DS-16 | 10,335,334 | 24,743,194 | DS | 16 | 2133-06-04 00:00:00 | 2133-06-05 16:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Amoxicillin / vancomycin
Attending: ___.
Chief Complaint:
Breakthrough seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Pt is a ___ y/o man with history of seizure s/p TBI and
recent renal transplant and recent titration of AED's following
his surgery.
He was admitted ___ for seizures at which time he was
switched
from depakote to keppra given that he had good control of his
seizures while on keppra. He was initially taken off of it
(keppra) because of worsening renal function and they thought it
was being cleared by his HD.
He was placed on dilantin at that time (___). When he came into
the hospital for his transplant he was switched off the
dilantin
and onto depakote (at that time he was seizure free x ___ yrs).
His most recent admission was for breakthrough seizures and he
was placed on back on keppra at 750 mg BID. The zonisamide 400mg
daily was never changed.
Since he was discharged he has had no other seizures.
Today he was at adult day care when he had reportedly two
seizures. There was no one at day care to get verbal report of
what they saw. ___ himself has no recollection of this and by
the time he was seen by me he was back to baseline. (the number
to this location is ___. He had no complaints here in
the ED. denies any other seizures. He denies tongue laceration
or
incontinence. He says he is taking all his meds although he is
not in control of these as they are given at his group home and
at the day care. He did endorse a rash for the past week over
his
abdomen which itched at times.
In the ED shortly after seeing him though he had an event. He
had
an ictal cry, was seen with eye and head deviation to the right
and the tonic clonic shaking of all extremities. The seizure
lasted about 1 min 45 sec. He was a little agitated and
lethargic
afterward. Did not stay there long enough to see how long his
post ictal phase was.
Past Medical History:
- ESRD of unclear etiology, on HD for several years, now s/p
transplant
- penetrating head trauma with metal blade ___, s/p L frontal
injury
- Epilepsy secondary to TBI
- HTN
- hypothyroid
Social History:
___
Family History:
His father had arthritis and died of an MI at age ___. His
mother has hypertension, breast cancer, and a tumor in her back.
Physical Exam:
Vitals; T98.5 p74 117/80 18 100%
General: cooperative, NAD.
HEENT: MMM,NC/At.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, has well healed RLQ scar.
Extremities: No C/C/E bilaterally
Skin: fine papules over the abdomen b/l. + puritis.
Neurologic: before his seizure.
-Mental Status: Alert, oriented to person, place and time. Able
to perform the ___ back ward without problem. Language is
fluent.
Speech was not dysarthric. Able to follow both midline and
appendicular
commands. The pt. able to name ___. There was no
evidence of apraxia or neglect. Delayed recall was ___ and 1
more
with choices.
-Cranial Nerves:
I: Olfaction not tested.
II: R pupil 4 mm Left 3mm Reactive, brisk.
III, IV, VI: EOMI. Horizontal endgaze nystagmus ___ beats). No
diplopia. Normal saccades.
V: Facial sensation intact to light touch.
VII: Right NL fodl flat on smile.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. Asterixus nto tested but this was + in the past.
Delt Bic Tri WrE FFl FE IO IP Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch , pinprick. No extinction
to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 2 0
R 3 3 3 2 0
Plantar response was flexor bilaterally.
-Coordination: FNF showed no ataxia.
- Gait: Normal based, able to perform tandem without difficulty.
Pertinent Results:
___ 02:52PM PLT COUNT-172#
___ 02:52PM NEUTS-83.6* LYMPHS-7.1* MONOS-5.1 EOS-3.6
BASOS-0.6
___ 02:52PM WBC-4.3 RBC-2.85* HGB-9.3* HCT-27.2* MCV-95
MCH-32.8* MCHC-34.4 RDW-13.3
___ 02:52PM estGFR-Using this
___ 02:52PM GLUCOSE-92 UREA N-36* CREAT-2.7* SODIUM-141
POTASSIUM-4.0 CHLORIDE-112* TOTAL CO2-18* ANION GAP-15
___ 04:45PM URINE AMORPH-RARE
___ 04:45PM URINE RBC-0 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 04:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 04:45PM URINE GR HOLD-HOLD
___ 04:45PM URINE HOURS-RANDOM
___ 04:45PM URINE HOURS-RANDOM
___ 04:57PM tacroFK-LESS THAN
Brief Hospital Course:
Neuro: Mr. ___ was admitted to Neuromedicine under Dr.
___. He was placed on Long Term Monitoring and found to have
multiple seizures during the first 24 hours of admission despite
Ativan 1mg TID being added. Shortly after admission due to his
continued seizures, he was loaded with Depakote and started at
500mg TID. Over the next day, he had a few breakthrough events
despite a VPA level of 61. Because of this, he was given an
extra 500mg of Depakote and his dose was increased to 750mg TID.
Goal VPA level was near 100 and on the day of discharge his
level was 98. His ativan was slowly tapered down to 0.5mg daily
and this will continue for two days after discharge. He has not
had any seizures since ___ and at this time we
feel he is at his baseline and safe for discharge. His keppra
and zonisamide were kept at the same doses.
Renal:
Nephrology was involved during the hospitalization regarding
recommendations for medications adjustments. Due to some
acidosis noted on an initial BMP and low bicarb on a VBG, sodium
bicarbonate supplementation was started on ___. As his
renal function seemed to show some improvement as well, his
valganciclovir was also increased to daily. Mr. ___
sirolimus levels were also monitored and his dose was changed to
7mg daily. He has follow up scheduled for this ___ in
clinic and his levels will be checked again then.
Heme:
On ___, Mr. ___ WBC count was noted to decrease to
2.6. A repeat was checked in the evening and found to be 3.1.
This continued to be monitored throughout his hospital course
and did not drop further. This will continue to be monitored as
the nephrologists are continually monitoring his blodowork.
FENGI:
Mr. ___ diet was advanced as tolerated.
ID:
There were no signs of acute infection
Cardio/Pulm:
Stable on room air during hospitalization
Medications on Admission:
zonisamide 400 mg daily
. Keppra 750 mg BID
. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY HS.
. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(mon, wed, fri).
. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
. mycophenolate mofetil 1 gram BID
. tacrolimus 3mg BID
. Sirolimus 9mg daily
Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
Disp:*120 Capsule(s)* Refills:*2*
9. sirolimus 1 mg Tablet Sig: Seven (7) Tablet PO DAILY (Daily).
10. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
13. divalproex ___ mg Capsule, Sprinkle Sig: Six (6) Capsule,
Sprinkle PO TID (3 times a day).
Disp:*540 Capsule, Sprinkle(s)* Refills:*2*
14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Traumatic Brain Injury
Seizures
Status Post Renal Transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ on
___ for breakthrough seizures. We monitored you on EEG while
you were admitted and made adjustments to your medications in
order to control your seizures. We added a third medication to
your regiment and also temporarily have you on ativan for added
seizure control.
We made the following changes to your medications:
Started Depakote 750mg three times daily
Ativan 0.5mg daily for the next two days after discharge
Valgancyclovir was increased to daily
Sodium Bicarbonate supplements were started
Rapamycin dose decreased to 7mg daily
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
___
|
10335518-DS-11 | 10,335,518 | 29,246,806 | DS | 11 | 2201-04-04 00:00:00 | 2201-04-04 10:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Percocet / seafood
Attending: ___.
Chief Complaint:
Right femoral neck fracture
Major Surgical or Invasive Procedure:
Percutaneous screw fixation of R femoral neck fracture
History of Present Illness:
___ with history of HTN, hypothyroidism, anxiety, depression, L
hip fracture s/p CRPP in ___ (Dr. ___ at ___ and
subsequent removal of painful hardware in ___ who now presents
with Right hip pain s/p fall. She was walking up to her house
this evening when she slipped on the leaves on the sidewalk. She
fell and hit the Right side of her head on a car then fell to
the ground landing on her Right hip. She had immediate pain and
was unable to ambulate. Denies loss of consciousness. Presented
to ___ where x-rays showed R femoral neck fracture. Ortho
consulted. Denies numbness/tingling or weakness.
Past Medical History:
PMH:
1. Anxiety/depression.
2. Hypertension.
3. Sacroiliac pain.
4. Hypothyroidism.
5. Bilateral ductal carcinoma in situ, ___.
PSH:
1. Bilateral bunionectomy, ___.
2. ORIF, left hip fracture repair, ___ (Dr. ___.
3. Removal of painful left hip screws, ___.
4. Bilateral mastectomy, ___.
5. TAH/BSO for fibroid, ___.
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Vitals: 97.6 81 160/75 18 96% RA
General: NAD, A&Ox3
Psych: appropriate mood and affect
Musculoskeletal:
Right Lower Extremity:
Skin clean - no abrasions, induration, ecchymosis
Thigh and leg compartments soft and compressible
Fires ___
Sensation intact to light touch sural, saphenous, tibial,
superficial and deep peroneal nerve distributions
1+ dorsal pedis and posterior tibial pulses
Left Lower extremity
Skin clean - no abrasions, induration, ecchymosis
Thigh and leg compartments soft and compressible
Fires ___
Sensation intact to light touch sural, saphenous, tibial,
superficial and deep peroneal nerve distributions
1+ dorsal pedis and posterior tibial pulses
On discharge:
AFVSS
GEN: NAD, A+OX3
RLE:
Staples intact over lateral proximal thigh wound, well healing.
Some surrounding ecchymosis but no ___ erythema,
edema, drainage, discharge, tenderness.
Compartments soft and compressible
SILT over ___ distributios
Motor intact GSC, TA, ___ toes
Pertinent Results:
___ 04:20AM BLOOD WBC-7.4 RBC-3.32* Hgb-10.5* Hct-30.9*
MCV-93 MCH-31.7 MCHC-34.1 RDW-12.6 Plt ___
___ 11:30PM BLOOD Neuts-74.8* Lymphs-14.8* Monos-8.1
Eos-2.0 Baso-0.4
___ 04:20AM BLOOD Plt ___
___ 11:30PM BLOOD ___ PTT-31.6 ___
___ 04:20AM BLOOD Glucose-83 UreaN-14 Creat-1.0 Na-145
K-2.8* Cl-112* HCO3-25 AnGap-11
___ 04:20AM BLOOD Calcium-6.6* Phos-2.9 Mg-1.7
___ 11:30PM BLOOD cTropnT-<0.01
___ 01:13AM BLOOD K-3.4
___ 05:20AM BLOOD WBC-8.0 RBC-3.47* Hgb-11.5* Hct-33.4*
MCV-96 MCH-33.1* MCHC-34.4 RDW-12.7 Plt ___
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 valgus-impacted femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for percutaneous
pinning, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with home ___ was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right lower extremity, and will be discharged on enoxaparin for
DVT prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 5 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Citalopram 20 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Estrogens Conjugated 0.625 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Citalopram 20 mg PO DAILY
4. Estrogens Conjugated 0.625 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Acetaminophen 650 mg PO Q6H
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
8. Enoxaparin Sodium 30 mg SC Q24H Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 30 mg SC once a day Disp #*14
Syringe Refills:*0
9. Senna 8.6 mg PO DAILY
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*70 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right femoral neck 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 30mg daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated in the right leg
Physical Therapy:
WBAT RLE
Treatments Frequency:
Dressings may be changed as needed for drainage. No dressings
needed if wounds are clean and dry.
Staples will be removed in ___ weeks at follow up appointment in
___ trauma clinic.
Followup Instructions:
___
|
10335518-DS-13 | 10,335,518 | 28,765,770 | DS | 13 | 2202-11-21 00:00:00 | 2202-11-23 09:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / seafood / Zoloft / strawberries / watermelon / Motrin
/ latex / lisinopril / buspirone
Attending: ___.
Chief Complaint:
Mild abdominal and lower extremity edema
Chronic skin rash/pruritus
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ year old woman with history of
chronic pruritis and rash, HTN, anxiety and depression
presenting with abdominal fullness, rash and concern for
possible CHF exacerbation.
Of note, the patient has chronic pruritis with rash for the
last ___ years with worsening of her lesions over the last 4
months. She received phototherapy for her lesions several months
ago at ___ in ___ and was started on oral
prednisone, gabapentin, Levcetrizine and triamcinolone cream
which initially helped however lesions worsened with repeat
phototherapy. There was concern for contribution from her
wellbutrin and this was recently tapered in favor of mirtazapine
after initial failure of discontinuation of wellbutrin due to
anxiety/depression. There is concern from Dr. ___
and Dr. ___ that there is a strong psychiatric
component to her itching and she was recently changed to
mirtazapine. She was then admitted ___ with worsening
symptoms and her mirtazapine was increased to 15mg qhs and
patient was discharged with follow-up as an outpatient.
Following discharge, patient was seen by Dr. ___ on ___
who recommended continuing her current meds including remeron
15mg qhs and gabapentin BID (morning and noon) with follow-up in
one week. The goal of the interventions was to decrease somatic
focus on itching and reduce excoriations. The patient was seen
immediately following by Dr. ___ with urinary concerns
including urinary retention. She was noting abdominal distention
which improved with urination but not to baseline per patient.
The recommendation was to return to the ED if the symptoms of
distention and urinary retention returned.
Upon return home on ___, patient notes that she had recurrent
abdominal fullness for a few days, feeling as though her abdomen
and her legs were a bit more swollen. She denied chest pain,
palpitations, SOB, cough, orthopnea, N/V, fevers, chils,
abdominal pain or dysuria. She reported bowel movement on ___
(1 day pta to ED). Due to her ongoing symptoms, she presented to
the ED for further evaluation.
In the ED initial vitals were: 98.9 72 127/47 18 100% RA
Exam notable for: diffuse allergic rash, no jaundice, abd soft
and nontender, mildly distended, 1+ pitting edema pretibial.
Labs notable for: normal CBC, K 5.2, BUN/Cr 40/1.3, trop 0.07,
AST 51, proBNP of 1075 (no prior) and repeat trop stable at 0.07
with flat MB.
Imaging notable for:
- CXR which showed no acute process, no edema
- EKG with SR at 70 bpm with normal axis, normal intervals and
no e/o ischemia.
Patient was given: Lasix 20mg IV and home medications.
Vitals on transfer: 98.0 75 110/67 18 100% RA
On the floor, patient reports that her symptoms were completely
resolved with regards to mild fullness of abdomen and leg edema.
ROS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope. Denies exertional buttock
or calf pain.
On further 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. All of the other review of systems were
negative.
Past Medical History:
PMH:
1. Anxiety/depression.
2. Hypertension.
3. Sacroiliac pain.
4. Hypothyroidism.
5. Bilateral ductal carcinoma in situ, ___.
PSH:
1. Bilateral bunionectomy, ___.
2. ORIF, left hip fracture repair, ___ (Dr. ___.
3. Removal of painful left hip screws, ___.
4. Bilateral mastectomy, ___.
5. TAH/BSO for fibroid, ___.
Social History:
___
Family History:
Both parents died after age ___, no known history of CHF.
Physical Exam:
=====================================
ADMISSION PHYSICAL EXAM
=====================================
VS: 97.4 PO 140/73 R Lying 74 18 100 RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate. Looks younger than stated age
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CARDIAC: RRR, no m/r/g
LUNGS: CTAB with good air movement throughout, no crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no edema in bilateral lower extremities
SKIN: Diffuse plaques over lower abdomen with papular rash with
confluence and excoriations over chest, back, arms and legs with
many open wounds, none appearing infected.
PULSES: Distal pulses palpable and symmetric
=====================================
DISCHARGE PHYSICAL EXAM
=====================================
Vitals: Tm 98.4, 103-147/50-73, 66-76, ___, 95-100% on RA
General: Lying in bed, with scant blood on sheets, scratching
skin, in good spirits
HEENT: Sclera anicteric. MMM.
CARDIAC: no JVD. RRR, no m/r/g
LUNGS: CTAB with good air movement throughout, no crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no edema in bilateral lower extremities
SKIN: Diffusely scattered confluescent erythematous plaques with
fine overlying scale and several punched out ulcers draining
sero-sanguinous fluid. Also w/ linear excoriations along dorsal
hands and chest. Eruption spares face
Pertinent Results:
ADMISSION LABS
============================
___ 12:09AM BLOOD WBC-4.5 RBC-3.59* Hgb-11.6 Hct-36.2
MCV-101* MCH-32.3* MCHC-32.0 RDW-13.0 RDWSD-47.9* Plt ___
___ 12:09AM BLOOD Neuts-52.8 ___ Monos-13.9*
Eos-8.4* Baso-0.2 Im ___ AbsNeut-2.39 AbsLymp-1.05*
AbsMono-0.63 AbsEos-0.38 AbsBaso-0.01
___ 12:09AM BLOOD Glucose-118* UreaN-40* Creat-1.3* Na-140
K-5.2* Cl-105 HCO3-24 AnGap-16
___ 12:09AM BLOOD ALT-29 AST-51* CK(CPK)-137 AlkPhos-56
TotBili-0.1
___ 12:09AM BLOOD CK-MB-3 cTropnT-0.07* proBNP-1075*
___ 06:55AM BLOOD cTropnT-0.07
___ 06:55AM BLOOD CK-MB-4
___ 12:09AM BLOOD Albumin-3.4*
DISCHARGE LABS
==============================
___ 06:00AM BLOOD WBC-5.2 RBC-3.80* Hgb-12.3 Hct-37.9
MCV-100* MCH-32.4* MCHC-32.5 RDW-12.7 RDWSD-45.8 Plt ___
___ 06:00AM BLOOD Glucose-95 UreaN-35* Creat-1.4* Na-141
K-4.2 Cl-103 HCO3-28 AnGap-14
___ 06:00AM BLOOD ALT-22 AST-28 AlkPhos-58 TotBili-0.3
MICRO
==========
___ URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
==================
___ CT CHEST W/O CONTRAST
No evidence of intrathoracic malignancy.
Small pulmonary nodules that in the absence of history of
smoking do not
require further followup
Status post bilateral mastectomy.
Top-normal left axillary lymph nodes but with no discrete
lymphadenopathy.
___ CT ABD/PELVIS W/O CONTRAST
1. No evidence for acute intra-abdominal process, within
limitations of a
noncontrast examination.
2. Cholelithiasis.
3. For description of the intrathoracic findings, please see
the separate CT
chest report.
___ BLADDER VOLUMETRIC US (PVR)
Under distended bladder. No evidence of elevated postvoid
residual volume (14
cc).
Brief Hospital Course:
Brief Hospital Course:
___ yo woman with a history of chronic pruritus and rash, HTN,
anxiety and depression, presenting with abdominal fullness and
lower extremity edema. Patient had full resolution of symptoms
after 20 mg IV Lasix. Likely ___ recent increase in mirtazapine
on last admission (from 7.5 mg to 15 mg). Cardiac work up was
performed with normal EKG (no signs of ischemia), stable
troponins, and CXR w/ no acute cardiopulmonary process.
Suspicion for CHF was not high enough to warrant echo.
Hospitalization was complicated by diffuse chronic rash, which
was evaluated with CT chest, CT Abdomen/Pelvis which were
normal. Will recommend that patient use fluocinionide x 1 week
after discharge to improve pruritus, then transition back to
triamcinolone to prevent skin atrophy.
# Abdominal fullness/Edema: Patient present with mild abdominal
fullness and peripheral edema that occurred over 2 days, likely
___ recent increase in mirtazapine on last admission (7.5 to 15
mg; occurs in 1% of patients). BNP elevated, however difficult
to interpret as patient's baseline unknown. Cardiac work up
was performed with normal EKG (no signs of ischemia), stable
troponins, and CXR w/ no acute cardiopulmonary process.
Suspicion for CHF was not high enough to warrant echo or to
start patient on outpatient diuretics. Patient with full
resolution of edema following 20mg IV Lasix.
#Chronic rash: Unclear etiology, rash has been going on for
years, but recently gotten worse. The rash is followed closely
by PCP and outpatient psychiatry (concern that the rash is at
least in part psychogenic). On recent hospitalization for her
rash, home mirtazapine was increased, she was given 0.025%
triamcinolone cream, and premarin was stopped (concern for
worsening her pruritus). On this admission, patient continued to
c/o severe itching, and had several open ulcers (none appeared
infected) along with linear excoriations. CT Chest, and CT
abdomen/pelvis were obtained, but showed no abnormalities that
could explain her rash. Her mirtazepine was reduced to original
dose of 7.5 given c/f precipitating her edema (as above), and
she was given fluocinonide ointment x 1 week for better control
of itch. She is to resume using triamcinolone ointment
afterwards.
#Pulmonary nodules: Patient was found to have incidental
pulmonary nodules on chest CT. Given patient's non-smoking
history and age, does not warrant further management.
# Hypertension: continued on her home telmisartan 10mg PO daily.
# Depression and anxiety. Stable. Managed by Dr. ___
Mr. ___. Her home citalopram was continued.
# Osteoporosis. Continued home calcium/vitamin D.
# Chronic lower back pain. known L1 vertebral fracture. Tx with
tylenol PRN. Home gabapentin continued.
=======================================================
Transitional Issues
-Consider TTE as outpatient
-Consider Goeckerman Therapy for future management of rash
(controversial, though can significantly improve pruritus in
eczema and psoriasis patients)
-Use fluocinonide ointment x1 week after discharge , then go
back to using triamcinolone ointment
-f/u with psychiatry and dermatology for rash
-f/u with gerentologist
# CODE: Full code
# CONTACT: ___, Daughter, cell phone: ___, see
above for more contacts
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 600 mg PO BID
2. Gabapentin 100 mg PO QAM
3. Gabapentin 100 mg PO Q2PM
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Mirtazapine 15 mg PO QHS
6. Senna 8.6 mg PO QHS
7. Vitamin D ___ UNIT PO QHS
8. Xyzal (levocetirizine) 5 mg oral DAILY
9. Citalopram 20 mg PO DAILY
10. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP TID
11. telmisartan 10 mg oral DAILY
12. LORazepam 0.25-0.5 mg PO DAILY:PRN severe anxiety
Discharge Medications:
1. Fluocinonide 0.05% Ointment 1 Appl TP BID:PRN itch
use for 1 week twice per day as needed, then transition to
triamcinolone
RX *fluocinonide 0.05 % apply to affected areas BID PRN
Refills:*0
2. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Calcium Carbonate 600 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Gabapentin 100 mg PO QAM
6. Gabapentin 100 mg PO Q2PM
7. Levothyroxine Sodium 75 mcg PO DAILY
8. LORazepam 0.25-0.5 mg PO DAILY:PRN severe anxiety
9. Senna 8.6 mg PO QHS
10. telmisartan 10 mg oral DAILY
11. Triamcinolone Acetonide 0.025% Ointment 1 Appl TP TID
12. Vitamin D ___ UNIT PO QHS
13. Xyzal (levocetirizine) 5 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Mild abdominal and lower extremity edema
Chronic skin rash/pruritus
Secondary diagnosis
anxiety/depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure being involved in your care.
Why you came in:
-You came to the ___ ED because you had abdominal fullness and
swelling in your feet
-You were also complaining of itching from your rash
What we did while you were here:
-We obtained some imaging of your chest (CXR) which was normal
-We gave you a small dose of a water pill (called Lasix) to help
you get rid of some of the extra fluid
-We also obtained imaging of your chest, abdomen and pelvis to
look for a cause of your rash. Your chest, abdominal and pelvis
imaging was all normal.
We think that the cause of your swelling was the increase in
your mirtazapine during your last hospitalization.
Your next steps:
-Please use fluocinonide ointment for 1 week INSTEAD of
triamcinolone. After that, please continue using triamcinolone.
-please follow up with your outpatient gerentologist
-please follow up with you outpatient psychiatrist and
dermatologist for your rash
-please follow up with your PCP ___ 1 week
We wish you well,
Your ___ Care Team
Followup Instructions:
___
|
10335704-DS-7 | 10,335,704 | 21,677,022 | DS | 7 | 2170-06-29 00:00:00 | 2170-07-07 17:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
griseofulvin / vancomycin
Attending: ___.
Chief Complaint:
left labial swelling
Major Surgical or Invasive Procedure:
___ I&D labial abscess
History of Present Illness:
___ year old female with h/o MRSA ?folliculitis?, vulvar
psoriasis, s/p labial
cyst removal ___ (derm) now p/w left labial abscess. The
patient
notes that 7 days ago, she felt a small tender bump on her left
labia that had green discharge. She noted this again 6 days ago.
Since then, the area has become larger and more painful. 3 days
ago, she noted significant swelling of the labia. She has since
been unable to wear underwear and now is barely able to walk ___
pain.
Past Medical History:
vulvar psoriasis, psoriasis, MRSA ___ axilla/thighs/buttocks
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam: ___: upon admission:
97.9 76 126/59 16 99% RA
Gen: appears uncomfortable
CV: RRR
Pulm: no resp distress
External genitalia: left labia with significant swelling,
erythema, and TTP along labia and ___ surrounding thigh, no
notable drainage, no ingunal lymphadenopathy
Physical examination upon discharge: ___:
General: NAD
CV: ns1, s2
LUNGS: clear
ABDOMEN: soft, non-tender
GYN: swollen, tender left labia, ___ drain removed
EXT: no pedal edema bil, no calf tenderness bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 06:23AM BLOOD WBC-9.6 RBC-3.61* Hgb-10.9* Hct-33.8*
MCV-94 MCH-30.2 MCHC-32.2 RDW-13.0 RDWSD-44.6 Plt ___
___ 09:11AM BLOOD WBC-14.2* RBC-3.68* Hgb-11.1* Hct-34.1
MCV-93 MCH-30.2 MCHC-32.6 RDW-12.9 RDWSD-43.8 Plt ___
___ 02:21AM BLOOD WBC-12.9* RBC-3.53* Hgb-10.8* Hct-32.6*
MCV-92 MCH-30.6 MCHC-33.1 RDW-12.8 RDWSD-43.3 Plt ___
___ 02:21AM BLOOD Neuts-78.8* Lymphs-12.5* Monos-6.8
Eos-1.0 Baso-0.5 Im ___ AbsNeut-10.15* AbsLymp-1.61
AbsMono-0.88* AbsEos-0.13 AbsBaso-0.06
___ 06:23AM BLOOD Plt ___
___ 09:11AM BLOOD ___ PTT-30.4 ___
___ 06:23AM BLOOD Glucose-88 UreaN-7 Creat-0.7 Na-140 K-4.1
Cl-103 HCO3-25 AnGap-12
___ 09:11AM BLOOD ALT-16 AST-19 AlkPhos-56 TotBili-0.8
___ 06:23AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.8
___: soft tissue ultrasound:
Transverse and sagittal images were obtained of the superficial
tissues of the left labia ___ the area of concern as indicated by
the patient, demonstrating a heterogeneously hypoechoic
collection with peripheral increased vascularity, measuring up
to 2.8 x 3.4 x 1.7 cm, consistent with abscess.
IMPRESSION:
Left labial abscess.
___: CT scan:
1. 2.1 x 1.9 x 1.5 cm fluid collection within the enlarged and
edematous left labia with surrounding stranding, corresponding
to the abscess seen on same day ultrasound. No subcutaneous gas
___ the perineum.
2. 4 mm -renal calculus ___ the right lower pole.
3. 3.3 cm simple left ovarian cyst.
___ 11:00 am SWAB LEFT LABIAL ABCESS.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary): RESULTS PENDING.
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
___ year old female admitted to the hospital with left labial
swelling and pain. Upon admission, the patient was made NPO,
given intravenous fluids, and underwent imaging. An ultrasound
of the left labia showed an abscess. To further evaluate the
extent of the abscess, the patient underwent a cat scan of the
pelvis which confirmed the finding of an abscess which was seen
on ultra-sound. The patient was started on a course of Bactrim
and taken to the operating room where she underwent I+D of left
labial abscess. A drain and packing were placed ___ the cavity.
The packing was removed on POD #1.
The post-operative course was stable. The patient was extubated
after the procedure and monitored ___ the recovery room. She
resumed a regular diet and was voiding without difficulty. Her
white blood cell count normalized.
The patient was discharged home on POD #2. Her vital signs were
stable and she was afebrile. The ___ drain was removed. She
was voiding without difficulty and her pain was controlled with
oral analgesia. She was given a prescription for Bactrim for
completion of ___ follow-up appointment was made
___ the acute care clinic. Discharge instructions were reviewed
and questions answered.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Ibuprofen 400 mg PO Q6H
please take with food
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
do not drive while on this medication, may cause drowsiness
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
6. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth twice a day Disp #*18 Tablet Refills:*0
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*13 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
labial abscess
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 left labial abscess.
You were taken to the operating room for drainage of the
abscess. You were started on a course of antibiotics. The
packing and drain was removed from the wound. You are preparing
for discharge home with the 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. Increased labial pain or swelling. Increased
drainage from left labia.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood ___ your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change ___ your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
10335755-DS-16 | 10,335,755 | 20,365,273 | DS | 16 | 2162-06-25 00:00:00 | 2162-06-25 23:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dizziness, diplopia and vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old left-handed ___
speaking
man with no reported past medical history who presented to
___ with multiple complaints including dizziness,
diplopia and vertigo found to have a left cerebellar hypodensity
on CAT scan.
History was obtained with a ___ interpreter over the
phone and was limited given poor health literacy and phone
interpretation. Patient reports that he woke up this morning at
6 AM and immediately felt dizzy. He had been normal on going to
bed last night. He reported a headache on one side and noted
that he is having some nausea and vomiting. He also had
difficulty walking on first getting up in the morning. He
reported his legs felt heavy on both sides.
He presented to ___ where his history was notable
for concern for blurry vision. According to the outside
hospital
records, patient reported he had trouble with his vision for
years and was focused on those symptoms. He also reported
heaviness in his feet and hands. He denied any dizziness to
those physicians. Visual acuity tested there was ___
bilaterally. He underwent head CT which showed a hypodensity in
the left cerebellum for which he was transferred to ___.
On further discussion with the patient, he reports that he is
having double vision with images side by side. When he closes
one eye (either eye), he is able to see single image. This
began
yesterday.
He reports overall feeling better in terms of nausea, vomiting
and headache. He is feeling more steady with walking as well.
Past Medical History:
None
Social History:
___
Family History:
No family history of stroke.
Physical Exam:
ADMISSION EXAMINATION
=====================
Vitals: T: 99.5 P: 60 R: 16 BP: 130/78 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
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 x 3. Difficulty relating
details
of history. Able to name days ___ week forward. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Patient was able to name high
frequency but not low-frequency objects though this may have
been
a language barrier. Speech was not dysarthric. Able to follow
both midline and appendicular commands though he had difficulty
with complex commands and some left-right confusion.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI with right
greater than left sustained direction changing nystagmus. VFF
to
confrontation. Reported horizontal diplopia though no change on
cover-uncover test or alternate-cover test.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, proprioception
throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 3 3 2
R 3 2 3 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Likely slowed finger tap on
the left. Mild dysmetria on left-sided finger-nose-finger. No
dysmetria on heel-knee-shin on the left. No truncal ataxia.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
DISCHARGE EXAMINATION
=====================
Vitals: Temp: 99.2 (Tm 100.1), BP: 115/72 (115-134/67-80), HR:
67
(64-75), RR: 16 (___), O2 sat: 97% (97-98), O2 delivery: RA
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Alert, cooperative. Language is fluent with
intact comprehension. Able to follow both midline and
appendicular commands.
-Cranial Nerves: Face symmetric at rest and with activation.
Hearing intact to conversation. Palate elevates symmetrically.
Tongue protrudes in midline.
-Motor: Moves all extremities purposefully.
-Sensory: Intact to LT throughout. Sways to left on Romberg.
-DTRs: ___.
-Coordination: Slight difficulty with finger taps and rapid
alternating movements on left compared to right.
-Gait: Slightly widened base but steady.
Pertinent Results:
___ 04:40AM BLOOD WBC-8.1 RBC-4.62 Hgb-14.2 Hct-42.4 MCV-92
MCH-30.7 MCHC-33.5 RDW-12.1 RDWSD-40.8 Plt ___
___ 10:26AM BLOOD ___ PTT-30.3 ___
___ 04:40AM BLOOD Glucose-97 UreaN-9 Creat-0.9 Na-141 K-4.7
Cl-101 HCO3-21* AnGap-19*
___ 07:04AM BLOOD ALT-12 AST-17 AlkPhos-75 TotBili-0.5
___ 04:25AM BLOOD Calcium-9.0 Phos-4.4 Mg-1.8
___ 10:26AM BLOOD D-Dimer-621*
___ 07:04AM BLOOD %HbA1c-5.4 eAG-108
___ 07:04AM BLOOD Triglyc-50 HDL-51 CHOL/HD-3.1 LDLcalc-99
___ 07:04AM BLOOD TSH-0.85
___ 8:29 ___ CTA HEAD AND CTA NECK
1. Continued evolution of acute to early subacute infarct in the
superior left cerebellar hemisphere, with slight involvement of
the superior vermis. No acute hemorrhage. No significant mass
effect.
2. Occlusion of the left PCA P3 segment.
3. Left superior cerebral artery appears patent, those distal
course is
difficult to assess definitively.
4. Normal neck CTA.
5. Paranasal sinus inflammatory changes without evidence for
acute sinusitis.
6. Periapical lucency and caries of the right mandibular first
molar. Please correlate with dental exam whether any associated
active inflammation may be present.
___ 11:41 ___ MR HEAD W/O CONTRAST
1. Stable extent of evolving acute/early subacute infarction in
the left
superior cerebellar artery territory.
2. Acute/early subacute infarction in the left posterior
cerebral artery
territory, involving the left occipital lobe, left posterior
temporal lobe, posterior left thalamus, and posterior limb of
left internal capsule, which likely occurred slightly later than
the cerebellar infarction.
3. No acute hemorrhage.
4. New mild partial effacement of the left superior aspect of
the fourth
ventricle, and of the left ambient cistern. No supratentorial
hydrocephalus. New minimal rightward shift of the falx
cerebellar I.
5. Distal left PCA occlusion is better seen on the recent CTA.
6. Slightly low bone marrow signal, which most likely represents
red marrow reconversion in the setting of anemia, smoking, or
chronic systemic illness. More rarely, this may be secondary to
an infiltrative process. Please correlate with clinical history
and laboratory data.
Portable TTE (Congenital, complete) Done ___ at 10:48:12
AM
Atrial septal aneurysm with a PFO. Normal global and regional
biventricular systolic function.
TEE ___ 13:42
No spontaneous echo contrast or thrombus in the left atrium/left
atrial appendage/right atrium/right atrial appendage. Aneurysmal
interatrial septum. Normal global left ventricular systolic
function. Simple atheroma in the descending thoracic aorta.
___ 4:16 ___ BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the bilaterallower
extremity veins.
___ 6:16 ___ MRV PELVIS W&W/O CONTRAST
Unremarkable examination. No evidence of pelvic DVT.
Brief Hospital Course:
Mr. ___ is a ___ left-handed man without known past
medical history presenting with acute-onset dizziness, diplopia,
nausea, and gait imbalance. Head and neck imaging with CT and
MRI demonstrated left cerebellar and occipital ischemic infarcts
concerning for a cardioembolic source. Follow-up TTE and TEE
revealed a patent foramen ovale with septal aneurysm, without
evidence of accompanying DVT on bilateral lower extremity
Doppler U/S or MRV pelvis. Additionally, no atrial fibrillation
was noted on inpatient cardiac telemetry. Notably, however,
elevated beta-2 glycoprotein IgM and IgG were noted (with
negative anticardiolipin antibodies and negative lupus
anticoagulant). Accordingly, evaluation for PFO closure was
deferred to the outpatient setting pending follow-up
antiphospholipid antibody testing at the Neurology follow-up
visit. In the meantime, aspirin was initiated for secondary
stroke prevention, with statin therapy deferred due to likely
cardioembolic mechanism of infarction. Ambulatory cardiac
monitoring was also arranged to assess for underlying paroxysmal
atrial fibrillation.
TRANSITIONAL ISSUES
1. Repeat beta-2 glycoprotein antibody, anticardiolipin
antibody, and lupus anticoagulant testing in at least 12 weeks.
2. Follow up cardiac monitoring for paroxysmal atrial
fibrillation.
3. Outpatient cardiology evaluation pending above testing for
PFO closure.
4. Started aspirin
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 99) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [likely
cardioembolic mechanism of stroke without cerebral vessel
atherosclerosis]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [likely
cardioembolic mechanism of stroke without cerebral vessel
atherosclerosis]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Enteric Coated Aspirin] 81 mg 1 (One) tablet(s) by
mouth once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left cerebellar ischemic infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
evaluation of dizziness, double vision, nausea, and
unsteadiness. An MRI scan of your brain showed that your
symptoms were caused by a stroke, a condition where a blood clot
stops blood flow to your brain and damages the brain. In your
case, blood tests showed that you may be at higher risk than
usual of forming blood clots. This will need to be confirmed
with a repeat blood test at your follow-up visit. You also
received a heart monitor to look for a heart rhythm that can
cause strokes. In the meantime, you were started on a new
medication (aspirin) to reduce your risk of future strokes; it
is important to take this medicine every day.
During your evaluation for stroke, we also found an abnormal
connection in between two chambers of your heart. You need to
follow up with cardiology for this.
Please follow up with your primary care provider within one week
of discharge. Please also follow up with Dr. ___ in
Neurology and with Dr. ___ in Cardiology at the appointments
listed below.
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___
Followup Instructions:
___
|
10335853-DS-14 | 10,335,853 | 23,548,432 | DS | 14 | 2128-08-04 00:00:00 | 2128-08-05 18:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
penicillin
Attending: ___.
Chief Complaint:
Bloody diarrhea
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
___ seen in the ER yesterday after 2 days of crampy intermittent
abdominal pain and bloody diarrhea (no fever/chills) who was
sent home on Cipro/Flagyl after consultation with GI, now
re-presenting one day later with continued bloody diarrhea.
In the ED, initial vitals: T 98.2, 87, 117/53, 18, 100%RA, Pain
___
- Labs notable for: Chem-7 and LFTs wnl, WBC 8.3, Hgb 14.8, Plts
136, Lactate 1.2.
- Imaging notable for: CT Abd/Pelvis w/ contrast revealed severe
thickening, with fat stranding is seen involving the terminal
ileum, and ascending colon to the level of the proximal
transverse colon, consistent with colitis. This is most likely
secondary to ___ colitis, however an infectious/ischemic
etiology cannot be excluded.
- Pt given: 1L NS
Patient was admitted to medicine obs for further workup and
management of colitis.
On arrival to the floor, pt reports that his last bloody bowel
movement was about 20 minutes ago. In ___ abdominal pain
which is diffuse and intermittent. Endorses good urine output.
Denies fevers, chills.
Past Medical History:
Asthma (not symptomatic or taking any inhalers as of ___
Social History:
___
Family History:
- Father: ___ disease
- No other family history of IBD or uveitis
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 98.4, 116/52, 59, 20, 100%RA, Pain ___
General: Well-developed young man in mild-moderate discomfort
HEENT: Anciteric sclera, MMM
Lungs: CTAB
CV: RRR w/o murmur, rub or gallop
Abdomen: Soft, only slightly tender even to deep palpation (more
prominent in RLQ), no rebound or guarding. +BS
Ext: No edema
Skin: No rashes
DISCHARGE PHYSICAL EXAM
Vitals: 97.6 53 96/52 18 99RA
General: Well-developed young man in NAD
HEENT: Anciteric sclera, MMM
Abdomen: Soft, non-tender, non-distended, no rebound or
guarding. +BS
Ext: No edema
Skin: No rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 11:40AM BLOOD WBC-8.9 RBC-5.06 Hgb-14.7 Hct-44.3 MCV-88
MCH-29.1 MCHC-33.2 RDW-13.0 RDWSD-40.6 Plt ___
___ 11:40AM BLOOD Neuts-80.9* Lymphs-11.3* Monos-6.6
Eos-0.7* Baso-0.3 Im ___ AbsNeut-7.20* AbsLymp-1.01*
AbsMono-0.59 AbsEos-0.06 AbsBaso-0.03
___ 06:01AM BLOOD ___ PTT-30.6 ___
___ 11:40AM BLOOD Glucose-99 UreaN-17 Creat-0.9 Na-136
K-4.7 Cl-98 HCO3-26 AnGap-17
___ 11:40AM BLOOD ALT-36 AST-42* AlkPhos-28* TotBili-0.4
___ 11:40AM BLOOD Lipase-18
___ 05:27AM BLOOD Lactate-1.2
MICROBIOLOGY:
=============
___ 6:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 8:00 am STOOL CONSISTENCY: LOOSE PRESENCE OF
BLOOD.
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
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.
.
MANY RBC'S.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
REPORTS:
========
___ CT A/P
IMPRESSION:
1. Severe thickening, with fat stranding is seen involving the
terminal ileum, and ascending colon to the level of the proximal
transverse colon, consistent with infectious or
___ colitis.
___ Colonoscopy
Evidence of inflammation including erythema, granularity,
decreased vascular markings was seen throughout the examined
colon. In the rectum and the sigmoid decreased vascularity was
present. Proximal to the mid-sigmoid, evidence of inflammation
was more severe. The procedure was aborted in the ascending
colon due to the degree of inflammation. Retroflexion in the
rectum was not performed due to active inflammation.
(biopsy, biopsy, biopsy, biopsy, biopsy). Otherwise normal
colonoscopy to ascending colon
___ Gastrointestinal biopsy
1. Ascending colon biopsy:
- Ischemic type colitis; see note.
2. Transverse colon biopsy:
- Colonic mucosa, within normal limits.
3. Descending colon biopsy:
- Changes suggestive of early ischemic type colitis.
4. Sigmoid colon biopsy:
- Ischemic type colitis; see note.
5. Rectum biopsy:
- Colonic mucosa within normal limits.
Note: The differential diagnosis includes vascular causes of
ischemia, certain infections (e.g: C.
difficile, enterohemorrhagic E. coli), and drug effect.
DISCHARGE LABS:
===============
___ 07:15AM BLOOD WBC-7.8 RBC-4.01* Hgb-11.5* Hct-34.9*
MCV-87 MCH-28.7 MCHC-33.0 RDW-12.8 RDWSD-40.4 Plt ___
___ 07:15AM BLOOD Glucose-115* UreaN-6 Creat-0.7 Na-138
K-3.9 Cl-105 HCO3-28 AnGap-9
___ 07:15AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.8
Brief Hospital Course:
Mr. ___ was admitted to ___ after 3 days of bloody diarrhea.
CT showed significant inflammation of the terminal ileum,
ascending and transverse colon, concerning for IBD vs infection.
He was treated with cipro and flagyl. Colonoscopy showed
significant inflammation as well. He was started on steroids
given the concern for IBD. Biopsies from the colonoscopy showed
ischemia consistent with infection or medication effect.
Steroids were stopped. Antibiotics were continued, though stool
studies for C Diff and all major infectious causes of
hemorrhagic diarrhea were negative. Aside from occult infection,
the only potential etiology illucidated was the patient's use of
the herbal supplement "C4", which contains bitter orange, an
ephedra-like compound linked to bowel ischemia in case reports.
The patient will complete a 2 week course of cipro/flagyl. He
was strongly advised to avoid herbal supplements in the future.
He should follow up with a gastroenterologist. A follow up
colonoscopy to assess for mucosal healing is recommended in 3
months.
TRANSITIONAL ISSUES
#Consider repeat colonoscopy in 3 months
#Patient is non-immune to hepatitis B, consider vaccinating
Medications on Admission:
-"C4" nutritional supplement
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*19 Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*29 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic bowel
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 having several days of bloody
diarrhea. We started you on antibiotics and consulted our
gastroenterologists. A colonoscopy showed a significant amount
of inflammation in your colon. Biopsies taken during the
procedure showed ischemia, or lack of oxygen to the tissues,
most likely consistent with an infection or a medication
complication. We tested you for all of the common
gastrointestinal infections that could cause bloody diarrhea and
they were all negative. We are continuing your antibiotics in
case this was caused by an infection we did not detect. We are
concerned that your illness may have been caused by the
nutritional supplement you were using. It contains an herb
called bitter orange, which has been linked to cases of bowel
ischemia similar to yours. We strongly recommend that you
discontinue use of this supplement and avoid any similar energy
boosting, weight loss or any such supplements in the future. You
should also follow up with a gastroenterologist at home. He or
she may wish to perform a follow up colonoscopy to check for
healing of your colon.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
10335936-DS-17 | 10,335,936 | 24,025,713 | DS | 17 | 2152-08-18 00:00:00 | 2152-08-28 07:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
___: ___ drainage of pelvic abscess
History of Present Illness:
HPI:
___ with known diverticulosis, otherwise healthy, presents with
abdominal pain and fevers for the past 24 hours and CT with
concern for appendicitis for which general surgery is consulted.
Pain started on ___ evening and was initially localized to
the
left lower quadrant. He experienced fevers and continued
abdominal pain which prompted him to present to his PCP for
evaluation. There, CT of the abdomen (not including pelvis) was
obtained due to concern for diverticulitis. The sigmoid colon
was
not included on CT scan; however, patient was told he did not
have diverticulitis and returned home. Once at home, fevers
continued and he had worsened abdominal pain. He thus presented
to the ___ ED for further evaluation. Here, CT scan shows RLQ
inflammation and a 1.2 cm appendix with a 6 mm appendicolith at
the base consistent with acute appendicitis. Since arriving to
ED, patient reports that his pain has now migrated and now
involves the right and left lower quadrants. Last bowel movement
was ___ at 10 am. Last meal was at 2 pm ___ which he
tolerated well. He denies any nausea, vomiting, chest pain,
shortness of breath, palpitations, constipation, obstipation,
diarrhea, melena, or hematochezia.
Last colonoscopy was ___ and showed diverticulosis.
Past Medical History:
PMH:
-diverticulosis
PSH:
-RIH repair with mesh, ___, Dr. ___
___ History:
___
Family History:
-no family history of colon cancers, Crohn's disease, or
ulcerative colitis
Physical Exam:
ADMISSION:
Vitals- 100.2 77 141/54 16 96% RA
GEN: NAD though uncomfortable appearing
HEENT: EOMI, MMM, no scleral icterus
CV: RRR
PULM: non-labored breathing, room air
ABD: soft, non-distended, exquisitely TTP in LLQ and RLQ over
McBurney's point with guarding, negative Rovsing, negative
psoas,
negative obturator signs; mesh palpable in right groin
EXT: no edema, WWP
NEURO: A&Ox3
PSYCH: appropriate mood, appropriate affect
Discharge
GEN: NAD
HEENT: EOMI, MMM, no scleral icterus
CV: RRR
PULM: non-labored breathing, room air
ABD: soft, non-distended, non-tender, incision sites well
healing, ___ drain in place with JP bulb attached to the end.
Drainage more serosang, minimal.
EXT: no edema, WWP
NEURO: A&Ox3
PSYCH: appropriate mood, appropriate affect
Pertinent Results:
___ CT ABD W/O CONTRAST:
1. Inflammation in the pelvis centered in the right lower
quadrant around the appendix which is large in diameter,
measuring up to 12 mm, with a 6 mm appendicolith at its base.
While the appendix is not as fluid-filled as normally seen in
acute appendicitis, and still contains some foci of air,
findings remain concerning for acute appendicitis. No
extraluminal air or fluid collection.
2. Sigmoid diverticulosis, with no evidence of acute
diverticulitis.
___ CT ABD&PELVIS:
1. Persistent inflammatory change in the right lower quadrant.
There are
dilated loops of proximal small bowel with stasis of the
intraluminal content and relative smooth tapering of the distal
small bowel. Findings are suggestive of postoperative ileus.
2. 3 x 7 x 3 cm abscess in the pelvis interposed between a loop
of distal
ileum and anterior rectum.
___ 06:00AM BLOOD WBC-7.0 RBC-3.38* Hgb-10.8* Hct-31.6*
MCV-94 MCH-32.0 MCHC-34.2 RDW-13.0 RDWSD-44.1 Plt ___
___ 06:00AM BLOOD WBC-12.1* RBC-3.78* Hgb-12.2* Hct-35.1*
MCV-93 MCH-32.3* MCHC-34.8 RDW-13.0 RDWSD-43.8 Plt ___
___ 06:12AM BLOOD WBC-11.0* RBC-3.96* Hgb-12.7* Hct-36.7*
MCV-93 MCH-32.1* MCHC-34.6 RDW-12.2 RDWSD-42.1 Plt ___
___ 11:20AM BLOOD WBC-9.4# RBC-4.34* Hgb-13.9 Hct-40.9
MCV-94 MCH-32.0 MCHC-34.0 RDW-12.2 RDWSD-42.4 Plt ___
___ 11:20AM BLOOD Neuts-85.2* Lymphs-6.3* Monos-7.5
Eos-0.1* Baso-0.5 Im ___ AbsNeut-8.04* AbsLymp-0.59*
AbsMono-0.71 AbsEos-0.01* AbsBaso-0.05
___ 08:07AM BLOOD Glucose-122* UreaN-21* Creat-0.8 Na-140
K-4.3 Cl-103 HCO3-24 AnGap-13
___ 06:00AM BLOOD Glucose-104* UreaN-12 Creat-0.8 Na-138
K-4.5 Cl-102 HCO3-23 AnGap-13
___ 05:52AM BLOOD Glucose-85 UreaN-14 Creat-0.8 Na-137
K-4.3 Cl-103 HCO3-21* AnGap-13
___ 11:36PM BLOOD ALT-19 AST-22 AlkPhos-78 TotBili-0.8
___ 06:00AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.1
___ 11:37PM BLOOD Lactate-1.5
___ 05:12AM BLOOD Lactate-1.1
Brief Hospital Course:
Mr. ___ is a ___ yo male with history of diverticulosis who
presented to the Emergency Department on ___ for evaluation
of LLQ abd pain and fever. Patient was seen by his outpatient
provider ___ and had a CT scan of the abdomen performed
that did not extend into the pelvis. CT showed no signs of
diverticulitis. Mr. ___ was discharged home where his fevers
continued with worsening abdominal pain.
Presented to ___ on ___, CT pelvis shows RLQ inflammation
and a 1.2 cm appendix with a 6 mm appendicolith at the base
consistent with acute appendicitis.
After arrival to the ED patient reported pain migrated now
involving LLQ and RLQ.
Temperature on arrival was 101, otherwise vitals unremarkable.
Labs notable for WBC 9.4 with left shift. Patient tender to
palpation across lower abdomen with guarding.
Informed consent obtained and pt taken to operating room on
___ for laparoscopic appendectomy. Please see operative
report for details. Pt extubated and taken to PACU in stable
condition. Once recovered pt transferred to floor for further
post-op management.
POD1 pain well controlled. Return of bowel function, diet
advanced to clears with minimal intake. Fever 101 with abdominal
distention, follow up urine and blood culture performed. POD2
PPI started for reflux. Nausea after solid foods, pt
self-limiting intake. POD4 WBC up to 8, increased abdominal
distention and discomfort. KUB obtained showing distended loops.
Diet changed to NPO with maintenance IV fluids initiated. POD 5
CT scan obtained showing ileus and 3cm pelvic abscess. ___
pigtail catheter inserted into collection and drained under CT
guidance.
POD6 multiple loose BM. POD8 he tolerated clears and continued
to have BM. Cipro and flagyl were discontinued, WBC cotinued to
be stable aroud 11K for two more days. Stool was sent to rule
out Cdiff, which was negative. He continues to tolerate regular,
had bowel movements, and passing flatus. He was then discharged
on ___.
Of note, the patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV
acetaminophen and morphine and then transitioned to oral
oxycodone and tylenol once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. The patient
remained stable from a pulmonary standpoint; vital signs were
routinely monitored. Effective pulmonary toileting, early
ambulation and incentive spirometry were encouraged throughout
hospitalization. The patient's fever curves, WBC, and surgical
site were closely monitored. Pt treated with Ciprofloxacin and
Flagyl. The patient's blood counts were closely watched for
signs of bleeding, of which there were none. The patient
received subcutaneous heparin and ___ dyne boots were used
during this stay. The pt was to ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. He was discharged with the ___ drain in a JP bulb.
___ was arranged for drain management and monitoring. 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. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Do not exceed 4000 mg/24 hours.
2. Artificial Tears ___ DROP RIGHT EYE PRN dry itchy eye
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID:PRN constipation
5. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID:PRN
erythema
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated appendicitis
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 acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. The appendix was noted to be perforated, and
you were started on a course of antibiotics. After surgery, you
continued to have abdominal pain and distention. A CT scan was
done and showed a pelvic abscess, which was drained. You
tolerated the procedure well and are now being discharged home
to continue your recovery with the following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DRAIN CARE:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output daily
and bring log to clinic.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
10336082-DS-12 | 10,336,082 | 25,215,689 | DS | 12 | 2128-01-02 00:00:00 | 2128-01-02 21:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / lisinopril / piperacillin
Attending: ___.
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
___ PMH HTN, new AF (not on AC), RA, CVA (w/residual visual
field defects ___ with recent admission for s/p L4-5
discectomy/fusion (___) by neurosurgery c/b wound infection
with MSSA and pseudomonas requiring re-exploration ___ and
pip/tazo who presented to the ED palpitations. Patient was
recently diagnosed with afib and was on Lovenox bridge to
coumadin but had nose bleeding and bleeding from her surgical
site at which time all AC was discontinued, except aspirin. She
was dischargd to rehab on ___ to continue antibiotics and ___.
Pt reports worsening palpitations and dypnea with exertion over
the last week. Pt feels as if she can't catch her breath at rest
currently. She also reports mild ___ edema, intermittent cough,
and decreased appetite. She denies CP, abdominal pain, n/v/d.
Her back pain is at baseline. Pt only ambulates at therapy with
full assistance.
In the ED intial vitals were: 98.2 118 175/79 18 100% Nasal
Cannula. Labs were significant for WBC 8, HCT 30.3, K 2.9, Cr
0.9, phos 2.0, BNP 19K, D-dimer ___, TnT <0.04, urinalysis was
negative. CXR showed left pleural effusion, moderate edema could
not exclude left base consolidation. Chest CT was negative for
PE but showed pulmonary edema and large bilateral effusions.
Patient was given potassium, mag, neutraphos and aspirin and
admitted to
Cardiology for further management.
Vitals on transfer: 98.2 118 175/79 18 100% Nasal Cannula
On the floor, patient triggered on arrival for tachypnea and
tachycardia with initial vitals: BP 194/146 ___ RR30 O2 sat 96%
2L. Spoke to patient with daughter, and pt states that was
saying she was anxious because she could not breath and her
heart was racing. EKG showed AF with RVR with a ventricular rate
of ~140 and RBBB with inferior QW and no new ischemic changes.
Patient was treated with Ativan 0.5mg IV, Metoprolol 5mg IV,
Lasix 40mg IV. A foley was placed and patient put out ~500cc of
clear urine immediately. Her HR decreased to ___, and RR was
down to 20. However, her BP increased to as high as 225/120 at
which point patient was started on a nitro gtt.
Past Medical History:
CVA w/ residual visual field deficits
Low Back Pain s/p L4-L5 medial facetectomies/foraminotomies
___
MI in ___, missed, no interventions
sCHF, EF 40%, ischemic as above
afib, CHADS2 score of 4 on warfarin
HTN
Rheumatoid arthitis
Hypothyroid
GERD
Hysterectomy
Right knee replacement
Renal biopsies
Appendectomy
Cholecystectomy
ERCP
Migraines
Social History:
___
Family History:
No family history of arrhythmias, heart disease, renal disease.
Physical Exam:
ADMISSION:
VS: 194/146 ___ RR30 O2 sat 96%
GENERAL: Anxious appearing women, tachypneic, using accessory
muscles to breath, clearly in acute distress.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Could not appreciate JVD ___ patient motion.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Tachycardic, Irregularly irregular rhythm. Normal S1, S2.
No appreciable m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: Bilateral wheezes audible anteriorly, decreased breath
sounds at the bilateral bases and intermittent crackles
throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ ___ edema bilaterally. No c/c.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ DP pulses bilaterally
DISCHARGE:
VS: 98.1 73 (60-70) 242/78 (90-140) 20 98% RA
I/O 610/650
Wt 84.1 <- 83.4 <- 86.5
GENERAL: elderly women, breathing comfortable, NAD.
HEENT: Sclera anicteric. no pallor or cyanosis of the oral
mucosa.
NECK: Could not appreciate JVD
CARDIAC:RRR Normal S1, S2. No appreciable m/r/g. No S3 or S4.
LUNGS: Trace crackles, breath sounds throughout
Back: Dressing lower back, C/D/I
ABDOMEN: Soft, NTND.
EXTREMITIES: trace ___ edema bilaterally. No c/c.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION:
============
___ 01:40PM PLT COUNT-220
___ 01:40PM NEUTS-76.5* LYMPHS-11.8* MONOS-5.2 EOS-6.2*
BASOS-0.4
___ 01:40PM WBC-8.0 RBC-3.21* HGB-9.8* HCT-30.3* MCV-95
MCH-30.7 MCHC-32.5 RDW-15.8*
___ 01:40PM CALCIUM-8.6 PHOSPHATE-2.0* MAGNESIUM-1.8
___ 01:40PM ___
___ 01:40PM cTropnT-0.04*
___ 01:40PM GLUCOSE-122* UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-2.9* CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
___ 02:15PM URINE RBC-2 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-1
___ 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
CARDIAC ENZYMES:
==================
___ 01:40PM BLOOD cTropnT-0.04*
___ 08:35PM BLOOD cTropnT-0.04*
___ 10:58PM BLOOD CK-MB-3 cTropnT-0.05*
___ 09:20AM BLOOD CK-MB-2 cTropnT-0.05*
DISCHARGE:
===============
___ 04:31AM BLOOD WBC-7.1 RBC-3.02* Hgb-9.1* Hct-29.1*
MCV-97 MCH-30.1 MCHC-31.2 RDW-15.7* Plt ___
___ 04:31AM BLOOD ___ PTT-132.5* ___
___ 04:31AM BLOOD Glucose-105* UreaN-21* Creat-1.3* Na-137
K-3.4 Cl-100 HCO3-32 AnGap-8
___ 04:31AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2
___ 11:54AM BLOOD Glucose-136* UreaN-22* Creat-1.3* Na-138
K-3.8 Cl-98 HCO3-30 AnGap-14
IMAGING/STUDIES:
CXR ___
FINDINGS: Frontal and lateral views of the chest were obtained.
Blunting of the left costophrenic angle is consistent with a
moderate pleural effusion with overlying atelectasis. Small
right pleural effusion is difficult to exclude. There is
mild-to-moderate interstitial pulmonary edema. The cardiac
silhouette is mildly enlarged. The aorta is calcified. A
left-sided PICC is again seen, distal aspect not well
appreciated; however, seen to at least the level of the low SVC.
Left base opacity may be due to combination of pleural effusion
and atelectasis; however, underlying consolidation is not
excluded.
IMPRESSION: Left pleural effusion with overlying atelectasis.
Difficult to exclude small right pleural effusion. Moderate
interstitial edema. Left base retrocardiac opacity may be due
to combination of pleural effusion or atelectasis, but
underlying consolidation is not excluded.
CTA ___
CTA CHEST: The distal pulmonary arteries are not well
opacified. There is no central filling defect to suggest large
pulmonary embolism. Thoracic aorta is notable for
atheroscerotic calcifications without aneurysmal dilatation or
dissection.
CT CHEST: There is no axillary, mediastinal or hilar
lymphadenopathy by CT criteria. Heart is mildly enlarged.
Coronary artery calcifications are noted. There is no
pericardial effusion.
Airways are patent to subsegmental level. Large bilateral
non-hemorrhagic pleural effusions are present with adjacent
compressive atelectasis. There is also fluid tracking along the
fissures bilaterally with increased septal thickening and
peripheral areas of ground-glass opacification reflecting
pulmonary interstitial edema. A punctate calcification in the
collapsed left lower lobe likely represets a granuloma. There
is no pneumothorax. This study is not optimized for evaluation
of subdiaphragmatic structures; however, limited view of the
upper abdomen does not show gross abnormalities.
Bone window does not show concerning osteolytic or
osteosclerotic lesion.
IMPRESSION:
1. No evidence of central pulmonary embolism.
2. Large bilateral pleural effusions with adjacent compressive
atelectasis.
3. Cardiomegaly, and diffuse interlobular septal thickening and
scattered areas of ground-glass opacification, most likely
related to pulmonary edema.
CXR ___
The patient is of the left thoracocentesis. There is a decrease
in extent of the left pleural effusion. No complications,
notably no pneumothorax.
Unchanged moderate cardiomegaly, unchanged appearance of the
right lung.
The study and the report were reviewed by the staff radiologist
___ CXR
In comparison with study of ___, there is little overall
change.
No evidence of pneumothorax after thoracentesis. Mild residual
opacification at the left base consistent with effusion and
atelectasis. Continued enlargement of the cardiac silhouette
without pulmonary vascular congestion.
___ Pleural Fluid
Cytology: No malignant cells
Pathology: PENDING
Brief Hospital Course:
___ PMH HTN, new AF (not on AC), RA, CVA (w/residual visual
field defects ___ with recent admission for s/p L4-5
discectomy/fusion (___) by neurosurgery c/b wound infection
with MSSA and pseudomonas requiring re-exploration ___ and
pip/tazo who presented to the ED with palpitations.
# Atrial Fibrillation: Patient with possible new AF over the the
last two months (unclear if CVA was in setting of AF),
previously with ventricular rates in the 40-50s with sinus
pauses. She was also supposed to start anticoagulation in
preparation for possible cardioversion, but this could not be
done as she has had ongoing oozing from her surgical site. Her
CHADSVASC = ~6, giving her a significant risk of another CVA in
the setting of not being on anticoagulation. Her HCT had been
stable, but given recent admission w/HCT 18 from bleeding
post-operatively she was not previously anticoagulated.
Neurosurgery was consulted to help weigh in on risks of
anticoagulation, and felt there was no contraindication. She was
initially treated with metoprolol but that was transitioned to
carvedilol in setting of hypertensive epsidoe. Her discharge
dose of coumadin was 5mg daily, until therapeutic. She was
started on heparin as a bridge for anticoagulation. INR on
discharge was 1.2.
# Acute Systolic Congetive Heart Failure: Patient with EF 40%
presented with dypsnea and palpitations found to have
significantly elevated BNP, ___ edema and pulmonary edema c/w CHF
exacerbation. Per family she has not been on diuretics in the
past suggesting that this acute decompensation is new and may
have been provoked by recent cardiac event vs. new AF. Although
pt was in acute decompensated HF, beta blocker use was warranted
given her AF w/RVR which may have been contributing to her
worsening pulmonary edema. She was diuresed with IV lasix then
transitioned to Torsemide 20mg daily. She was continued on her
losartan at a decreased dose of 50mg daily. Her discharge weight
was 84.1kg.
# Pleural Effusions: Patient noted to have large bilateral
pleural effusions on imaging with decreased sounds at bases and
orthopnea. Patient was diuresed with IV lasix. IP performed a
thoracentesis with removal of 1L of serous fluid. Pleural Fluid
analysis showed transudative effusion. Repeat xray showed
decreasing effusion. Cytology was still pending at discharge.
# HTN: patient was very hypertensive on arrival and BP as high
as 225, likely resulting in worsening pulmonary edema given her
respiratory distress on arrival. Additionally, this may have
been exacerbated by anxiety. Her BPs as outpatient usually range
in 160s systolic. She required a nitroglycerin drip on
presentation that was weaned over the first night. She was
maintained on her losartan and carvedilol.
# CAD: No evidence of active ischemia, troponin 0.05 which may
represent demand ___ a fib w/ rvr, but EKG suggestive of prior
cardiac event suggesting CAD and hypokinesis inferolaterally on
recent TTE with depressed EF suggests this as well.
She was treated with carvedilol as above. She was continued on
home atorvastatin, aspirin.
# Anemia: HCT improved from prior, blood loss likely ___ recent
surgery. This was monitored.
# s/p L4-L5 discectomy/fusion c/b infcction: Patient currently
at rehab working with ___, was bedbound for 5 months prior to her
surgery. She was continued on her Zosyn per previous
recommendations. She was seen by neurosurgery who recommended
continuation of TLSO brace and antibiotics.
# Anxiety: continued home xanax
# GERD: continued home omeprazole
# RA: continued home leflunomide and hydroxychloroquine
# CODE: FULL CODE (confirmed)
# CONTACT: Patient, ___ (daughter): ___
**TRANSITIONAL ISSUES**
-Would consider outpatient pMIBI to rule out ischemia
-continue zosyn, being followed by OPAT
-Titrate carvedilol for HR and BP control
-Titrate diuretics
-daily INR until therapeuitc on coumdin (goal ___
- Started on 5 mg coumadin daily on ___ will likely need
decreased dose after ___ days
-continue heparin until therapeutic on coumadin
-F/u with neurosurgery as previously planned
-f/u pleural effusions
-f/u flow cytometry
-Monitor rash (resolving at time of discharge, likely a mild
dermatitis)
- Daily chemistry until K stabilizes
- Pt had loose stool on afternoon of discharge. C. dif sent and
pending. Please f/u
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. Cyclobenzaprine 5 mg PO TID:PRN muscle spasms
6. Gabapentin 100 mg PO Q12H
7. Losartan Potassium 100 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. leflunomide 20 mg ORAL DAILY
10. Ferrous Sulfate 325 mg PO DAILY
11. Ondansetron ___ mg PO Q8H:PRN nausea
12. Hydroxychloroquine Sulfate 200 mg PO DAILY
13. Metoprolol Tartrate 25 mg PO BID
14. Piperacillin-Tazobactam 4.5 g IV Q6H
15. Pantoprazole 40 mg PO Q24H
16. Senna 17.2 mg PO BID:PRN constipation
17. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
18. Levothyroxine Sodium 150 mcg PO DAILY
19. ALPRAZolam 0.25 mg PO Q8H:PRN anxiety
20. ALPRAZolam 0.25 mg PO QHS
21. QUEtiapine Fumarate 25 mg PO QHS
22. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain
2. ALPRAZolam 0.25 mg PO Q8H:PRN anxiety
RX *alprazolam 0.25 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*4 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Gabapentin 100 mg PO Q12H
8. Hydroxychloroquine Sulfate 200 mg PO DAILY
9. leflunomide 20 mg ORAL DAILY
10. Levothyroxine Sodium 150 mcg PO DAILY
11. Losartan Potassium 50 mg PO DAILY
12. Ondansetron ___ mg PO Q8H:PRN nausea
13. Pantoprazole 40 mg PO Q24H
14. Piperacillin-Tazobactam 4.5 g IV Q6H
15. Potassium Chloride 20 mEq PO DAILY
Hold for K >5
16. Senna 17.2 mg PO BID:PRN constipation
17. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
18. Vitamin D 1000 UNIT PO DAILY
19. Carvedilol 25 mg PO BID
20. Torsemide 20 mg PO DAILY
21. Cyclobenzaprine 5 mg PO TID:PRN muscle spasms
22. Heparin IV per Weight-Based Dosing Guidelines
No Initial Bolus
Initial Infusion Rate: 1500 units/hr
Start: Today - ___, First Dose: 1200
Target PTT: 60 - 100 seconds
23. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Atrial Fibrillation w/ Rapid Ventricular Response
Acute on Chronic Systolic Congestive Heart Failure
Hypertension
Secondary Diagnosis:
surgical site infection
rash
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___ during your
admission. You presented to the hospital with palpitations and
were found to have Atrial Fibrillation with a Rapid Ventricular
Response (your heart beating too fast). You were given
medication to control your heart rate. You were also found to be
in congestive heart failure (too much fluid in your body). You
were given medication to remove the fluid from your body. You
were also seen by neurosurgery who evaluated your surgical site.
You were started on Coumadin to anticoagulate ("thin") your
blood. You will be on heparin until you are therapeutic on your
coumadin. Your doctor ___ check blood tests to make sure your
goal is therapeutic.
You also had a procedure to remove fluid from your lungs.
You were started on several new medications. Please see the
attached list of your new medications
Followup Instructions:
___
|
10336114-DS-6 | 10,336,114 | 22,796,335 | DS | 6 | 2172-08-29 00:00:00 | 2172-08-29 14:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ w/ hx of severe aortic stenosis, chronic renal
insufficiency, chronic thrombocytopenia and anemia, CABG who
presents w/ tachycardia and hypotension. Pt is a poor historian,
but his son-in-law (who is his PCP) called and provided more
information. The patient has felt generalized weakness for the
past few days, with increase in home o2 requirement from 2->3L.
He has also had a poor appetite for a few weeks with constant
nausea, and vomited yesterday. He had a fever of ___ yesterday.
He reports that he has been anxious and intermittently short of
breath with exertion over the past month and presented today
because could no longer tolerate symptoms.
PCP called the ___ with the following information: Has chronic
renal insufficiency, Cr 3 but recently 2. Recently BNP 400, but
normally in the 1000s. hct ___. plt 80-90.
In the ___, initial vitals: 98.4 130 92/39 36 100% on 15L
Non-Rebreather. He had a white count of 20k, lactate of 4.0. Cr
of 2.9. BNP of 18292. Troponin of 0.11 which downtrended to
0.09. CXR showed Pneumothorax on the right, bilateral pleural
effusions, interstitial abnormality suggesting mild pulmonary
edema, and bibasilar opacities. Bedside ultrasound showed a
collapsible IVC. He was given 3L of IVF as well as Vanc and
Cefepime. Lactate improved to 2.0.
Past Medical History:
Aortic Stenosis; Chronic thrombocytopenia; Anemia; Chronic Renal
Insufficiency; GERD; Gout; Arthritis; s/p Hernia repair; s/p
Cataract Surgery
Social History:
___
Family History:
Denies premature coronary artery disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: afebrile BP 109/73, HR 127, RR 14, sat 94% on 2L
General: NAD
HEENT: adentuous, dry oropharynx
Neck: supple, no JVD, transmitted murmur to carotid noted
Heart: tachycardia, normal s1s2, ___ systolic ejection murmur
Lungs: Bibasilar crackles
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Skin: Left pre-patellar healing wound with dirty band aid.
scattered senile pupura
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.8, 60-92, 98-112/50-67, 98 on 3L
General: Cachectic, elderly gentleman, cooperative and
comfortable in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVD not assessed.
Lungs: clear to auscultation in anterior lung fields.
CV: Regular rate and rhythm, normal S1 + S2, III/VI late peaking
systolic ejection murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS ON ADMISSION:
======================
___ 05:45PM BLOOD WBC-20.7*# RBC-3.15* Hgb-10.7* Hct-33.9*
MCV-108*# MCH-34.0* MCHC-31.5 RDW-14.2 Plt ___
___ 05:45PM BLOOD Neuts-75* Bands-14* Lymphs-2* Monos-8
Eos-0 Baso-0 Atyps-1* ___ Myelos-0
___ 05:45PM BLOOD Glucose-123* UreaN-64* Creat-2.9* Na-129*
K-5.8* Cl-91* HCO3-24 AnGap-20
___ 03:12AM BLOOD ALT-15 AST-30 LD(LDH)-189 AlkPhos-294*
TotBili-0.8
___ 05:45PM BLOOD ___
___ 05:45PM BLOOD cTropnT-0.11*
___ 12:35AM BLOOD cTropnT-0.09*
___ 05:45PM BLOOD Calcium-8.5 Phos-5.1* Mg-2.1
___ 05:58PM BLOOD ___ pO2-56* pCO2-40 pH-7.42
calTCO2-27 Base XS-0 Intubat-NOT INTUBA
___ 05:58PM BLOOD Lactate-4.0*
___ 09:12PM BLOOD Lactate-3.0*
___ 12:45AM BLOOD Lactate-2.0
IMAGING:
=====================
___ V/Q scan
IMPRESSION: Low likelihood of pulmonary embolism. Findings
suggest congestive heart failure.
___ CXR
IMPRESSION: Pneumothorax on the right. Bilateral pleural
effusions.
Interstitial abnormality suggesting mild pulmonary edema.
Although opacities at the lung bases, greater on the left than
right, are probably compatible with atelectasis, underlying
infectious process is not entiredly excluded by this
examination.
___ echo:
Conclusions
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness is mildly increased and cavity
size is normal. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the basal to mid inferior
wall, inferolateral and anterolateral walls (EF 40-45%).The
right ventricular free wall is hypertrophied. The right
ventricle is mildly dilated with borderline normal function.
There is abnormal septal motion/position. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. [Due to
acoustic shadowing, the severity of aortic regurgitation may be
significantly UNDERestimated.] There is severe mitral annular
calcification. There is mild functional mitral stenosis (mean
gradient 3 mmHg) due to mitral annular calcification. Mild to
moderate (___) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is (at least) moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional left ventricular systolic dysfunction c/w possible CAD.
Right ventricular hypertrophy with mildly dilated cavity size
and borderline normal function. At least moderate pulmonary
artery systolic hypertension. Severe aortic stenosis.
Mild-to-moderate mitral regurgitation with functional mitral
stenosis due to annular calcification.
___ CT Chest:
IMPRESSION:
1. Moderate-to-large right hydropneumothorax.
2. Loculated left effusion.
3. Right upper lobe pneumonia.
4. Cardiomegaly.
5. Dense calcification of the aortic valve.
6. Anasarca.
LABS ON DISCHARGE:
========================
___ 08:15AM BLOOD WBC-13.3* RBC-2.78* Hgb-9.5* Hct-29.0*
MCV-104* MCH-34.2* MCHC-32.8 RDW-13.9 Plt Ct-80*
___ 08:15AM BLOOD Glucose-93 UreaN-103* Creat-2.5* Na-133
K-4.9 Cl-98 HCO3-23 AnGap-17
___ 08:15AM BLOOD Calcium-9.2 Phos-5.3* Mg-2.4
Brief Hospital Course:
Impression: ___ w/ hx of severe aortic stenosis, chronic renal
insufficiency, chronic thrombocytopenia and anemia, CABG who
presents with shortness of breath and found to have severe
sepsis.
# Severe sepsis: Patient presented with hypotension,
tachycardia, elevated white count with bandemia and elevated
lactate with an unknown source of infection -lung or GU most
likely. CXR findings confounded by poor forward flow from aortic
stenosis and heart failure and anxiety. UA benign. Patient
treated with empiric vancomycin and cefepime. He did not require
intubation or any pressor support. He was transferred to the
floor on hospital day 1 and narrowed to Levofloxacin for 10-day
course. Last day ___.
# Dyspnea: Multifactorial, likely acute on chronic process with
contributions from CHF, pneumonia, pneumothorax, and infection.
V/Q scan negative for pulmonary embolism. At baseline the
patient is on ___ of oxygen. CT chest showed moderate to large
hydropneumothorax which him and his PCP/HCP decided against
treating (recommended chest tube in right side). He also has
possible right sided pneumonia as well as old left sided
loculated effusion (pulmonary did not recommend tapping this).
He is to have follow up CXR in 1 week to evaluate.
# Heart failure: Patient has a history of critical AS and acute
on chronic shortness of breath and pulmonary edema with elevated
BNP. Will hold off on diuresis in the setting of hypotension,
sepsis and AS. Echo showed LVEF 45-50%, LVH, likely CAD and AS
with an ___ of 0.5. Patient diuresed carefully given initial
presentation of hypotension. Home atenolol was held.
# Leukocytosis: Given history of fever most concerning for an
infectious process but given age and "bands" cannot exclude
hematologic process. Pt. treated for infection as above and WBC
downtrended.
# Pneumothorax: Unclear etiology but patient has a smoking
history. Currently oxygenating well on room air. Serial CXRs
showed stable pneumothorax.
# Tachycardia: Has a history of chronic and paroxysmal afib and
presenting rhythm appears to be narrow complex tachycardia with
regular rhythm that may not be sinus (no clear P waves).
Challenged with fluids and tachycardiac resolved.
# Chronic renal failure. Creatinine at baseline.
# Anxiety: Home lorazepam was held initially given concern for
ICU delirium.
TRANSITIONAL ISSUES:
- Pt. has b/l pleural effusions (left loculated is old) and
right pneumothorax. Please follow with serial CXRs. If worsening
respiratory status, please consider interventional pulmonology
consult for right sided chest tube given concern for worsening
pneumothorax or parapneumonic effusion.
- Left sided loculated effusion is likely old following CABG in
___
- Levofloxacin for pneumonia 10-day course last day ___
- Code - DNR/DNI
- Contact - PCP ___ Dr. ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 12.5 mg PO DAILY
2. Paroxetine 10 mg PO DAILY
3. Furosemide 60 mg PO QAM
4. Allopurinol ___ mg PO DAILY
5. Omeprazole 20 mg PO BID:PRN heartburn
6. Prochlorperazine 10 mg PO Q8H:PRN nausea
7. Lorazepam 0.5 mg PO HS:PRN insomnia
8. Aspirin 81 mg PO DAILY
9. Furosemide 40 mg PO QPM
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Furosemide 60 mg PO QAM
4. Lorazepam 0.5 mg PO HS:PRN insomnia
5. Omeprazole 20 mg PO BID:PRN heartburn
6. Paroxetine 10 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Docusate Sodium 100 mg PO BID
9. Levofloxacin 500 mg PO Q48H
last day ___. Metoprolol Tartrate 12.5 mg PO Q6H
11. Senna 8.6 mg PO DAILY
12. Furosemide 40 mg PO QPM
13. Prochlorperazine 10 mg PO Q8H:PRN nausea
14. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Sepsis
Pneumonia
Secondary Diagnoses:
Bilateral pleural effusions
Stable pneumothorax
Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for a pneumonia. Initially you were
very sick and required the intensive care unit. With
antibiotics, you improved significantly. On chest xray and CT
scan, we noted some fluid accumulation around your lungs and a
pneumothorax in the right lung (air outside the lung in the
chest cavity). After discussion with you and your PCP, it was
decided to not intervene on the fluid with a chest tube. You
should continue to follow this with chest x rays. If you should
have worsening symptoms, you should reconsider an intervention
by the pulmonologist. Please follow-up with your PCP within ___
week of leaving rehab.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your medicine team at ___
Followup Instructions:
___
|
10336685-DS-17 | 10,336,685 | 23,945,869 | DS | 17 | 2174-08-25 00:00:00 | 2174-08-26 13:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of hypertension, glaucoma presents
with acute onset left-sided headache. Pain started suddenly, and
persisted despite aspirin and ibuprofen so presented to ED. His
headache is associated with eye pain and temporal tenderness.
There is no reported weakness or numbness. There is no rash.
Patient was referred by PCP to ___ bleed. Patient is not on
anticoagulation.
In the ED, initial vitals were 97.6 66 127/85 18 100% on RA. On
exam, there was tenderness ofver the left temple. A slight left
eyelid droop was noted. Neurology exam was benign. Labs were
generally unremarkable. IOP was 13. CT head and CTA head and
neck were unremarkable. LP was attempted and unsuccessful.
Neurology was consulted and recommended CTA, LP and admission to
Medicine for expedited temporal artery biopsy. Patient received
prednisone 60 mg x 1, morphine sulfate 2 mg x 1, acetaminophen
650 mg x 1, and midazolam 0.5 mg x 4 IV.
Currently, the patient reports no headache or vision changes.
There is no shoulder pain, chest pain or dyspnea. He notes no
weakness or numbness of his extremities or face.
Review of systems:
10 pt ROS negative other than noted
Past Medical History:
Hypertension
Glaucoma
Social History:
___
Family History:
Mother and father with glaucoma
Mother with ___
Physical Exam:
ADMISSION EXAM:
Vitals: 98.3PO 139/89 85 18 100 RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM. Minimal tenderness to palpation of left temporal
artery.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: Cranial nerves ___ grossly intact, muscle strength ___
in all major muscle groups, sensation to light touch intact,
non-focal.
PSYCH: Appropriate and calm.
DISCHARGE EXAM:
VS: 98.1PO 123/83 68 16 99 RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM. No tenderness to palpation of the temporal artery
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: Cranial nerves ___ grossly intact, muscle strength ___
in all major muscle groups, sensation to light touch intact,
non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
ADMISSION LABS:
___ 04:13PM BLOOD WBC-6.3 RBC-4.80 Hgb-14.0 Hct-42.6 MCV-89
MCH-29.2 MCHC-32.9 RDW-14.4 RDWSD-45.5 Plt ___
___ 04:13PM BLOOD Neuts-55.4 ___ Monos-7.3 Eos-3.8
Baso-0.3 Im ___ AbsNeut-3.48 AbsLymp-2.07 AbsMono-0.46
AbsEos-0.24 AbsBaso-0.02
___ 04:13PM BLOOD ___ PTT-29.0 ___
___ 04:13PM BLOOD Glucose-108* UreaN-23* Creat-1.0 Na-136
K-7.0* Cl-105 HCO3-24 AnGap-14
___ 04:55PM BLOOD Calcium-9.6 Phos-2.3* Mg-2.1
___ 05:39PM BLOOD K-4.5
___ 04:55PM BLOOD SED RATE-Test
IMAGING:
CT head w/o contrast:
No acute intracranial process.
CTA head/neck:
1. Normal head and neck CTA.
2. Enlarged mediastinal and right hilar lymph nodes,
indeterminate, likely
reactive in etiology. Further evaluation with dedicated imaging
can be
performed as clinically indicated.
3. Enlarged right submandibular lymph node measuring 2.2 cm,
indeterminate,
likely reactive in etiology. However, neoplasm is not excluded.
RECOMMENDATION(S): Prominent mediastinal lymph nodes,
indeterminate, likely reactive in etiology. Further evaluation
with dedicated imaging can be performed as clinically indicated.
Temporal artery ultrasound ___:
No evidence of left temporal arteritis by duplex criteria.
MRI head w/o contrast ___:
1. There is no evidence of acute intracranial process,
specifically there is no evidence of intracranial hemorrhage.
2. Few scattered foci of high signal intensity identified in
the subcortical white matter are nonspecific and may reflect
changes due to small vessel disease.
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-11.2* RBC-4.84 Hgb-13.9 Hct-42.9
MCV-89 MCH-28.7 MCHC-32.4 RDW-14.3 RDWSD-45.5 Plt ___
___ 07:35AM BLOOD ___ PTT-25.6 ___
___ 07:35AM BLOOD Glucose-105* UreaN-26* Creat-0.9 Na-141
K-3.5 Cl-105 HCO___ AnGap-14
___ 07:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:08PM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Brief Hospital Course:
___ year old male with hypertension and glaucoma presents with
acute headache.
# Headache: acute, sudden, CTA and CT negative for bleed or
other etiology. LP unsuccessful in ED, and ultimately deemed
unnecessary by Neurology team. ESR 2. Patient had temporal
artery tenderness on admission, no vision changes. He was
placed on high-dose prednisone on admission for possible
temporal arteritis. Headache resolved upon arrival to the
medical floor. No reported history of substance abuse,
toxicology screen negative. Neurology and Rheumatology
evaluated him. Temporal artery ultrasound showed no evidence of
temporal arteritis. Temporal artery biopsy was planned, but he
could not be fit on the schedule during admission, and is
tentatively scheduled for ___. MRI head w/o contrast
showed ... He was given acetaminophen for pain. Patient will
remain on high dose steroids until temporal artery biopsy
results return. He will be contacted at home with a ___
plan with Rheumatology. He was instructed to return to the ED
if he experiences another severe headache.
# Hypertension: continued home losartan and HCTZ
# Glaucoma: continued home meds
# Lymphadenopathy: noted on CT head/neck. Patient states this
has been noted before, and has not been a worry. Will notify
patient's PCP to handle potential ___ of this finding.
TRANSITION OF CARE
------------------
# ___: Patient is scheduled for temporal artery biopsy on
___, and has been given instructions for this. Patient
will remain on high dose steroids until temporal artery biopsy
results return. He will be contacted at home with a ___
plan with Rheumatology. He was instructed to call ___ if he
experiences another severe headache. He was also scheduled for
PCP ___.
# Code status: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
2. Tamsulosin 0.4 mg PO QHS
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
4. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID
2. Tamsulosin 0.4 mg PO QHS
3. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. losartan-hydrochlorothiazide 50-12.5 mg oral DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Acetaminophen 1000 mg PO Q8H
8. PredniSONE 30 mg PO BID
RX *prednisone 10 mg 3 tablet(s) by mouth twice a day Disp #*42
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Severe headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___. You came for
further evaluation of severe headache. Various tests were
performed, none of which specifically elucidated the cause of
your headache.
It is important that you continue to take your medications as
prescribed and follow up with the appointments listed below.
Followup Instructions:
___
|
10336837-DS-21 | 10,336,837 | 26,999,400 | DS | 21 | 2123-06-09 00:00:00 | 2123-06-10 13:55:00 |
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
===============
___ 08:52PM BLOOD WBC-7.7 RBC-3.03* Hgb-7.8* Hct-25.8*
MCV-85 MCH-25.7* MCHC-30.2* RDW-15.3 RDWSD-47.8* Plt ___
___ 08:52PM BLOOD Neuts-74.2* Lymphs-5.2* Monos-11.7
Eos-7.8* Baso-0.4 Im ___ AbsNeut-5.69 AbsLymp-0.40*
AbsMono-0.90* AbsEos-0.60* AbsBaso-0.03
___ 08:52PM BLOOD Glucose-167* UreaN-41* Creat-3.8* Na-139
K-5.4 Cl-105 HCO3-20* AnGap-14
___ 08:52PM BLOOD ALT-29 AST-33 CK(CPK)-271 AlkPhos-220*
TotBili-0.2
___ 08:52PM BLOOD Albumin-3.9 Calcium-8.8 Phos-4.4 Mg-2.0
OTHER PERTINENT LABS/MICRO
===========================
___ 08:52PM BLOOD CK-MB-6 proBNP-9623*
___ 08:52PM BLOOD cTropnT-0.11*
___ 02:15AM BLOOD CK-MB-5 cTropnT-0.11*
___ 02:15AM BLOOD Iron-14*
___ 02:15AM BLOOD calTIBC-217* Ferritn-154 TRF-167*
___ 12:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 2:15 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 7:50 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
IMAGING
========
CXR ___
Comparison to ___. Stable moderate cardiomegaly.
Stable signs of mild to moderate pulmonary edema. No pleural
effusions. No pneumonia. No pneumothorax.
TTE ___
The left atrial volume index is moderately increased. There is
no evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is >15mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. Left ventricular cardiac index is high (>4.0
L/min/m2). There is a mild (peak 10 mmHg) resting left
ventricular outflow tract gradient. No ventricular septal defect
is seen. Tissue
Doppler suggests an increased left ventricular filling pressure
(PCWP greater than 18 mmHg). There is echocardiographic evidence
for diastolic dysfunction (grade indeterminate). Moderately
dilated right
ventricular cavity with normal free wall motion. The aortic
sinus diameter is normal for gender with a normal ascending
aorta diameter for gender. The aortic arch diameter is normal
with a mildly dilated descending aorta. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. There is trace aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve prolapse.
There is trivial mitral regurgitation. The pulmonic valve
leaflets are normal. There is mild pulmonic regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
mild [1+] tricuspid regurgitation. There is moderate to severe
pulmonary artery systolic hypertension. There is a very small
pericardial effusion. There are no 2D or Doppler
echocardiographic evidence of tamponade.
CHEST (PORTABLE AP) Study Date of ___ 10:16 AM
IMPRESSION:
Comparison to ___. Pre-existing signs of pulmonary
edema have improved. The edema is now mild in severity.
Moderate cardiomegaly persists. Stable mild retrocardiac
atelectasis. No pneumonia. No pleural effusions.
DISCHARGE LABS
===============
___ 07:04AM BLOOD WBC-5.2 RBC-3.59* Hgb-9.2* Hct-30.4*
MCV-85 MCH-25.6* MCHC-30.3* RDW-15.5 RDWSD-47.5* Plt ___
___ 07:04AM BLOOD Glucose-151* UreaN-71* Creat-4.2* Na-145
K-3.9 Cl-98 HCO3-27 AnGap-20*
___ 07:04AM BLOOD Calcium-9.3 Phos-4.5 Mg-2.0
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ] Patient hypertensive emergency likely secondary to dietary
non-discretion. Please encourage low salt diets for him.
[ ] Labetalol and hydralazine were increased for better blood
pressure control.
[ ] On TTE, noted to have 'Moderate to severe pulmonary artery
systolic hypertension' Should have repeat TTE to ensure
improvement, otherwise he should be managed for pulmonary
hypertension. Additinoally he would likely benefit from an
outpatient stress test
BRIEF HOSPITAL COURSE:
======================
The patient is a ___ male with a history of type 2
diabetes mellitus, stage IV chronic kidney disease,
hypertension, heart failure with preserved ejection fraction,
hepatitis C status post Harvoni with residual cirrhosis, who
presented with several days of chest pain, cough, dyspnea,
fevers with concern for multifocal pneumonia. His course was
complicated by hypoxemic respiratory failure likely ___ HFpEF
exacerbation iso hypertensive urgency which improved on BiPAP
and nitro gtt, now s/p aggressive diuresis and improved BP
control on po medications
ACUTE ISSUES
=======================
# Acute HFpEF exacerbation
# Hypertensive urgency
# Chest pain
# Troponinemia
The patient came in with elevated blood pressures and was found
to be in flash pulmonary edema likely acute HFpEF exacerbation
iso hypertensive urgency. His TTE did not show any significant
left ventricular dysfunction, but did show moderate to severe
pulmonary artery hypertension and right ventricular dysfunction.
The patient improved on BiPAP and nitro drip. There was a
brief concern for ACS, but his EKG was without ischemic changes,
and his troponin and CK-MB were unremarkable. Likely demand
ischemia. The patient was started on boluses of Bumex and placed
on Bumex drip, with metolazone added to improve diuresis. His
volume status gradually improved, as did his subjective dyspnea.
He was restarted on his home hydralazine, labetalol, nifedipine,
and isosorbide 20mg TID was added to improve blood pressure.
Labetolol was increased. His losartan was held in the setting of
his ___. The patient continued his home atorvastatin. The
patient was intermittently placed on BiPAP, but after diuresis
he did not require BiPAP. He should obtain a stress test as an
outpatient.
# Hypoxia
# Acute HFpEF exacerbation
# Multifocal pneumonia
The patient's dyspnea, fevers, cough and hypoxia with opacities
on chest x-ray was concerning for multi focal pneumonia
superimposed on pulmonary edema iso HFpEF. The patient did
improve on BiPAP, but he was also started on ceftriaxone and
azithromycin for community-acquired pneumonia coverage x5 day
course. The patient was eventually weaned down to 2L nasal
cannula. His blood and urine cultures were unremarkable, sputum
cultures did not show any growth. MRSA swab was pending,
although there was a low suspicion for MRSA. Legionella antigen
was negative.
# ___ on ___:
Patient receives his care with nephrology at ___. His baseline
creatinine is around 3 per outside records, and the thought was
this was prerenal versus cardiorenal process. The patient's
creatinine was at 3.8 around the time of his admission, and was
stable. His home losartan was held in the setting of his ___.
Cr ranged from 3.7 to 4.2 which is his baseline, renal consulted
here to bridge management with ___ doctors ___ and
rising Cr iso diuresis.
# Normocytic anemia:
The patient's hemoglobin and hematocrit were at baseline.
Likely low in the setting of his chronic kidney disease. He was
guaiac negative and did not exhibit any signs of active bleeding
during the MICU course. Received 2 U pRBC this admission.
CHRONIC ISSUES
=======================
# DM2:
Held home oral DM2 meds, continued ISS
# Depression
# Anxiety
Continued home buproprion and sertraline
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. BuPROPion XL (Once Daily) 150 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. GlipiZIDE XL 5 mg PO DAILY
5. HydrALAZINE 75 mg PO Q8H
6. Labetalol 300 mg PO TID
7. Losartan Potassium 25 mg PO DAILY
8. MetOLazone 2.5 mg PO DAILY:PRN weight > 225 lbs
9. NIFEdipine (Extended Release) 90 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Prazosin 1 mg PO QHS:PRN ___ tabs PRN
12. Sertraline 100 mg PO DAILY
13. Sodium Bicarbonate 1300 mg PO BID
14. Torsemide 80 mg PO BID
15. linaGLIPtin 5 mg oral DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. HydrALAZINE 100 mg PO Q8H
2. Labetalol 600 mg PO TID
3. Atorvastatin 40 mg PO QPM
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
7. GlipiZIDE XL 5 mg PO DAILY
8. linaGLIPtin 5 mg oral DAILY
9. Losartan Potassium 25 mg PO DAILY
10. MetOLazone 2.5 mg PO DAILY:PRN weight > 225 lbs
11. NIFEdipine (Extended Release) 90 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Prazosin 1 mg PO QHS:PRN ___ tabs PRN
14. Sertraline 100 mg PO DAILY
15. Sodium Bicarbonate 1300 mg PO BID
16. Torsemide 80 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
======================
- CAP
- ADHF
- NSTEMI-II
SECONDARY DIAGNOSIS
======================
- ___ on ___
- T2DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were feeling short of breath
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You were initially sent to the ICU for medications and oxygen
for your shortness of breath.
- You had several imaging studies that showed volume overload,
but we were able to get the volume off and your breathing
improved
- Additionally we increased your blood pressure medications for
better control
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___. We
wish you all the best,
- Your ___ Care Team
Followup Instructions:
___
|
10337403-DS-37 | 10,337,403 | 24,483,484 | DS | 37 | 2137-10-11 00:00:00 | 2137-10-16 15:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Codeine Anhyd / Ambien
Attending: ___.
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M w/uncontrolled HTN, DM II, end stage infarct dementia and
end stage renal disease with recent fall in ___ with
subsequent ___ (now nonverbal at baseline) who is transferred
from ___ for PNA and hypotension.
Of note, wife reports that patient was improving at ___
___ up until 2 days prior to admission. He remained
non-verbal but was starting to nod to voice and open his eyes.
Two days ago, his wife noticed that he was opening his eyes
intermittently and not as responsive. She was called the day of
admission by rehab staff that patient had had "seizures" and
needed to go to the hospital.
Patient arrived to OSH with fevers, CXR concerning for pna. He
was given a dose of Meropenem and transferred to ___.
In the ED, initial SBP was ___ other VS were 100.8 112 26 100%
2L Nasal Cannula. Patients labs were notable for WBC 9.9 with
86%N, H and H 5.5/17.7 (baseline Hct 25), lactate 1.4, and
chem-7 of 152/4.3/124/13/103/4.9. Guaiac negative, no obvious
source of bleeding. CXR showed RLL infiltrate. Hypotension
improved with fluid bolus' and patient was given Vancomycin for
further tx of HCAP (already received ___ at OSH). On transfer,
VS had improved to 100.8 94 138/58 24 99%.
On arrival to the MICU, vitals were 100.1 102 154/57 22 96%
6L/NC.
Past Medical History:
Vascular Dementia
HTN
CVA
Diabetes
DVT: late ___ s/p filter
CKD baseline Cr around 3.5
peripheral neuropathy
glaucoma with legal blindness
skin grafts on B UE burns from automobile fire in ___
hepatitis B and C
anemia baseline Hct ___
history of alcohol and cocaine use
a history of osteomyelitis - Left hip replacement joint
infection.
erectile dysfunction
Social History:
___
Family History:
Per OMR (patient is unresponsive and unable to participate)
Non contributory.
Physical Exam:
ADMISSION PHYSICAL:
General: Frail appearing male with frothy saliva at his mouth.
Unresponsive to sternal rub.
HEENT: Unable to assess JVP ___ absent patient cooperation.
Neck: Unable to assess ___ absent patient cooperation.
CV: Obscured by respiratory sounds.
Lungs: Using accessory muscles to breathe. Prominent upper
inspiratory and expiratory breath sounds obscure any findings.
Abdomen: Soft, nontender, normoactive bowel sounds
GU: foley
Ext: Warm. No peripheral edema peripheral pulses 2+ ___
Neuro: Pupils pinpoint and unreactive.
Pertinent Results:
ADMISSION LABS
--------------
___ 01:15AM BLOOD WBC-9.9 RBC-1.81*# Hgb-5.5*# Hct-17.7*#
MCV-98 MCH-30.1 MCHC-30.8* RDW-15.1 Plt ___
___ 01:15AM BLOOD Neuts-86.4* Lymphs-5.2* Monos-7.6 Eos-0.6
Baso-0.2
___ 01:15AM BLOOD Glucose-130* UreaN-103* Creat-4.9*#
Na-152* K-4.3 Cl-124* HCO3-13* AnGap-19
___ 09:17AM BLOOD Type-ART pO2-63* pCO2-21* pH-7.40
calTCO2-13* Base XS--8
___ 09:17AM BLOOD Lactate-1.4
___ 09:17AM BLOOD O2 Sat-91
DISCHARGE LABS
--------------
MICROBIOLOGY
------------
___ 1:15 am BLOOD CULTURE Site: ARM
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
IMAGING
-------
CXR on admission:
IMPRESSION: Right basilar pneumonia.
Brief Hospital Course:
___ year old male with end-stage dementia and renal disease
recently discharged to rehab after sustaining a subarachnoid
hemorrhage, leaving him non-verbal, who presents with multifocal
pneumonia and Staphylococcus bacteremia.
-------------------
ACUTE ISSUES:
# Goals of Care: family discussion was held given patient's
worsening clinical status when patient was transferred to the
floor. It was decided that patient should no longer be
transferred to the ICU, and that the focus should be on keeping
the patient comfortable. Palliative care, inpatient hospice, and
our social worker in conjunction with the medical team provided
care and support for the patient and his family as he was made
comfortable and passed away.
# Sepsis/pneumonia/bacteremia: Patient presented to an outside
hospital hypotensive, febrile, tachycardic, with a left shift in
___ found to have a right lower lobe infiltrate consistent with
pneumonia. He also had positive blood cultures with
methicillin-resistant Staphylococcus aureus bacteremia.
Patient's long-standing neurologic compromise as well as
anatomical position of infiltrates were typical for an
aspiration pneumonia, though this also could have been MRSA
pneumonia as well. Surveillance blood cultures have been
negative. Given switch in patient's goals of care, TTE was not
pursued. The patient was treated with
vancomycin/piperacillin-tazobactam/levofloxacin with continued
worsening in infiltrates, and copious secretions. Patient was
switched to comfort-focused measures and antibiotics, while
initially continued for comfort, were ultimately discontinued
with the agreement of the patient's wife.
# Transfusion reaction: Resolved. Patient was febrile to 102.1
30 minutes after starting transfusion.
# Acute on Chronic Anemia: Patient with chronic anemia thought
secondary to his renal disease. Baseline hematocrit was 25,
however, 17 on admission, but improved to baseline with one unit
PRBC transfusion. Patient was guaiac negative, abdomen soft,
with no obvious source.
# Hypovolemic hypernatremia: Na 152 on admission. Likely due to
poor intake and insensible losses. Free water deficit 3.4L
corrected with oral free water and IV D5W.
# Hypertension: home Lisinopril, Isosorbide mononitrate,
Hydralazine and clonidine patch were held in setting of sepsis.
Intermittent labetalol was given for hypertension, and was
ultimately discontinued when he was no longer able to take PO
and transitioned to comfort measures.
CHRONIC ISSUES:
# Chronic kidney disease: Patient with baseline CKD stage IV-V.
Most recently discharged with a Cr >6, presented with 4.9.
# Recent subarachnoid hemorrhage: patient started on phenytoin
with increased seizure risk. Continued dose while patient was
admitted. There was some concern for possible seizure activity,
for which lorazepam was given and EEG showed epileptiform
discharges but no seizures. He was kept on standing lorazepam
for seizure prophylaxis.
# Diabetes mellitus: ISS, which was ultimately discontinued.
TRANSITIONAL ISSUES:
# Code status: DNR/DNI, comfort-focused care
# Contact: ___ (wife, HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO ___
2. Atorvastatin 10 mg PO DAILY
3. bimatoprost *NF* 1 drop 0.03% solution in each eye ___
4. Calcitriol 0.5 mcg PO DAILY
5. Calcium Acetate 1334 mg PO TID W/MEALS
6. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
8. Famotidine 20 mg IV Q24H
9. Furosemide 80 mg PO BID
10. Heparin 5000 UNIT SC TID
11. HydrALAzine 100 mg PO Q8H
12. Glargine 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
14. Lisinopril 10 mg PO DAILY
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Nitroglycerin SL Dose is Unknown SL PRN chest pain
17. Phenytoin (Suspension) 200 mg PO Q12H
18. Pilocarpine 4% 1 DROP BOTH EYES Q8H
19. TraZODone 25 mg PO HS:PRN agitation
20. Cyanocobalamin 1000 mcg PO DAILY
21. Docusate Sodium 100 mg PO BID
22. Senna 1 TAB PO DAILY:PRN constipation
23. Labetalol 200 mg PO BID
24. Nystatin Oral Suspension 5 mL PO QID
25. Acetaminophen (Liquid) 650 mg PO Q6H
26. Lorazepam 0.25 mg PO Q8H:PRN agitation
27. Lactulose 30 mL PO Q8H:PRN constipation
28. Nitroglycerin Ointment 2% 0.5 in TP Q6H
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Pneumonia
Secondary:
Dementia
Intracranial hemorrhage
Diabetes
Discharge Condition:
Expired
Discharge Instructions:
Mr. ___ was admitted to ___ with pneumonia and hypotension.
He was treated briefly in the ICU, stabilized and called out to
the floor. Given his ongoing worsening condition since his
intracranial hemorrhage in ___, many family meetings were held
with his wife and HCP ___, and it was decided to change the
focus of his care to comfort measures.
Followup Instructions:
___
|
10337761-DS-23 | 10,337,761 | 25,226,278 | DS | 23 | 2160-04-06 00:00:00 | 2160-04-08 08:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Atazanavir / fresh fruit
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
right heart catheterization
History of Present Illness:
___ with h/o HIV (CD4=563,VL<50 ___ on HAART, DM, HTN, CKD,
recent ureteral stone w/ pyelonephritis complicated by hematoma
f/ stent placement, on HD for several weeks, who p/w dyspnea for
3 weeks.
.
Three weeks ago she started having dyspnea that is not related
to exertion. She also has a cough that is not productive and
occasional pain in the middle of her chest. Chest pain occurs
occasionaly and is not related to breathing or excercise. She
also had occasional pain in the abdomen - more in the stomach
area on different occasions, but unrelated to position or chest
pain. As she has a h/o astma, she was taking nebulizers w/o any
relief. She denies ___ edema, trauma of the legs or travelling.
She also stopped smoking about 1 month ago by using bupropion
which she is still taking. Weight has been stable. Denies
N/V/D/C. No urinary complaints. Reports adherence with meds.
She recently had prolonged admissions in ___ for right
ureteral stone/obstruction complicated by E. coli pyelonephritis
and bloodstream infection status post nephroureteral stent
placement complicated by large hematoma and ICU stay, on HD for
several weeks, recently s/p stone and stent removal ___.
Drainage from prior nephrostomy site is steadily diminishing.
ECHO in ___ with preserved EF (LVEF>55%), mild mitral and
aortic regurgitation.
.
In ED 98.0 HR: 98 BP: 147/78 Resp: 20 O(2)Sat: 100 Normal, she
was breathing comfortably. Initial labs were significant for hct
28.5 (baseline 26), Sodium 131, Creatinine 1.7 (baseline 1.5-2),
troponin <0.01, BNP 10,929, d-dimer 3182. An EKG showed no
stemi, CXR: no signs of infection or malignancy. Concern for
possible pulmonary embolism, a VQ scan was performed V/Q scan
negative for PE (Cr too high for CTA).
.
Review of systems:
(+) Per HPI positive for dyspnea, coug and abdominal pain.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Castleman's Disease
- HIV, diagnosed in ___, CD4 of 668 and viral load
undetectable on ___ at an outside hospital
- Hepatitis C
- Shingles
- Migraines
- HTN
- DM II
- MRSA
- Recurrent UTI
- HSV
- Pancytopenia ___ HAART medications
Social History:
___
Family History:
- Father died of MI
- Mother with diabetes
- Sister with lung cancer at age ___ and was a heavy smoker.
- Bother with diabetes
- She had a second daughter, who was HIV positive and who died
at age ___
Physical Exam:
Admission PEx:
Vitals: T:97.5 BP: 144/86 P: 101 R:20 O2: 100/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, systolic murmurs,
rubs, gallops
Abdomen: soft, distended, non-tender, bowel sounds present, no
rebound tenderness or guarding, liver enlarged 10 cm, spleen not
palpable
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Physical Exam on Discharge
VS: T96.1F, 122/70, HR 75, RR 18, O2Sat 100% RA, I/O 1240/1200+
with 1x BM
Gen: A&Ox3, NAD
HEENT: sclera anicteric, MMM, OP clear
Neck: supple
Lungs: minimal bibasilar crackles
CV: RRR, normal S1/S2, ___ LUSB systolic murmur and ___ systolic
murmur at the apex
Abd: soft, distended, NT, BS+, no rebound or guarding, enlarged
liver
Ext: warm, well perfused, trace edema
Pertinent Results:
Labs on Admission:
___ 11:44AM BLOOD WBC-9.3 RBC-3.23* Hgb-9.4* Hct-30.1*
MCV-93# MCH-29.2 MCHC-31.4 RDW-15.6* Plt ___
___ 11:44AM BLOOD Neuts-74.6* Lymphs-17.2* Monos-6.5
Eos-1.2 Baso-0.5
___ 08:02AM BLOOD ___
___ 11:44AM BLOOD WBC-9.3 Lymph-17* Abs ___ CD3%-83
Abs CD3-1306 CD4%-40 Abs CD4-636 CD8%-41 Abs CD8-652 CD4/CD8-1.0
___ 11:44AM BLOOD UreaN-25* Creat-1.8* Na-131* K-6.6*
Cl-103 HCO3-18* AnGap-17
___ 11:44AM BLOOD ALT-28 AST-94*
___ 08:02AM BLOOD ALT-21 AST-49* LD(LDH)-160 AlkPhos-106*
TotBili-0.5
___ 07:05AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.6
___ 01:20PM BLOOD D-Dimer-3182*
___ 11:44AM BLOOD %HbA1c-5.3 eAG-105
___ 11:44AM BLOOD TSH-8.2*
___ 06:39AM BLOOD T4-PND
.
HIV ultrasensitive: HIV-1 RNA detected, less than 20 copies/mL
.
Blood cultures ___: NGTD
Imaging:
EKG: Sinus rhythm. Left atrial abnormality. Low limb lead
voltage. QS deflection in leads V1 and V2. There is variation in
precordial lead placement as compared with previous tracing of
___. Consider prior anterior myocardial infarction.
Otherwise, no diagnostic interim change.
V/Q scan: Perfusion images in the same 8 views show no perfusion
defects and less heterogeneity than on the ventilation. No
unmatched findings.
Chest x-ray shows cardiomegaly without evidence of overt
failure.
IMPRESSION: The above findings are consistent with a low
likelihood ratio of recent pulmonary embolism.
.
ECHO (___): The left atrium is dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is mildly dilated. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). There is a mild resting
left ventricular outflow tract obstruction. 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 masses or vegetations are seen on the aortic valve.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No mass or vegetation is seen on
the mitral valve. An eccentric, posteriorly directed jet of at
least moderate (2+) mitral regurgitation is seen. Due to the
eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). At least moderate
[2+] tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Biatrial enlargement. Mildly dilated left ventricle
with preserved global and regional biventricular systolic
function. Mild resting LVOT obstruction. Mild aortic
regurgitation. At least moderate mitral regurgitation. At least
moderate tricuspid regurgitation. Severe pulmonary artery
systolic and diastolic hypertension.
Compared with the prior study (images reviewed) of ___,
the left ventricle is now mildly dilated. The severity of aortic
regurgitation has decreased. The severity of mitral
regurgitation and tricuspid regurgitation has increased. Severe
pulmonary artery systolic hypertension is now present; it was
previously mild.
The absence of valvular vegetations on transthoracic
echocardiogram does not preclude the presence of endocarditis.
If clinical suspicion is high, a transesophageal echocardiogram
may be considered.
.
Cath (___): 1. Resting hemodynamics revealed moderately
elevated left and right sided filling pressures with a mean PCWP
of 21 mmHg and an RVEDP of 21 mmHg. There was moderate pulmonary
arterial systolic hypertension with a PASP of 55 mmHg. The
cardiac index was preserved at 2.5 L/min/m2. Pulmonary vascular
resistance was not significantly elevated. Baseline PVR was 5.1
___ which decreased to 2.7 ___ after 10 minutes of 100% FiO2.
There was a modest increase in cardiac output with 100% FiO2
with minimal change in mean PA pressures and mean PCWP.
FINAL DIAGNOSIS:
1. Moderate LV diastolic dysfunction.
2. Moderate RV diastolic dysfunction.
3. Moderate pulmonary hypertension.
Brief Hospital Course:
Brief Hospital Course
___ yo F with h/o HIV (CD4=563,VL<50 ___ on HAART, DM, HTN,
CKD, recent ureteral stone w/ pyelonephritis complicated by
hematoma f/ stent placement, on HD for several weeks, who p/w
dyspnea for 3 weeks found to have severe pulmonary hypertension,
worsening MR.
.
Active Issues:
.
Dyspnea: Presenting symptoms of orthopnea and dyspnea on
exertion. BNP elevated on admission. (10,000). Lungs are clear,
but her JVP clearly elevated and legs with edema. PFTs
demonstrated mixed obstructive/restrictive process not
responisive to bronchodilater therapy. TTE demonstrated
worsening known mitral regurgitation and severe pulmonary
hypertension. Subsequent right heart catheterization
demonstrated low PVR, moderate pulmonary artery hypertension and
LV/RV dysfunction. She was started on metoprolol and imdur as an
inpatient. Her beta blockade was titrated to symptom tolerance.
She received IVF in setting ___ and worsening hyponatremia
which worsened her lower extremity edema and she was ultimately
diuresed and discharged on 40mg PO lasix on discharge. She was
started on guaifenacin with codeine every evening and
fluticasone nasal spray in the setting of symptoms consistent
with post nasal brochitis. Her shortness of breath was improved
at the time of discharge. She has close follow-up with primary
care and cardiology.
.
UTI: She was treated with 3 days of IV ceftriaxone for a culture
positive UTI.
.
Elevated TSH: found on labs however T4 was 8.7. She should have
complete thyroid function tests repeated in the outpatient
setting.
.
HIV: Her HIV has been well-controlled on current regimen,
continue. The last CD4=563, VL<50 ___. VL<20 ___.
.
DM: Her HbAIC 5.4 has been under good control with diet.
.
CKD: baseline Cr ~1.6. Patient takes NaHCO3 supplements and
recently started valsartan that might increase Cr. Creatinine
increased to 2.2 fom 1.8 while in the hospital. Valsartan held.
There was concern for contrast mediated renal injury also. A
trial of IVF did not improve her renal function. Her discharge
creatinine was 2.0.
.
Hepatomegaly: Her liver is enlarged at 10 cm and she has
chronically elevated LFTs; now in ___, most probably due to
HAART tx, hepatitis C with stage 2 fibrosis and prior alcohol
abuse. Her large hematoma secondary to nephrostomy placement
several months ago also likely contributes to liver
displacement.
.
Hyponatremia: Chronic hyponatremia since the ___. Urine
lytes concerning for SIADH. She has close follow-up with
nephrology on discharge.
.
Non Anion Gap Acidosis: Chronic on sodium bicarbonate supplement
in outpatient setting. Venous blood gas suggests could be in
part due to compensation for primary respiratory alkalosis.
Difficult to assess acute versus chronic contribution given her
labs were stable and consistent with chronic changes on
admission. She was continued on sodium bicarbonate with
follow-up in ___ clinic.
.
Transitional Issues:
1. Follow-up with PCP, nephrology and cardiology
2. code: full
3. Follow-up Labs: lytes, thyroid function tests
Medications on Admission:
HOME MEDS:
abacavir [Ziagen] 300 mg Tablet 1 Tablet(s) by mouth twice a day
albuterol sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler ___
puffs po q4-6hr as needed for cough
bupropion HCl 150 mg Tablet Extended Release 1 Tablet(s) by
mouth twice a day
nr clonazepam 0.5 mg Tablet 1 Tablet(s) by mouth twice a day as
needed
darunavir [Prezista] 400 mg Tablet 2 Tablet(s) by mouth once a
day famciclovir [Famvir] 500 mg Tablet 1 Tablet(s) by mouth once
a day folic acid 1 mg Tablet
lamivudine [Epivir] 150 mg Tablet 1 Tablet(s) by mouth once a
day
ritonavir [Norvir] 100 mg Tablet 1 Tablet(s) by mouth once a day
trazodone 100 mg Tablet 1 Tablet(s) by mouth at bedtime
valsartan [Diovan] 160 mg Tablet
aspirin 81 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by
mouth once a day (OTC)
diphenhydramine HCl 25 mg Capsule 1 Capsule(s) by mouth at
bedtime as needed for itching
sodium bicarbonate 650 mg Tablet 1 Tablet(s) by mouth twice a
day
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing.
3. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. lamivudine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
8. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
10. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
13. Guaifenesin AC ___ mg/5 mL Liquid Sig: Twenty (20) mL PO
at bedtime.
Disp:*qS * Refills:*2*
14. furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day
for 2 weeks: Follow-up with your cardiologist and nephrologist
for outpatient dose adjustments.
Disp:*60 Tablet(s)* Refills:*0*
15. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day) for 2 weeks.
Disp:*qS * Refills:*0*
16. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: ___ Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
17. famciclovir 500 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pulmonary Hypertension with peripheral edema
2. HIV, Chronic Kidney Disease, Hepatitis C
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 symptoms of shortness of
breath. An ultrasound of your heart demonstrated evidence of
pulmonary hypertension (elevated pressures in you lung vessels).
You were evaluated by our cardiologists who performed a right
heart catheterization which confirmed pulmonary hypertension.
You were started on a medication (imdur) to help with your
symptoms. You were also started on furosemide (lasix) to help
remove excess fluid. Please follow-up closely, with cardiology,
nephrology and your primary care physician.
The following changes were made to your medication list:
1. START Isosorbide Mononitrate (Imdur) 30mg daily
2. START Guaifenacin (robitussin or mucinex) twice daily
3. START Guaifenacin with Codeine in the evening for cough
4. START Flonase intranasally for 2 weeks
5. START Metoprolol 12.5mg daily
6. START Furosemide 40mg daily (2 pills)
Please hold your valsartan until you see your primary care
doctor in the clinic.
Followup Instructions:
___
|
10337761-DS-24 | 10,337,761 | 25,341,548 | DS | 24 | 2160-05-01 00:00:00 | 2160-05-02 19:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Atazanavir / fresh fruit
Attending: ___
Chief Complaint:
short-of-breath
Major Surgical or Invasive Procedure:
THORACENTESIS
RIGHT HEART CATHETERIZATION
History of Present Illness:
___ with h/o HIV (CD4=636 on ___ on HAART, DM, HTN, CKD and
CHF w/recent admit for exacerbation p/w worsening DOE and
episode of R-sided chest pain last night.
.
Patient recently admitted for CHF exacerbation during which she
had a TTE and cardiac cath. Discharged ___ since then, she has
been seen in her ___ office multiple times, most recently 3d
ago. At last appt her Lasix was increased to 60mg bid. Today her
___ NP called to check in on her and the patient reported
increased dyspnea on exertion, progressive fatigue, and one
brief episode self-resolving R-sided stabbing chest pain like "a
pounding headache in her chest." No nausea or diaphoresis
associated, no sudden-worsening SOB at the time. Not aware of
any weight change since last admission, and not aware of change
in abdominal girth or pant fit. Does report 2 episodes hematuria
yesterday overnight, which is unusual for her. Pt is unsure of
the reason for her chronic renal failure but reports continual
low-grade serosang drainage from R perinephric hematoma. Thinks
urine output unchanged, no improvement after increasing lasix
yesterday; no dysuria, frequency or incontinence recently. Dry
cough continues.
.
In the ED today, she denied F/C/CP/SOB/AB PAIN/N/V/D. Initial VS
were 99.3 71 145/64 18 100% RA. Labs notable for elevated
creatinine, normal troponin, UA concerning for UTI, and CXR
showing new R moderate pleural effusion. Given aspirin and
nitrofurantoin and admitted for CHF workup.
.
On the floor, she says she is comfortable but still tired. She
reports history as above, with corroborating information from
her 2 children.
.
Review of sytems:
(-) Denies sick contacts, fever, chills, changes in vision,
changes in hearing, pain L chest/left
arm/shoulder/neck/jaw/back, syncope, abd pain, worsening abd
distension, diarrhea, constipation, hemetemesis, hematochezia,
melena.
Past Medical History:
- HIV, diagnosed in ___, on HAART
- Castleman's Disease
- Hepatitis C
- Shingles
- Migraines
- HTN
- DM II
- MRSA
- Recurrent UTI
- HSV
- Pancytopenia ___ HAART medications
- CKD (nephrolithiasis, pyelonephritis & perinephric abscess c/b
perinephric hematoma during stenting ___
Social History:
___
Family History:
- Father died of MI
- Mother with diabetes
- Sister with lung cancer at age ___ and was a heavy smoker.
- Brother with diabetes
Physical Exam:
ADMISSION
VS 97.8 151/93 74 16 100/RA
GEN: thin cushingoid woman appears older than stated age, in NAD
lying in bed at 30* angle, some transient apparent dyspnea
w/exertion required to sit up for exam but otherwise
comfortable-appearing
HEENT: Sclera anicteric, MMM, oropharynx clear, +JVD
Lungs: clear, but diminished breath sounds right base
CV: RRR normal S1 + S2, no murmurs, rubs, gallops
Abdomen: prominently distended (akin to 9-mo gravid belly)
w/liver edge palpable 4 cm below costal margin, nontender, no
fluid wave appreciated. normoactive BS. no rebound/guarding.
Ext: WWP, 2+ pulses, no edema
Neuro: AOX3, speech fluent, CNII-XII intact, strength ___
throughout, moves all 5 limbs spontaneously, gait not assessed.
.
DISCHARGE
GEN: thin woman appears older than stated age, in NAD,
comfortable-appearing
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: clear, diminished breath sounds right base
CV: RRR normal S1, S2, +S4, holosystolic murmur heard best at
apex ___
Abdomen: distended, liver edge palpable 4 cm below costal
margin, mildly TTP
Ext: WWP, 2+ pulses, no edema
Neuro: flat affect, CNII-XII intact, strength ___ throughout,
moves all 5 limbs spontaneously, gait not assessed.
.
Pertinent Results:
Images:
___ ABD US W/DOPPLER
FINDINGS:
There are no focal hepatic liver lesions. The portal vein,
hepatic arteries and hepatic veins are patent with normal
waveforms. There is no intra-or extra-hepatic biliary dilatation
with the common bile duct measuring 5 mm. A gallstone is seen
without evidence of acute cholecystitis. The partially
visualized pancreas is grossly unremarkable. A mass-like
echogenic process is seen at the right kidney, consistent with
known history of hematoma, ill-defined and not well evaluated.
There is small amount of ascites and there are bilateral small
pleural effusions. Ascites is also seen in the right lower
quadrant.
IMPRESSION:
1. Small-to-moderate amount of ascites.
2. Patent hepatic vasculature including patent portal vein.
3. Gallstone, but no findings to suggest acute cholecystitis.
.
___ CXR
FINDINGS: Frontal and lateral views of the chest were obtained.
Since the prior study, there has been interval development of a
small-to-moderate right pleural effusion with overlying
atelectasis. Underlying consolidation is not excluded. The left
lung is clear. The cardiac silhouette remains moderately
enlarged. No overt pulmonary edema is seen. Mediastinal and
hilar contours are stable.
IMPRESSION: Interval development of small-to-moderate right
pleural effusion with overlying atelectasis, underlying
consolidation not excluded. Persistent enlargement of the
cardiac silhouette.
.
___ EKG: HR 71 sinus w/left venticular hytertrophy, T wave
flattening in V1, Twave inversions and various subtle ST
depressions V4-V6
.
___ CXR PA/LAT
IMPRESSION:
1. Persistent but stable layering right effusion with associated
airspace disease which could reflect compressive atelectasis,
although pneumonia cannot be excluded. Left lung is grossly
clear. The heart remains enlarged which could reflect
cardiomegaly or a pericardial effusion. Clinical correlation is
advised. Calcification of the aortic knob suggests
atherosclerosis. No pneumothorax. No left effusion.
.
___ CXR LAT DECUB
1. There is a small layering right-sided effusion with patchy
airspace opacity at the right base likely representing patchy
atelectasis, although superimposed pneumonia cannot be excluded.
The left lung remains well inflated without focal airspace
consolidation. The heart remains enlarged with a somewhat
globular appearance raising concern for pericardial effusion
although this may just reflect stable cardiomegaly. Clinical
correlation is advised.
Brief Hospital Course:
___ w/hx HIV on HAART (CD4=563,VL<50 ___, DM, HTN, CKD,
and recent urolithiasis/pyelonephritis requiring several weeks
HD now p/w progressive dyspnea and fatigue, found to have
transudative pleural effusion, moderate ascites and RH cath
showed worsening dCHF; diuresed back to dry weight with
symptomatic improvement.
# dCHF FLARE (DYSPNEA, ABDOMINAL DISTENSION)
On admission, ddx for her dyspnea w/R pleural effusion and
ascites included dCHF flare, liver failure (w/hepatic
hydrothorax), malignant effusion, and infection (w/broad
differential in this HIV patient). She is an active smoker and
has a sister with lung CA. Thoracentesis performed by IP
demonstrated transudative pleural fluid. RH cath showed
worsening dCHF. Together, the pleural fluid and cath results
suggested that dCHF underlies all current symptoms. Aggressive
diuresis yielded symptomatic relief, first w/IV lasix then PO
torsemide. Discharged on PO torsemide and BB, ASA, nitrate as
before.
# HEMATURIA
Intermittent during this admission. Urinalysis revealed numerous
intact red cells, no acanthocytes, no casts. Likely ___ chronic,
incompletely-healed perinephric hematoma in setting of
nephrostomy stent placement in ___ for R
nephrolithiasis. Urology consult saw the pt in-hospital,
recommended outpatient urology hematuria w/u with cystoscopy
and/or CT urogram.
# ACUTE-ON-CHRONIC RENAL FAILURE
Baseline during most of admission, increased above baseline in
the setting of aggressive diuresis. Continued NaCo3 supplement.
Renal following as an outpatient.
# POSITIVE UA
She received a few antibiotic doses (macrobid, then vanc, then
ampicillin) for an indeterminate admission UA which subsequently
grew enterococcus. No urinary symptoms.
# hx HIV
On HAART: abacavir 300 mg BID, lamivudine 150 mg DAILY,
darunavir 400 mg DAILY, ritonavir 100 mg. No regimen change
indicated since pt had no demonstrated benefit for sildenafil or
a CCB on RH cath and very few crystals were seen on urinalysis.
#Hx HSV
Continued ppx famciclovir 500 mg Tablet QD.
# hx ANXIETY
On bupropion HCl 150 mg BID, clonazepam 0.5 mg BID, trazodone
100 mg HS PRN. Continuing all home meds.
TRANSITIONAL ISSUES
- cardiology follow up in ___ weeks
- follow up with nephrologist
- PCP follow up in one week and will follow up on creatinine and
electrolytes (creatinine increased during admission and thought
to be secondary diuresis)
- urology follow up for chronic hematuria
Medications on Admission:
aspirin 81 mg QD
albuterol sulfate 90 mcg/Actuation ___ puffs every ___ hours PRN
(Qd)
abacavir 300 mg BID
lamivudine 150 mg DAILY
darunavir 400 mg DAILY
ritonavir 100 mg
bupropion HCl 150 mg BID (smoking cessation)
clonazepam 0.5 mg BID (anxiety)
trazodone 100 mg HS PRN
sodium bicarbonate 650 mg BID
folic acid 1 mg DAILY
isosorbide mononitrate 30 mg DAILY
Guaifenesin AC ___ mg/5 mL, Twenty (20) mL PO qHS PRN
furosemide 40>60 BID
metoprolol succinate 25 mg Tablet QD
famciclovir 500 mg Tablet QD
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB,
wheeze.
3. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. lamivudine 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. ritonavir 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID.
8. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
10. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet PO DAILY.
13. codeine-guaifenesin ___ mg/5 mL Syrup Sig: Twenty (20) ML
PO HS as needed for cough.
14. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet PO DAILY.
15. famciclovir 500 mg Tablet Sig: One (1) Tablet PO QD ().
16. Outpatient Lab Work: Please check CHEM-7 on ___.
Diagnosis: CHF, diuretic therapy, chronic kidney disease. Please
fax results to Dr. ___: ___.
17. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY.Disp:*30
Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACUTE ON CHRONIC DIASTOLIC HEART FAILURE
TRANSUDATIVE PLEURAL EFFUSION
ASCITES
HIV
CHRONIC KIDNEY DISEASE
HEMATURIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with a flare of congestive
heart failure.
You had another cardiac catheterization and a pleural fluid
sampling (thoracentesis), both of which ruled out other possible
diagnoses and therapies.
We gave you aggressive doses of diuretics (intravenous lasix)
for several days to rid you of extra water weight you had on
your lungs and belly. By the time you left you were able to
comfortably walk around without becoming short-of-breath or
tired.
We made the following changes to your medications:
STARTED torsemide 40mg daily
STOPPED lasix
Followup Instructions:
___
|
10337896-DS-4 | 10,337,896 | 23,906,079 | DS | 4 | 2185-04-01 00:00:00 | 2185-04-02 10:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dark stools
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Primary Care Physician: ___, MD ___
Chief Complaint: ___
Reason for MICU transfer: GI bleed with coagulopathy
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ year-old male with a history of Down's
sydrome, CAD, HFrEF (50%), PE on warfarin and recurrent small
bowel obstruction s/p ex-lap + trach/PEG (recently reversed) who
was brought to ___ by his caretakers due to melena.
Of note per ___ records, he had been living at rehab until
___ when he was deemed safe to go back to home group. There
is a mention of him being on hospice care at some point. His
warfarin had recently been changed from 2.5mg qod to 3.0mg/2.5mg
alternating daily.
Prior to arriving to ___, had SBPs in the ___ during transport
for which he received IVF bolus with subsequent decrease in
O2sats to 90%. At ___ his caretakers reported that he had been
having large amounts of black tarry stool over one day. He was
found to have Hb 6.1/ Hct 20.8 and an INR at 14. He received 1U
PRBCs as well as vitamin K 10mg iv. He received a bolus of
pantoprazole 80mg iv and was then transferred to ___.
In the ED :
-His initial vitals were 97.8 80 109/46 15 98% 2L NC
-He was agitated and combative, did not collaborate with exam.
-EKG showed SR with flattened Tw from V4-V6
-CBC 9.1>7.1/23.5<171, N72% | INR 2.4
-BUN 62 / Cr 1.0, Alb 2.3 Mg 1.5, Lact 2.2
-proBNP 137, TnT<0.01
-He was continued on a pantoprazole gtt at 8mg/h, received
olanzapine 5mg IM x2 for agitation
-Rectal with melena
-Evaluated wound with surgical resident and only superficial
oozing, unrelated to melena
-Vitals prior to transfer: 82 121/49 16 90% 2L NC
Review of systems:
Patient unable to provide review of systems
Past Medical History:
PAST MEDICAL HISTORY: (Per OMR)
-Down syndrome with severe mental retardation
-HTN
-T2DM
-HLD
-CAD
-CHF (EF 50% in ___
-PE (previously on Coumadin)
-Hx of TB c/b Pulmonary Fibrocalcific disease
-Chronic lymphedema causing Elephantiasis Verrucosa Nostra
-Bilateral ventral hernias
-Hypothyroidism
-COPD on 2L home O2 at night time
-Anxiety, depression
PAST SURGICAL HISTORY: (Per OMR)
___: Exploratory laparotomy, small-bowel resection, lysis of
adhesions and then temporary abdominal closure with VAC
assisted device.
___: Reopening of recent laparotomy, ventral hernia
repair with mesh, small bowel anastomosis, and reconstruction
of abdominal wall.
___: Tracheostomy + PEG
___: PEG reversal
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 82 121/49 16 90% 2L NC
GENERAL: Chronically ill-appearing, pale, minimally verbal
-screams no- alert, no oriented
HEENT: thick secretions in both eyes, sclera anicteric, MMM,
oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Bibasilar ronchi and dry crackles
CV: Regular rate and rhythm, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly; 5x5 abdominal
wall wound clean with minimal red bloody oozing
EXT: Warm, well perfused, week pulses, no cyanosis, +1 edema,
chronic stasis changes
SKIN: Patchy spots of desquamation and erythema, chronic stasis
lesions in both lower extremities
NEURO: Alert, minimally verbal, responds no to every prompt,
able to move 4 extremities but not on command
DISCHARGE PHYSICAL EXAM:
VS: 98.2 97.4 70 98/48 18 98/2L
GENERAL: epicanthal folds, flat nasal bridge consistent with
known Down syndrome. NAD. pleasant. conversant, but speech is
hard to understand at times. answers yes/no questions.
HEENT: left eye with prominent ectropion (lower lid turned out),
leaving a beefy red palpepral conjunctiva exposed, lids with
some yellow crust, corneas clear, sclera anicteric, MMM,
oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: inspiratory crackles anteriorly; patient does not sit
forward to facilitate posterior exam
CV: Regular rate and rhythm, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly; 5x5 abdominal
wall wound clean and dressed
EXT: Warm, well perfused, weak pulses, no cyanosis, +1 edema
Skin: lower extremities with dark brown, verrucous, confluent
plaques concerning for elephantiasis nostras verrucosa; red
scaly plaques over bilateral arms and chest
NEURO: Alert, able to move 4 extremities but not on command
Pertinent Results:
Labs on admission:
___ 12:15AM BLOOD WBC-9.1 RBC-2.48* Hgb-7.5* Hct-23.5*
MCV-95# MCH-30.2 MCHC-31.9 RDW-20.8* Plt ___
___ 12:15AM BLOOD Neuts-72.5* ___ Monos-6.0 Eos-1.5
Baso-0.5
___ 12:15AM BLOOD ___ PTT-37.0* ___
___ 12:15AM BLOOD Plt ___
___ 12:15AM BLOOD Glucose-115* UreaN-62* Creat-1.0 Na-141
K-4.4 Cl-106 HCO3-26 AnGap-13
___ 12:15AM BLOOD ALT-9 AST-10 AlkPhos-44 TotBili-0.4
___ 12:15AM BLOOD cTropnT-<0.01 proBNP-137
___ 12:15AM BLOOD Lipase-16
___ 12:15AM BLOOD Albumin-2.3* Calcium-8.2* Phos-3.3
Mg-1.5*
___ 05:09AM BLOOD ___ Temp-36.7 O2 Flow-2 pO2-30*
pCO2-57* pH-7.37 calTCO2-34* Base XS-5 Intubat-NOT INTUBA
___ 12:31AM BLOOD Lactate-2.2*
Other notable labs:
___ 05:26AM BLOOD Lactate-0.9
___ 07:45PM BLOOD Lactate-5.6*
___ 10:02PM BLOOD Glucose-81 Lactate-6.3*
___ 01:14AM BLOOD Lactate-3.3*
___ 05:42AM BLOOD Glucose-85 Lactate-1.6
___ 01:19PM BLOOD Lactate-1.7
Labs on discharge:
___ 06:00AM BLOOD WBC-7.6 RBC-2.80* Hgb-8.8* Hct-27.6*
MCV-99* MCH-31.5 MCHC-32.0 RDW-20.3* Plt ___
___ 05:01AM BLOOD Neuts-74.4* ___ Monos-4.7 Eos-1.6
Baso-0.6
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-32.4 ___
___ 06:00AM BLOOD Glucose-85 UreaN-12 Creat-0.9 Na-143
K-3.4 Cl-109* HCO3-29 AnGap-8
___ 06:00AM BLOOD Calcium-7.4* Phos-4.1 Mg-2.0
Microbiology:
___ 8:57 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ <=2 S 4 S
AMPICILLIN/SULBACTAM-- <=2 S 4 S
CEFAZOLIN------------- <=4 S 16 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
___ 5:01 am SEROLOGY/BLOOD CHEM S# ___.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
___ 7:32 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Imaging and studies:
EGD report, excerpt: Two cratered non-bleeding 10 mm ulcers were
found in the duodenal bulb. There was no high risk stigmata of
bleeding requiring endoscopic intervention.
Impression: ___- esophagus was seen.
Medium hiatal hernia
Ulcer in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
CXR ___:
Cardiomediastinal contours are unchanged. Mild to moderate
pulmonary edema has worsened. Small to moderate right and small
left effusions have increased. Multiple calcified lymph nodes
and granulomas are again noted.
ECG ___: Sinus rhythm. Narrow, likely insignificant, inferior Q
waves. Compared to the previous tracing the rhythm appears to be
sinus.
Brief Hospital Course:
Hospital course: Mr. ___ is a ___ year-old male with a
history of Down's sydrome, CAD, HFrEF (50%), PE on warfarin, and
recurrent small bowel obstruction transfered from ___ for
evaluation of melena. He was admitted to the MICU and found to
have 2 nonbleeding duodenal ulcers, H.pylori positive, and an
E.coli and proteus UTI. He will be discharged on H.pylori
treatment and off on any anticoagulation pending follow up with
PCP.
Active issues:
#UGIB: Presenting with melena and found to have 2 nonbleeding
duodenal ulcers, H.pylori positive on EGD. Treated with received
2 units rRBCs total in the MICU, and transfered to medicine
where treatment with clarithromycin, amoxicillin and PPI were
continued.
#HX OF PE ON WARFARIN: Given recent bleeding, risk of continuing
anticoagulation outweights potential benefit, and per discussion
with his PCP, he was discharged off of anticoagulation with
plans for outpatient follow up and reconsideration of this
issue.
#Complicated UTI: Patient with a history of hypotension in the
MICU, and his infectious work up was positive for E.coli >100K
after a foley had been placed, for which he was treated with
cefepime. Sensitivities notable for amp-sensitivity, which had
fortuitous overlap with his H.pylori treatment of amoxicillin,
which will cover a two week course for UTI as well.
#HYPOXIA: Most likely secondary to fibrocalcific disease as a
sequelae of TB. Per his PCP, patient with 2L NC baseline o2
requirement at night. He was treated with suplemental O2 to SpO2
90% and Albuterol/Ipratropium nebs prn
#ABDOMINAL WOUND: Clean & dressed. He was seen by acute care
surgery and found to be healing well.
#CONJUNCTIVITIS: Patient with prominent ectropion of the left
eye. Bilateral lids with crusting and conjunctival injection. He
was treated with erythromycin 1 drop tid both eyes, artificial
tears qid. For his ectropion, outpatient follow up was arranged,
for consideration of surgical management of ectropion to protect
the ocular surface
#Elephantiasis nostras verrucosa: Patient with dark brown,
verrucous, confluent plaques suggestive of lymphatic
obstruction. He was treated with: elevate legs when sitting;
compression stockings; aquaphor for moisturization; clotrimazole
for tinea superinfection
Chronic issues:
#HYPOTHYROIDISM: He was treated with levothyroxine
#CHF: Not decompensated at this time given CXR w/o edema and
normal proBNP
#CAD: Some non-specific EKG changes in setting of anemia and
negative TnT. Aspirin was continued.
Transitional issues:
-He was started on a PPI, clarithromycin, and amoxicillin for
H.pylori (day 1: ___ for total 14 day course. He may benefit
from continuing PPI course after completion of H.pylori regimen.
-E.coli and proteus UTI sensitive to amoxicillin and will be
covered with his H.pylori treatment
-His coumadin was held on discharge after discussion with his
PCP with plans for reinstatement at her discretion
-Prednisone discontinued given GI bleed
-Ophthalmology follow up was scheduled for evaluation of
ectropion
-Home O2 as needed per outpatient providers
-___ on discharge: 8.8/27.6
CODE: Full (confirmed with guardian)
COMMUNICATION: Patient and
EMERGENCY CONTACT HCP: HCP ___ ___ ___
(___ at ___ home) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. vitamin A and D one layer topical QAM
2. Aspirin 81 mg PO DAILY
3. Chloraseptic Throat Spray 1 SPRY PO Q8H:PRN sore throat
4. Warfarin 2.5 mg PO DAILY16
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob
6. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE TID
7. Hydrocortisone Cream 1% 1 Appl TP BID:PRN skin rash
8. Levoxyl (levothyroxine) 125 mcg oral QAM
9. nystatin 100,000 unit/gram topical BID abdominal folds
10. PredniSONE 5 mg PO EVERY OTHER DAY
11. protein 1 scoop oral TID
12. Vitamin D 50,000 UNIT PO 2X/WEEK (MO,TH)
13. Gabapentin 300 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Chloraseptic Throat Spray 1 SPRY PO Q8H:PRN sore throat
3. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
4. Gabapentin 300 mg PO QHS
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob
6. Vitamin D 50,000 UNIT PO 2X/WEEK (MO,TH)
7. Amoxicillin 1000 mg PO Q12H
RX *amoxicillin 500 mg 2 capsule(s) by mouth twice a day Disp
#*48 Capsule Refills:*0
8. Aquaphor Ointment 1 Appl TP BID
RX *white petrolatum [Hydrolatum] apply thinly to lower legs
twice a day Refills:*0
9. Artificial Tears Preserv. Free ___ DROP BOTH EYES QID
RX *artificial tears(hypromellose) 0.4 % ___ drops both eyes
four times a day Refills:*0
10. Clarithromycin 500 mg PO Q12H
RX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day Disp
#*24 Tablet Refills:*0
11. Clotrimazole Cream 1 Appl TP BID
RX *clotrimazole 1 % apply thinly to both hands and feet twice a
day Refills:*0
12. Levoxyl (levothyroxine) 125 mcg oral QAM
13. nystatin 100,000 unit/gram topical BID abdominal folds
14. protein 1 scoop oral TID
15. vitamin A and D 0 layer TOPICAL QAM
16. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary diagnoses:
Upper GI bleeding - duodenal ulcers
H.pylori
E.coli and proteus UTI
Secondary diagnoses:
Down syndrome
History of PE on coumadin
Type 2 diabetes
Ectropion - left eye
Elephantiasis nostras verrucosa
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with dark stool. We found that this was due to
an ulcer in your small intestine, possibly associated with
H.pylori infection. You were discharged on medicines to block
acid and treat the infection. You were also found to have a
urinary tract infection. Your coumadin was stopped until you
follow up with your primary care doctor next week.
Best wishes,
Your ___ Medicine Team
Followup Instructions:
___
|
10337941-DS-10 | 10,337,941 | 27,173,167 | DS | 10 | 2125-10-14 00:00:00 | 2125-10-15 07:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with osteoporosis and recently diagnosed osteoarthritis of
hips who presents with hip pain R > L. She describes bilateral
hip pain starting 5 days ago, worse with weight bearing and
active motion. Can't say if it feels muscular or skeletal.
Non-radiating. No F/C, weight loss, N/V/D, dysuria. She was seen
by her PCP ___, who took Xrays that were c/w osteoarthritis,
also with incompletely evaluated lucencies in the proximal
femoral shafts b/l and in the L femoral head and neck. She was
given Percocet and tramadol with some control of her pain. She
was able to return to her job as a ___ on ___ (her job
requires standing ~7 hrs a ___. She awoke on ___ unable to
get out of bed due to increased pain.
.
In the ED initial vitals were: 98.7, 90, 153/70, 16, 99% RA. She
received morphine and Toradol without relief and was initially
unable to ambulate. She was admitted for pain control and
consideration of additional workup.
On the floor, she received oxycodone/acetaminophen and says her
pain is markedly improved. She is able to ambulate a few steps
with assistance, although her provokes pain.
ROS: 10-point ROS negative except as mentioned above in HPI
Past Medical History:
Osteoporosis
Osteoarthritis
Hypertension
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no tenderness to palpation over greater trochanters
bilaterally. Full ROM of hip on left without pain, including
flexion, extension, internal and external rotation. Able to walk
in a few halting steps with assistance, antalgic gait.
PULSES: 2+ DP pulses bilaterally
NEURO: Face symmetric ___ strength in lower extremities
bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL
Vitals - 98.3, 98, 120/70, 75, 16, 100% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no tenderness to palpation over greater trochanters
bilaterally. Full ROM of hip on left without pain, including
flexion, extension, internal and external rotation.
PULSES: 2+ DP pulses bilaterally
NEURO: Face symmetric ___ strength in lower extremities
bilaterally, able to walk without pain or support.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
==============
___ 07:05AM GLUCOSE-101* UREA N-23* CREAT-0.8 SODIUM-139
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-34* ANION GAP-13
___ 07:05AM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-2.0
___ 07:05AM WBC-10.1 RBC-4.14* HGB-12.3 HCT-37.3 MCV-90
MCH-29.6 MCHC-32.8 RDW-13.2
___ 07:05AM PLT COUNT-200
___ 07:05AM ___ PTT-24.9* ___
___ 07:05AM SED RATE-83*
___ 07:05AM CRP-116.7*
.
IMAGING:
=========
Knee Xray ___:
RIGHT KNEE: No fracture or lipohemarthrosis identified. There is
moderate
osteoarthritis, with moderate narrowing of the medial
femorotibial compartment and tricompartmental spurs. No
suspicious lytic or sclerotic lesion detected. Small joint
effusion. NO definite chondrocalcinosis.
LEFT KNEE: No fracture or lipohemarthrosis identified. There is
mild-to-moderate osteoarthritis, with mild-to-moderate narrowing
of the femorotibial compartment and tricompartmental spurs. No
suspicious lytic
or sclerotic lesion detected. Possible faint chondrocalcinosis
accounting for small density seen along the medial and lateral
edges of the knee. No joint effusion.
IMPRESSION: No fracture detected in either knee. Bilateral
osteoarthritis,
worse on the right. Probable chondrocalcinosis on left side.
,
Hip Xray ___:
There is no fracture or dislocation. Mild joint space narrowing
and osteophytosis is noted in both hip joints. There are also
subchondral cysts bilaterally, likely degenerative. The SI
joints and pubic symphysis are intact. The sacrum is obscured
by a non-obstructive bowel gas pattern.
.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
Ms. ___ is a ___ year old woman with recently diagnosed
osteoarthritis of the hip who presented with 2 weeks of hip pain
worsening acutely over the last two days. She had bilateral hip
pain R>L that prevented her from getting out of bed the ___
prior to admission. Her pain improved markedly on standing
Tylenol, not requiring any narcotics. Hip and knee xrays
demonstrated known OA but were negative for fracture or
lytic/blastic lesions. ESR was 83, CRP 117, however there was no
clinical concern for osteomyelitis or other
infectious/inflammatory process given that her pain rapidly
improved on Tylenol and abscense of fevers/ other systemic
symptoms. She was able to ambulate with a walker at discharge.
She may benefit from evaluation for hip intra-articular
corticosteroid injections in the future.
ACTIVE ISSUES
# Hip OA: Likely ___ known osteoarthritis although acute is
somewhat unusual. Hip and knee Xrays were negative for fracture
or lytic/blastic lesions. Pt reported subtantially improved pain
soon after ___ admitted to the floor and was able to walk
unasisted with physical therapy. Although inflammatory markers
were elevated (ESR 83 and CRP 117) we had a low suspicion for an
inflammatory/infectious process given that she improved so
quickly and was afebrile with good ROM. At discharge, she can
tolerate walking, though with pain, making an occult fracture is
unlikely. Pain was controlled on acetaminophen. Pt may benefit
from intrarticular corticosteroid injections for hip OA. She
will also get home safety evaluation and home ___ evaluation. We
also provided her with a phone number to schedule an appointment
with a ___ orthopedist.
We explained that this was likely OA to the family and the
patient and provided her with a copy of her lab results to take
home.
CHRONIC ISSUES
# Hypertension: Continued home chlorthalidone
# Osteoporosis: Continued home alendronate, dose ordered but not
given on ___.
TRANSITIONAL ISSUES
- Code: Full code
- Emergency Contact: Daughter, ___ ___
- Results pending at discharge: none
- Pt has been provided phone number for ___ orthopedics if she
wishes to pursue hip steroid injections.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
2. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
3. Alendronate Sodium 70 mg PO QMON
4. Chlorthalidone 25 mg PO DAILY
Discharge Medications:
1. Chlorthalidone 25 mg PO DAILY
2. Acetaminophen 650 mg PO Q8H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 8 hours Disp
#*180 Tablet Refills:*0
3. Naproxen 500 mg PO Q8H:PRN hip pain
Take with food
RX *naproxen [Naprosyn] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*45 Tablet Refills:*0
4. Alendronate Sodium 70 mg PO QMON
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Outpatient Physical Therapy
Lower extremity strengthing for osteoarthritis of the hip ICD-___
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hip osteoarthritis
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for hip pain. We took Xrays of your
hips and knees and fortunately we saw no sign of a broken hip or
other concerning problems. You do have osteoarthritis of your
hip, which is the most likely cause of the pain. We gave you
tylenol for your pain. We would suggets that you follow up with
an orthopedist for consideration of steroid injections into your
hip joint if you have ongoing pain (see below). We would also
like you to follow up with your primary care doctor.
We wish you all the best!
Sincerely,
The ___ Team
Followup Instructions:
___
|
10337961-DS-13 | 10,337,961 | 26,061,931 | DS | 13 | 2118-11-04 00:00:00 | 2118-11-04 20:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
allopurinol
Attending: ___.
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy ___
Bone marrow biopsy ___
Bone marrow biopsy ___
Lymph node biopsy on ___
attach
Pertinent Results:
Admission Labs
==============
___ 08:55AM BLOOD WBC-4.3 RBC-2.20* Hgb-7.0* Hct-22.3*
MCV-101* MCH-31.8 MCHC-31.4* RDW-17.3* RDWSD-59.2* Plt Ct-41*
___ 08:55AM BLOOD Neuts-0* Bands-0 ___ Monos-1*
Eos-0* Baso-0 Atyps-6* ___ Myelos-0 Other-74* AbsNeut-0.00*
AbsLymp-1.08* AbsMono-0.04* AbsEos-0.00* AbsBaso-0.00*
___ 08:55AM BLOOD Plt Smr-VERY LOW* Plt Ct-41*
___ 08:56PM BLOOD ___ 08:45PM BLOOD Ret Aut-1.1 Abs Ret-0.02
___ 08:55AM BLOOD UreaN-12 Creat-1.0 Na-141 K-4.8 Cl-104
HCO3-23 AnGap-14
___ 08:45PM BLOOD ALT-9 AST-14 LD(LDH)-326* AlkPhos-63
TotBili-0.6
___ 06:26PM BLOOD Calcium-7.7* Phos-3.7 Mg-2.1 UricAcd-3.6
___ 08:45PM BLOOD calTIBC-248* ___ Ferritn-527*
TRF-191*
___ 08:55AM BLOOD %HbA1c-7.1* eAG-157*
___ 08:55AM BLOOD Triglyc-63 HDL-31* CHOL/HD-3.5 LDLcalc-64
___ 08:55AM BLOOD TSH-20*
___ 06:26PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
___ 04:00AM BLOOD HIV Ab-NEG
___ 06:26PM BLOOD HCV Ab-NEG
___ 06:28PM BLOOD Lactate-0.7
Pertinent Labs
==============
___ 11:40PM BLOOD HBV VL-NOT DETECT
___ 06:26PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
___ 04:00AM BLOOD HIV Ab-NEG
___ 12:00AM BLOOD CRP-126.8*
___ 08:55AM BLOOD TSH-20*
___ 01:20PM BLOOD TSH-6.8*
___ 08:55AM BLOOD %HbA1c-7.1* eAG-157*
___ 05:10AM BLOOD ALT-17 AST-14 LD(LDH)-171 AlkPhos-133*
TotBili-3.3*
___ 06:03AM BLOOD ALT-16 AST-14 LD(LDH)-186 AlkPhos-103
TotBili-2.1* DirBili-1.6* IndBili-0.5
___ 05:52AM BLOOD ALT-13 AST-14 LD(___)-158 AlkPhos-117
TotBili-1.8* DirBili-1.2* IndBili-0.6
___ 05:48AM BLOOD ALT-11 AST-9 LD(___)-155 AlkPhos-126
TotBili-2.0* DirBili-1.5* IndBili-0.5
___ 06:04AM BLOOD ALT-11 AST-8 LD(___)-143 AlkPhos-120
TotBili-1.6* DirBili-1.2* IndBili-0.4
___ 06:12AM BLOOD ALT-13 AST-10 LD(___)-145 AlkPhos-134*
TotBili-1.9* DirBili-1.4* IndBili-0.5
___ 06:03AM BLOOD ALT-13 AST-10 LD(___)-191 AlkPhos-106
TotBili-2.1* DirBili-1.5* IndBili-0.6
___ 05:25AM BLOOD ALT-13 AST-9 LD(___)-155 AlkPhos-106
TotBili-1.9* DirBili-1.4* IndBili-0.5
___ 12:06AM BLOOD proBNP-1234*
___ 06:00AM BLOOD Albumin-2.3* Calcium-7.2* Phos-2.8 Mg-1.9
UricAcd-6.1
___ 06:03AM BLOOD ___ 08:45PM BLOOD calTIBC-248* ___ Ferritn-527*
TRF-191*
___ 01:20PM BLOOD PTH-14*
___ 12:01AM BLOOD 25VitD-49
Discharge Labs
==============
___ 06:00AM BLOOD WBC-2.1* RBC-2.64* Hgb-7.6* Hct-23.0*
MCV-87 MCH-28.8 MCHC-33.0 RDW-14.2 RDWSD-44.1 Plt Ct-33*
___ 06:00AM BLOOD Neuts-71 Bands-8* Lymphs-13* Monos-4*
Eos-2 Baso-0 Atyps-2* AbsNeut-1.66 AbsLymp-0.32* AbsMono-0.08*
AbsEos-0.04 AbsBaso-0.00*
___ 06:00AM BLOOD ___ PTT-35.1 ___
___ 06:00AM BLOOD ___ 05:48AM BLOOD WBC-2.0* Lymph-11* Abs ___ CD3%-85
Abs CD3-188* CD4%-36 Abs CD4-79* CD8%-45 Abs CD8-99*
CD4/CD8-0.79*
___ 06:00AM BLOOD Glucose-124* UreaN-14 Creat-0.9 Na-137
K-4.0 Cl-104 HCO3-21* AnGap-12
___ 06:00AM BLOOD ALT-16 AST-15 LD(LDH)-165 AlkPhos-127
TotBili-3.1*
Relevant Studies
================
___ MRI ABDOMEN W/WO CONTRAST
1. Numerous hepatic abscesses as described above.
Differentiation between TB versus fungal etiology would be
difficult on imaging basis, however in the setting of known
pulmonary TB, TB should be favored.
2. Mild hemosiderosis.
___ CT CHEST W/O CONTRAST
1. A previously seen 5 mm nodule in the left lower lobe isn't
definitely seen, however evaluation of this region is slightly
limited by respiratory motion. Otherwise no significant change
in diffuse bilateral micro nodules compatible with miliary
tuberculosis.
2. Interval slight improvement in mediastinal and hilar
lymphadenopathy. A hypoenhancing right supraclavicular lymph
node is not significantly changed.
3. Previously seen right pleural effusion has resolved.
4. Multiple hyperenhancing foci throughout both lobes of the
liver measuring up to 2.4 cm were not previously seen, however
are incompletely characterized.
Dedicated multiphasic CT abdomen is recommended.
RECOMMENDATION(S): Multiphasic CT abdomen.
___ LIVER GALL BLADDER U/S
1. The liver parenchyma is within normal limits, no evidence of
focal hepatic
lesions.
2. Cholelithiasis without evidence of acute cholecystitis.
3. No sonographic evidence of choledocholithiasis.
___ MYELOID SEQUENCING
Review of the accompanying requisition indicates acute
myeloblastic leukemia. Sufficient DNA was present for molecular
analysis and all quality control metrics were met. No mutations
were detected by next generation sequencing
targeting the genomic regions summarized in the NGS Gene Table.
In particular, no mutations were detected in NPM1,
FLT3, CALR, CEBPA, DNMT3A, JAK2, IDH1, IDH2 and other genes that
are listed in the ___ guidelines for MPN, MDS
and AML
___ BONE MARROW BX
PATH
MARKEDLY HYPOCELLULAR BONE MARROW ASPIRATES WITH VERY SCANT
HEMATOPOIESIS AND NO EVIDENCE OF INVOLVEMENT BY ACUTE MYELOID
LEUKEMIA
CYTOGENETIC DIAGNOSIS: 46,XY[2] Normal male karyotype
FLOW
Diagnostic immunophenotypic features of involvement by leukemia
are not seen in this specimen.
___ CT Chest w/ Contrast
IMPRESSION:
Constellation of findings are consistent with active miliary
tuberculosis including diffusely distributed bilateral micro
nodules and central mediastinal peripherally enhancing enlarged
lymph nodes.
Substantially decreased bilateral right pleural effusion, and
complete resolution of the left pleural effusion.
___ Ultrasound Neck
IMPRESSION:
In the right supraclavicular region is an avascular echogenic
fluid collection
which may reflect an inflamed hair follicle, furuncle or
deflated epithelial
inclusion cyst. No evidence of retained foreign body.
___ Lymph Node Biopsy: +AFBs, with negative 16S PCR,
confirmed as M. tuberculosis by MALDI-TOF at the ___ lab.
___ PET-CT
1. Extensive FDG avid supraclavicular, mediastinal and right
hilar
lymphadenopathy in a pattern consistent with lymphoma. 2.
Bilateral pleural effusions are slightly smaller from prior with
associated compressive atelectasis. A small pericardial
effusion is unchanged. 3. No abnormal FDG uptake within the
abdomen or pelvis.
___ Pleural Fluid: negative for malignant cells: reactive
mesothelial cells, histiocytes, small lymphocytes and
neutrophils.
Bone Marrow biopsy Hematopathology ___
NORMOCELLULAR BONE MARROW WITH MATURING TRILINEAGE
HEMATOPOIESIS. NO
EVIDENCE OF INVOLVEMENT BY ACUTE MYELOID LEUKEMIA. MONOCYTOSIS
IS NOTED.
Bone Marrow Biopsy Flow Cytometry ___
RESULTS:
10-color analysis with CD45 vs. side-scatter gating is used to
evaluate for leukemia. Approximately 98% of total acquired
events are evaluable non-debris events. The viability of the
analyzed non-debris events, done by 7-AAD is 90%. CD45-bright,
low side-scatter gated lymphocytes comprise 5% of total analyzed
events. No abnormal events are identified in the blast gate.
Bone Marrow Biopsy ___
1) FISH: NEGATIVE for MYC REARRANGEMENT. No evidence of
interphase bone marrow cells with amplification of the MYC gene
that was observed in bone marrow collected on ___.
2) FISH: NEGATIVE for TETRASOMY 4. No evidence of interphase
bone marrow cells with four intact PDGFRA probe signals due to 4
copies of chromosome 4 that were observed in bone marrow
collected on ___.
Immunophenotyping ___:
RESULTS:
10-color analysis with CD45 vs. side-scatter gating is used to
evaluate for leukemia/lymphoma. Approximately 97.8% of total
acquired events are evaluable non-debris events. The viability
of the analyzed non-debris events done by 7-AAD is 99.3%.
CD45-bright, low side-scatter gated lymphocytes comprise 15.7%
of total analyzed events. B cells comprise 5.4% of lymphoid
gated events, are polyclonal and do not co-express aberrant
antigens. T cells comprise 85.7% of lymphoid gated events and
express mature lineage antigens (CD3, CD5, CD2, and CD7). A
minor subset (11.5%) of T cells shows dim/variable loss of CD7
(nonspecific finding). T cells have a CD4:CD8 ratio of 2.5
(usual range in blood 0.7-3.0). There is a population of
double-negative (CD4 negative/CD8 negative) T cells comprising
3.1% of CD3 positive cells. Approximately 9.5% of CD3 positive T
cells co-express CD56. CD56 positive, CD3 negative natural
killer cells represent 4.4% of gated lymphocytes and are
decreased in number (usual range in blood ___. They
co-express CD2, CD7 and CD8 (subset). Cell maker analysis
demonstrates that the majority (81.5%) of the cells isolated
from this peripheral blood are in the CD45-dim/low side-scatter
blast region. They co-express CD34, ___, CD117, CD64
(subset), CD38, CD33, CD13, CD11c (dim, subset), CD7 (major
subset) and cMPO and are negative for CD2, CD3, CD4, CD5, CD8,
CD10, CD14, CD16, CD19, CD20, CD23, CD56, cCD11b, cCD22, cCD3,
cCD79A, and nTdT. Blast cells comprise 81.5% of total analyzed
events. Please correlate with the peripheral blood smear
differential for a definitive blast count. Flow cytometry blast
counts may differ from smear blast counts due to hemodilution,
artifact of preparation and other factors.
ECHO ___
Volumetric left ventricular ejection fraction is 59 % (normal
54-73%)
CT ___
IMPRESSION:
1. No evidence of focal consolidation to suggest infection.
2. Pulmonary edema with small bilateral pleural effusions.
3. Bilateral perifissural pulmonary nodules measuring 6 mm,
follow-up is
recommended per the ___ criteria as detailed below.
BMBx ___
INVOLVEMENT BY ACUTE MYELOID LEUKEMIA, SEE NOTE.
Note: The peripheral blood film shows pancytopenia with 63%
circulating blasts. The blasts are intermediate to large in size
with scant amounts of cytoplasm, slightly irregular nuclear
contours, open chromatin, and variably prominent nucleoli. A
minor subset of blasts display cytoplasmic granulation, however,
Auer rods are not observed. The bone marrow aspirate
shows 72% blasts with similar morphologic findings. The bone
marrow core biopsy is suboptimal for evaluation, however, a
discrete population of immature mononuclear cells compatible
with blasts are present and comprise the vast majority of the
cellularity. By immunohistochemistry, the core biopsy shows that
90% of the evaluable marrow cellularity is
occupied by blasts that coexpress CD34 and CD117. CD138
highlights scattered plasma cells comprising 5% of the overall
cellularity. By kappa and lambda light chain immunostaining,
clonality cannot be assessed due to a paucity of plasma cells as
well as high background staining. By flow cytometric analysis
performed on the peripheral blood (see separate
pathology report ___ for full details), blasts comprise
approximately 81% of events and display a myeloid
immunophenotype. Flow cytometry performed on the bone marrow
aspirate shows that evaluable plasma cells are polytypic in
nature (see separate pathology report
___ for full details). Cytogenetic analysis primarily
demonstrates CMYC amplification in the form of ___
double-minute chromosomes per cell and tetrasomy 12 (see
separate cytogenetics reports ___ and ___ for full
details). CMYC amplification is rare in acute myeloid leukemia
but know to occur in a minor subset with poor prognosis.
Overall, and in the context of the morphologic and
immunophenotypic features present, the findings are of an acute
myeloid leukemia. Correlation with clinical, laboratory, and
molecular
diagnostic findings is recommended.
___
CYTOGENETIC DIAGNOSIS: 49,XY,+4,+4,+21,2~10dmin[20]
INTERPRETATION/COMMENT: Every metaphase bone marrow cell
examined had an abnormal karyotype with tetrasomy 4, trisomy 21
and double minutes that FISH has confirmed have resulted in
amplification of the MYC gene (see FISH below). These findings
were observed in peripheral blood
collected on ___ and are consistent with acute myeloid
leukemia with an unfavorable prognosis. FISH: POSITIVE for MYC
AMPLIFICATION. 87% of the interphase bone marrow cells examined
had abnormal probe signal patterns consistent with amplification
of the MYC gene that were observed in peripheral blood collected
on ___.
MICROBIOLOGY
=================
___ 2:45 pm TISSUE
SOURCE: CERVICAL LYMPH NODE ADDED PER REQUESTION,
___.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Final ___:
Reported to and read back by ___ (___) @
14:30,
___.
Reported to and read back by ___ @
___.
MYCOBACTERIUM TUBERCULOSIS COMPLEX.
Identified by ___ Laboratory ,REPORT DATE:
___.
Reported to and read back by ___ @ 15:30,
___.
Reported to and read back by ___ @ 16:30,
___.
.
INTERIM MOLECULAR REPORT RECEVIED FROM "CDC", REPORT
DATE:
___.
Please see results in the "reports" tab under
"Pathology" in OMR..
FINAL CDC REPORT, PLEASE SEE RESULTS IN THE "REPORT"
TAB IN OMR,
REPORTED ___.
MYCOBACTERIA DRUG SUSCEPTIBILITY REPORT ___
(INDIRECT)
-DRUG- # OF COLONIES % OF POP. R/S
(AT 1%)
CONTROL 300 100
ISONIAZID 0.2 0 0
S
ISONIAZID 1.0 0 0
S
ISONIAZID 5.0 0 0
S
ETHAMBUTOL 5.0 0 0
S
STREPTOMYCIN 10.0 0 0
S
KANAMYCIN 5.0 0 0
S
PYRAZINAMIDE 100.0 0 0
S
CYCLOSERINE 30.0 0 0
S
CAPREOMYCIN 10.0 0 0
S
ETHIONAMIDE 5.0 0 0
S
RIFAMPIN 1.0 0 0
S
AMIKACIN 4.0 0 0
S
MOXIFLOXACIN 0.5 0 0
S
ALL OTHER BCX, UCX NEG
Brief Hospital Course:
PATIENT SUMMARY
===============
___ y/o ___ speaking man with hypothyroidism, presented to
PCP with fatigue, found to have thrombocytopenia & neutropenia
with bone marrow biopsy c/w acute myeloid leukemia. Flow and
biopsy results showed complex cytogenetics. Admitted to ___ for
treatment and initiated C1 Decitabine/Venetoclax on ___, C2 on
___. Course was complicated by febrile neutropenia, for which
Mr. ___ was treated with antibiotics. Had persistent daily
fevers and was found to have disseminated TB with lymphadenitis
of R supraclavicular node, R ocular granuloma, cutaneous leg
lesions, and suspicious hepatic lesions, though not
bx-confirmed. Started on RIPE (~3 wks at time of discharge).
Repeat D14 BMBx showed no disease. Pancytopenia c/b
malnutrition, and requiring 1U pRBCs per week and 1U plts every
___ days. Also had melena which resolved, but deferred
endoscopic eval given low counts. Will follow with 1* Oncologist
___.
TRANSITIONAL ISSUES
===================
[] AML
[] continue MWF visits to ___ clinic for transfusions; has
LUE PICC
[] will need repeat BMBx before next cycle of treatment
[] if receiving venetoclax again, will need to t/b with ID
for interactions with rifampin
[] needs to discuss GOC
[]IH pentamidine qmonth, last ___
[] Disseminated TB: will follow-up with ID in ___ clinic
[] Ocular TB: follow-up with Ophtho within 1 week
[] Hepatic lesions c/f TB: repeat MRI abdomen w/contrast in 2
weeks.
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
FOLLOW UP APPOINTMENTS: The ___ will schedule follow up
and
contact the patient or discharge facility. All questions
regarding outpatient parenteral antibiotics after discharge
should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
[] Melena: had in setting of thrombocytopenia. Needs GI
endoscopic w/u
[] Tbili is elevated 3.1 on discharge. Thought ___ sargramostim.
Should repeat
[] Incidental imaging: Bilateral perifissural pulmonary nodules
on CT. Will need follow-up in 3 to 6 months and in 18 to 24
months
[] Elevated A1C (7.1), consider repeat as an outpatient for
glycemic control
Code Status: Full
HCP: Son ___, ___
ACUTE ISSUES
============
#AML,
Presented to his PCP at ___ with several
weeks of malaise and fatigue. Had pancytopenia c/f acute
leukemia with complex karyotype, CEBPA+, FLT3-. HIV, HCV neg.
HBcAB+, started on entecavir, with neg VL. TTE normal. He was
found to have pancytopenia with immature WBCs on review of
peripheral smear, concerning for acute leukemia. Initiated
decitabine/venetoclax ___. BMBx ___ with <
1% blasts. Venetoclax held given continued pancytopenia.
Requiring 1U pRBCs per week and 1U plts every ___ days.
- On ppx acyclovir, entecavir. Stopped ___ d/t recovery of
counts.
#Lymphopenia
For PJP ppx, on IH pentamidine, ___. Should be monthly.
Avoiding Bactrim, dapsone d/t counts and atovaquone d/t
interaction with rifampin.
#Thrombocytopenia
#Anemia
___ venetoclax and AoCD, malnutrition. Transfused for plts <10
and Hg <7, except when having melena. Had vit B12 shots x 5
days. Zinc, copper supplemented.
- Neupogen 300mcg ___ daily
- sargramostim 325mcg (250mcg/m2)daily ___
- s/p pRBCs 1U ___, 1U ___, 2U ___, 1U ___, 1U ___, 1U
___
- s/p plts 1U ___, 2U ___, 3U ___, 1U ___, 1U ___, 1U
___, 1U ___, 1U ___, 1U ___, 1U ___, 1U ___, 1U
___, 1U ___, 1U ___, 1U ___, 1U ___
#Febrile neutropenia
#Fever of unknown origin
#Disseminated TB
Upon arrival to the floor, patient was persistently febrile for
> 24 hours with no source. Had persistent fevers. CT torso had
pleural effusions. ___ on ___ showed no evidence of
infection, with ___ below TB levels. Repeat PET-CT ___ showed
avid supraclavicular, mediastinal, hilar LAD. Bx of
supraclavicular LN showed +AFBs. ___ coccidioides Ab were +
and started on posaconazole for treatment. CT ___ showed
miliary lung disease. Sputum Cx were neg x 7 for AFB. Started
RIPE + levaquin + ___. Repeat CT chest ___ with stable
disease and decrease in LN size. Final susceptibilities from CDC
had no resistance, and regimen decreased to RIPE + B6 for
discharge, for induction for at least 2 months. MRI abdomen ___
showed ~ 10 x 1cm abscesses, c/f TB. None are large enough to be
aspirated or visualized on U/S. Will re-eval in ___ clinic.
MDPH notified, he should only reside with previously exposed
people, with no infants in the home. No other airborne
precautions needed.
- TB treatment (D1: ___- )
-Rifampin 10mg/kg = 450mg PO daily
-Isoniazid (5 mg/kg) 200 mg PO daily
-Pyridoxine (B6) 50 mg PO daily
-Pyrazinamide 1000 mg PO daily
-Ethambutol (20 mg/kg) 800 mg daily
# Ocular/Cutaneous TB
Patient has white/yellow retinal lesions which are c/f
presumptive choroidal tuberculomas. He also has skin findings
that are c/f cutaneous manifestation of TB. Lesions improved
with TB treatment. Last eye exam ___. Should have monthly eye
exams.
# Nausea
Related to TB meds. Should take meds on full stomach. Zofran,
compazine PO effective and as pre-meds. Zyprexa 5mg daily
#Rash
Morbilliform drug eruption ___, confirmed by skin bx. Treated
with 60mg solumedrol x 5 days. Thought ___ to allopurinol.
#Epistaxis
Given Afrin, cold compresses, applied pressure.
#Malnutrition
Given dronabinol. Encouraged PO intake. Had NGT placed for 2
days but did not tolerate well d/t pain.
CHRONIC/STABLE
==============
#Hypothyroidism
Mr. ___ was last seen in ___ over year
ago, and was at the time prescribed Levothyroxine. He has not
taken the medication in over a year. Prescription was last
filled in ___. TSH was 20 on admission, and the patient was
treated with Levothyroxine 25mcg daily while inpatient.
#H/o C. diff PCR+
C. diff PCR+, toxin neg. Colonized
- continue GI contact precautiosns
# C/f thrush
Oropharynx now clear
- nystatin PO ___
#Hyperglycemia
Mr. ___ was found to have an elevated A1c on admission, with a
glucose of 250. He was initially placed on a sliding scale for
likely pre-diabetes, but sugars were all within normal limits
for the first 48 hours of admission. The patient also noted
annoyance with frequent finger sticks, and sliding scale and
finger sticks were thus discontinued. Repeat A1c should be
checked as an outpatient.
#Tobacco Use
Patient smokes one pack per day. He continued on nicotine patch
while inpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Calcium Carbonate 1000 mg PO BID
3. Dronabinol 5 mg PO BID
RX *dronabinol 5 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
4. Entecavir 0.5 mg PO Q48H
5. Ethambutol HCl 800 mg PO DAILY
6. Famotidine 20 mg PO Q12H
7. Isoniazid ___ mg PO DAILY
8. Levothyroxine Sodium 25 mcg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Nicotine Patch 14 mg/day TD DAILY
11. OLANZapine 5 mg PO DAILY
12. Ondansetron 4 mg PO Q6H:PRN Nausea/Vomiting - First Line
please take ___ minutes before taking your antibiotics
13. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
14. Pyrazinamide 1000 mg PO DAILY
15. Pyridoxine 50 mg PO DAILY
16. RifAMPin 450 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Acute Myeloid Leukemia
Febrile Neutropenia
Fever of unknown origin
Mycobacterium tuberculosis
SECONDARY
=========
Upper GI bleed
Hypothyroidism
Hyperbilirubinemia, direct
Nausea
Drug eruption
Thrombocytopenia
Pancytopenia
Epistaxis
Tobacco Use
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___!
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital to begin chemotherapy for
treatment of your acute myeloid leukemia.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You underwent a bone marrow biopsy which confirmed your
diagnosis of acute myeloid leukemia.
- You were started on chemotherapy on ___ with Decitabine and
Venetoclax. You tolerated these medications well.
- You were treated with antibiotics for your fevers, since your
immune system was low due to both the cancer and chemotherapy.
- You had a repeat bone marrow biopsy which showed no leukemia
activity in the bone marrow.
- Extensive workup for fever revealed your diagnosis of
mycobacterium tuberculosis. You were treated with medications.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all your medications as prescribed.
- Please follow-up with your doctor on as noted in your
discharge paperwork.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
10337985-DS-10 | 10,337,985 | 20,468,929 | DS | 10 | 2149-08-12 00:00:00 | 2149-08-19 19:37:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nephrolithiasis
Major Surgical or Invasive Procedure:
NONE during this admission
History of Present Illness:
___ year old male with history of uric stone formation presenting
with an obstructing 4mm left distal ureteral stone with evidence
of ___. His pain is well controlled at this time. ___ possibly
explained by resorption of urine creatinine from calyceal
rupture, however cannot definitively say at this time. We will
plan to admit the patient for IV hydration and
observation. We will consider stent vs. ureteroscopy tomorrow if
the patient feels unwell or his labs fail to improve.
Past Medical History:
Notable medical history includes FVL disease with history of
multiple DVTs. The patient takes coumadin daily with a goal INR
1.8-2.5 per report. He stopped taking his coumadin yesterday
when he noted blood in his urine. He is scheduled to stop taking
his coumadin late this week anyways in preparation for a
prostate biopsy with Dr. ___ week for elevated PSA.
Additionally, the patient takes Kcitrate daily for his uric acid
stone history
Problems (Last Verified ___ by ___, MD):
CROHN'S DISEASE
KIDNEY STONES
GOUT
FATTY LIVER
DEEP VENOUS THROMBOSIS
DEEP VEIN THROMBOSIS
DEEP VEIN THROMBOSIS
CHRONIC PANCREATITIS
S/P ILEAL RESECTION
Ureteroscopy at ___
Social History:
___
Family History:
non-contributory
Physical Exam:
gen: No acute distress, alert & oriented
HEENT: Extraocular movements intact, face symmetric
CHEST: Warm and well-perfused
BACK: Non-labored breathing, no CVA tenderness bilaterally
ABD: Soft, non-tender, non-distended, no guarding or rebound
EXT: Moves all extremities well
PSY: Appropriately interactive
Pertinent Results:
___ 06:50AM BLOOD WBC-7.6 RBC-4.72 Hgb-13.5* Hct-40.6
MCV-86 MCH-28.6 MCHC-33.3 RDW-13.5 RDWSD-42.2 Plt ___
___ 01:52AM BLOOD WBC-10.1* RBC-5.24 Hgb-14.7 Hct-44.7
MCV-85 MCH-28.1 MCHC-32.9 RDW-13.3 RDWSD-41.1 Plt ___
___ 01:52AM BLOOD Neuts-78.0* Lymphs-9.6* Monos-10.8
Eos-0.9* Baso-0.4 Im ___ AbsNeut-7.84* AbsLymp-0.97*
AbsMono-1.09* AbsEos-0.09 AbsBaso-0.04
___ 06:50AM BLOOD Glucose-104* UreaN-19 Creat-1.9* Na-140
K-4.4 Cl-105 HCO3-25 AnGap-10
___ 10:00AM BLOOD Glucose-100 UreaN-19 Creat-1.6* Na-140
K-4.7 Cl-108 HCO3-22 AnGap-10
___ 01:52AM BLOOD Glucose-108* UreaN-20 Creat-1.4* Na-139
K-4.4 Cl-104 HCO3-22 AnGap-13
___ 12:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ was admitted for observation as stated and with
improvement in pain and ___, was deferred for outpatient
management. At discharge on HD2, His pain was controlled with
oral pain medications, he was tolerating regular diet,
ambulating without assistance, and voiding without difficulty.
Mr. ___ was explicitly advised to follow up as directed
next ___ for a pre-arranged procedure and to continue
holding his warfarin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Potassium Citrate 10 mEq PO BID
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Cholestyramine 4 gm PO DAILY
4. Warfarin 2 mg PO DAILY16
5. Multivitamins 1 TAB PO DAILY
6. Cyanocobalamin 25 mcg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*0
3. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg ONE capsule(s) by mouth at bedtime Disp
#*30 Capsule Refills:*0
4. TraMADol 25 mg PO Q6H:PRN BREAKTHROUGH PAIN
RX *tramadol 50 mg HALF tab by mouth Q6hrs Disp #*10 Tablet
Refills:*0
5. Cholestyramine 4 gm PO DAILY
6. Cyanocobalamin 25 mcg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Potassium Citrate 10 mEq PO BID
10. Vitamin D 400 UNIT PO DAILY
11. HELD- Warfarin 2 mg PO DAILY16 This medication was held. Do
not restart Warfarin until cleared by Dr. ___ your
procedure next ___.Outpatient Lab Work
Return to the lab on ___, for blood work.
Discharge Disposition:
Home
Discharge Diagnosis:
obstructing 4mm left distal ureteral stone
acute kidney injury (creat to 1.9)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or,
if applicable to you, the indwelling ureteral stent. You may
also experience some pain associated with spasm of your ureter.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urinethis, as noted above, is expected and will gradually
improvecontinue to drink plenty of fluids to flush out your
urinary system
-Resume your pre-admission/home medications EXCEPT COUMADIN and
as noted.
-You should ALWAYS call to inform, review and discuss any
medication changes and your post-operative course with your
primary care doctor.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that may
be health care spending account reimbursable.
-Docusate sodium (Colace) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
Followup Instructions:
___
|
10338450-DS-7 | 10,338,450 | 26,912,153 | DS | 7 | 2125-08-16 00:00:00 | 2125-08-16 20:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / heparin
Attending: ___.
Chief Complaint:
R leg weakness
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
performed ___
NIHSS Total: 8 (some points due to previous stroke)
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 2
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 2
6b. Motor leg, right: 3
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 0
HPI:
___ with PMH with recent left anterior choroidal artery
territory
stroke ___ who presented to the ED from ___ neurology
clinic with 3 days of right leg paralysis concerning for stroke.
On ___ night, patient was walking up the stairs to her
apartment (on the ___ floor) and fell when she got to the top of
the stairs. She states she did not trip over anything, but just
fell. She has some residual weakness in her legs since her
previous stroke, which may have contributed. She was able to
pick
herself up and go on with her day. The next day (___), she
was suddenly unable to walk. Per outpatient notes she woke up
unable to walk, but she tells me that she was ok in the morning,
but later in the day suddenly became weaker in the R leg. She
was
unable to bear weight on the right leg, and had pain in her
right
foot where she may have sprained it. She went to urgent care,
where right foot and ankle x-ray showed possible widening of the
superior lateral ankle mortise and mild diffuse soft tissue
swelling around the ankle possibly related to ligamentous
injury.
She was given a right foot boot. Patient then made an
appointment
on ___ with her outpatient neurologist Dr. ___
(___).
For her stroke history from clinic notes, in ___, she
developed right leg weakness. She could lift her leg, had
trouble walking upstairs, and had to lift her right leg with her
hand to use the gas pedal. About a week after the onset of the
symptoms, she developed intermittent tingling in her bilateral
feet and lower legs. She went to ___ ED where head CT showed no
acute intracranial process. LP showed WBC ___ with lymphocyte
predominance, RBC 0, protein 25, glucose 63, culture negative.
She left AMA prior to admission for MRIs. She was seen in
neurology clinic ___, when exam showed dysarthria, right face
droop, upper motor neuron pattern of weakness in her right arm
and leg. Her outpatient neurologist recommended admission to
___, but she refused. Labs ___ were notable for ___
positive at 1:1280, anti-Ro positive at 80, CRP 80.3, ESR 27,
vitamin B12 237, folate 13.8, TSH 0.87, thiamine 105, syphilis
screen NR, HgA1c 5.4%, SPEP consistent with inflammation,
anti-La
negative. MRI brain with and without contrast ___ was
consistent with a subacute left anterior choroidal artery
territory infarct, and a demyelinating plaque was thought to be
less likely. Her outpatient neurologist was concerned about a
possible autoimmune/vasculitis cause of her stroke, and referred
her to rheumatology but she did not keep the appointment. She
was started on aspirin 81 mg daily and atorvastatin 80 mg.
Subsequent lab work for hypercoagulable workup including
cardiolipin antibody, lupus anticoagulant, beta-2 glycoprotein,
factor V Leiden, prothrombin gene, protein C and S, and
antithrombin III all negative/normal. TTE ___ showed LVEF
60%, no PFO/ASD.
Patient thinks that prior to her fall on ___, she thought she
was getting better. She was able to drive, shop, do laundry,
walk upstairs, clean off her car. She was walking independently
without walker or cane. She thinks that her dysarthria and the
numbness/tingling in her feet and lower legs are improved.
However, since ___, she has had to use a walker to get
around. On day of presentation, she was using a wheelchair.
Given patient's labs, Dr ___ was concerned about a possible
autoimmune or vasculitic cause of her stroke, possible
vasculitic
neuropathy affecting the right leg or possible spinal cord
abnormality. patient was initially instructed to go to ___
to
be admitted to neurology service for expedited work-up, but she
initially refused. Patient became argumentative and declined to
go. Neurologist called EMS to bring her to the hospital. While
admitted, the following were recommended: MRI brain, MRI spine,
vessel imaging of the head and neck, consider EMG for the right
leg weakness. Rheumatology consult for consideration of
steroids.
Past Medical History:
Uterine fibroid
Ovarian cyst
Left anterior choroidal artery stroke
Rosacea
Social History:
Patient is living with her mother. Works as an ___ at a ___ unit. Previously smoked half a pack of
cigarettes per day, but quit recently in ___.
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[x] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
No known family history of stroke, MS, or neuropathy
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
Vitals: T: 98.4 BP: 116/71 HR: 81 RR: 16 SaO2: 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, Able to relate history without difficulty
although somewhat tangential. Attentive, Language is fluent
with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Able to name both high and low frequency
objects. Able to read without difficulty. Mild dysarthria that
is been present since her last stroke. Able to describe cookie
picture. Able to follow both midline and appendicular commands.
-Cranial Nerves:
II, III, IV, VI: L pupil 4->2 R pupil 3->2 (baseline per
patient). EOMI without nystagmus. Normal saccades. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: R lower facial droop since her previous stroke
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline
-Motor: No pronator drift. No adventitious movements, such as
tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 3 5 5 5 5
R 5- 5 5 5 5 5 1 0 0 0 0
Patient states she feels tired and cannot lift her L leg up
against resistance.
-Sensory: No deficits to light touch, pinprick, vibration in
bilateral big toes. Decreased proprioception in R big toe.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach
L 2 2 2 2 1
R 2 2 3 3 1
Upgoing toe on R
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF bilaterally.
-Gait: deferred
DISCHARGE PHYSICAL EXAMINATION:
===============================
General: Awake, cooperative, NAD.
HEENT: MMM
CV: warm and well-perfused
Pulm: No increased WOB on room air
Abd: NT,ND +BS
Neurologic:
-Mental Status: Alert, Able to relate history without
difficulty.
Attentive. Normal prosody. Mild dysarthria. Able to follow both
midline and appendicular commands.
-Cranial Nerves: R lower facial droop since her previous
episode. Hearing intact to conversation
-Motor: No evidence of pronator drift.
[
D
e
l
___
L 5 5 5 5 5 4+ 3 2 ___ ___
R 5 5 5 5 5 4+ 0 0 0 0 1 1 0
0.
-Reflexes:
2 beats clonus on l, 1 on R. Upgoing toe on R and L.
-Gait: deferred
Pertinent Results:
ADMISSION LABS:
___ 02:30PM BLOOD WBC-7.5 RBC-4.65 Hgb-12.5 Hct-40.3 MCV-87
MCH-26.9 MCHC-31.0* RDW-13.7 RDWSD-43.2 Plt ___
___ 02:30PM BLOOD Neuts-66.9 Lymphs-16.6* Monos-9.7 Eos-5.7
Baso-0.7 Im ___ AbsNeut-5.03 AbsLymp-1.25 AbsMono-0.73
AbsEos-0.43 AbsBaso-0.05
___ 02:30PM BLOOD ___ PTT-30.7 ___
___ 02:30PM BLOOD Plt ___
___ 02:30PM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-136
K-3.8 Cl-101 HCO3-25 AnGap-10
___ 02:30PM BLOOD ALT-15 AST-30 AlkPhos-160* TotBili-0.4
___ 02:30PM BLOOD Lipase-38
___ 02:30PM BLOOD cTropnT-<0.01
___ 02:30PM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.7 Mg-2.2
___ 07:22AM BLOOD %HbA1c-4.9 eAG-94
___ 07:22AM BLOOD Triglyc-70 HDL-42 CHOL/HD-2.7 LDLcalc-56
PERTINENT LABS:
___ 06:55PM BLOOD Lupus-NOTDETECTE dRVVT-S-0.99 SCT-S-0.82
___ 06:55PM BLOOD ANCA-POSITIVE*
___ 06:35AM BLOOD RheuFac-<10 dsDNA-PND
___ 06:55PM BLOOD CRP-5.3*
___ 06:30AM BLOOD IgG-1473 IgA-302 IgM-502*
___ 06:55PM BLOOD PEP-NO SPECIFI b2micro-2.9*
___ 06:40AM BLOOD HIV Ab-NEG
___ 06:55PM BLOOD C3-119 C4-23
___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:55PM BLOOD Lupus-NOTDETECTE dRVVT-S-0.99 SCT-S-0.82
___ 05:30PM BLOOD D-Dimer-703*
___ 04:05AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:55PM BLOOD ANCA-POSITIVE*
___ 06:35AM BLOOD RheuFac-<10 dsDNA-NEGATIVE
___ 06:55PM BLOOD CRP-5.3*
___ 06:30AM BLOOD IgG-1473 IgA-302 IgM-502*
___ 06:55PM BLOOD PEP-NO SPECIFI b2micro-2.9*
___ 06:55PM BLOOD C3-119 C4-23
___ 05:30PM BLOOD D-Dimer-703*
___ 04:05
___ VIRUS ANTIBODY WITH REFLEX TO INHIBITION ASSAY
Test Result Reference
Range/Units
INDEX VALUE 0.20 H
JCV ANTIBODY INDETERMINATE A
Test Result Reference
Range/Units
SM ANTIBODY <1.0 NEG <1.0 NEG AI
RNP ANTIBODY
Test Result Reference
Range/Units
RNP ANTIBODY <1.0 NEG <1.0 NEG AI
___:35
ALDOLASE
Test Result Reference
Range/Units
ALDOLASE 16.1 H <=8.1 U/L
___ 18:55
VITAMIN D ___ DIHYDROXY
Test Result Reference
Range/Units
VITAMIN D, 1,25 (OH)2, TOTAL 44 ___ pg/mL
VITAMIN D3, 1,25 (OH)2 44 pg/mL
VITAMIN D2, 1,25 (OH)2 <8 pg/mL
NMO/AQP4 FACS Titer, S
Result Name ___ Unit Reference ___ Performing Site
High NMO/AQP4 FACS Titer, S Positive > ___ titer <1:5 ___ MCR
Multiple Sclerosis Profile
Received: ___ 13:54 Reported: ___ 16:41
CSF Bands SDL
3 bands
SDL
Reference Value
<4
CSF Olig Bands Interpretation
0 bands
The oligoclonal band assay detected 3 or fewer unique IgG
bands in the CSF. This is a negative result.
Serum Bands SDL
3 bands
Discharge labs
===============
___ 06:15AM BLOOD WBC-7.0 RBC-3.60* Hgb-10.1* Hct-32.9*
MCV-91 MCH-28.1 MCHC-30.7* RDW-16.0* RDWSD-53.7* Plt Ct-78*
___ 10:15AM BLOOD PTT-64.1*
___ 05:28AM BLOOD Ret Aut-2.4* Abs Ret-0.09
___ 04:24PM BLOOD HIT Ab-POS* HIT ___
MR HEAD:
1. Periventricular T2/FLAIR white matter enhancing and
nonenhancing lesions. Further, nonenhancing T2/FLAIR
hyperintensity with diffusion signal abnormality
abutting/involving the ventrolateral aspect of the left
thalamus.
2. The appearance of periventricular lesion associated with the
corpus
callosum signal abnormalities are suggestive of edema and teen
disease such as multiple sclerosis. However, given the
extensive spinal abnormality, neuromyelitis optica should also
be considered in the differential diagnosis while absence of
signal abnormalities in the optic nerves are against this
diagnosis. Subacute infarcts are un likely given spinal cord
abnormality
MR ___ SPINE:
1. Long segment of extensive T2 signal abnormality within the
cord from C3 to T7 level, which demonstrates patchy enhancement
throughout. There is mild associated increased caliber of the
cord throughout. Additional focal enhancement in the left side
of the conus. The findings are in keeping with demyelination.
The extensive long segment nature of the signal abnormality is
atypical for multiple sclerosis. The differential includes
neuromyelitis optica.
2. Cervical spondylosis, with moderate spinal canal narrowing
secondary to central disc extrusions at C5-C6 and C6-C7. Mild
thoracic and lumbar
spondylosis, as described.
CT NECK:
Slightly prominent cervical and supraclavicular lymph nodes
unchanged from the previous CT angiography of ___.
No a symmetric mass lesion identified. No fluid collection is
seen.
CT CHEST:
1. Bilateral lower lobe predominant subpleural fibrotic changes
suggest
fibrotic pattern of NSIP.
2. Prominent number of axillary and supraclavicular lymph nodes
measuring up to 0.9 cm in short axis.
3. Right upper lobe pulmonary nodules measure up to 3 mm.
CT A/P:
1. Multiple retroperitoneal and mesenteric lymph nodes as
described above are mildly prominent but at the upper limits of
normal. No definite
lymphadenopathy.
2. Please refer to same day chest CT for description of thoracic
findings.
DVT
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity
veins.
2. Small right ___ cyst.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[ ] Please repeat CBC to evaluate platelet count on ___ and
then Qweekly pending resolution of thrombocytopenia
[ ] Pt's SRA antibodies are still pending, will need to remain
on fondaparinux until we have this result. We will call you with
this with further instructions, and she will need further
follow-up with hematology which is being organized
[ ] NSIP noted on CT torso. Per pulmonology, she requires PFTs
(should have occurred inpatient, but patient unable to tolerate
given weakness). She additionally will need a repeat CT chest in
3 months (___) along with pulmonology follow-up
[ ] Pt has evidence of mild lymphadenopathy on her CT chest, in
some cases NMO can be paraneoplastic and it will be important
that the patient has outpatient mammogram and colonoscopy (vs
PET). We discussed this with the patient and she declined
further oncologic inpatient workup
[ ] Pt does have evidence of positive immunologic workup that
could be indicative of an early sjogren's disease especially in
setting of NSIP, although there is also an association with
positive sjogren's and autoimmune antibodies in the setting of
NMO alone
SUMMARY:
========
___ is a ___ year old woman with a possible left anterior
choroidal infarct vs possible demyelinating lesion with right
leg weakness, difficulty walking up stairs, and bilateral lower
extremity tingling in ___ for which a workup was not
completed as she left ___. She was seen as
an outpatient by Dr. ___ performed a workup that was
revealing for likely autoimmune process (elevated ___, anti-Ro,
CRP, ESR). She presented to ___ from her outpatient
neurologist's office on ___ with 4 days of worsening lower
extremity weakness. On presentation to ___, she was evaluated
with MRI spine, which was notable for longitudinally extensive
transverse myelitis from C3 to T7 associated with patchy
enhancement throughout, with mildly increased caliber of the
cord throughout along with focal enhancement in the left side of
the conus. Brain MRI showed periventricular white matter
enhancing and non-enhancing lesions, along with FLAIR
hyperintensity with diffusion signal abnormality of the VPL,
which does not appear to be in a vascular distribution. There
were also corpus callosum signal abnormalities. Her exam
progressed to bilateral ___ paraplegia.
At this point, there was high concern for aggressive
demyelinating process such as neuromyelitis optica. A lumbar
puncture was performed, notable for 6 WBC, 24 RBC, 39 protein,
73 glucose. Despite lymphoma on the differential diagnosis, she
was started on IV methylprednisolone as NMO was much higher on
the differential. Plasmapheresis was also recommended given no
clinical response to steroids, and 5 sessions were completed.
Unsurprisingly, her AQP4 antibodies were quite elevated at
>100,000. ___ evaluated this patient and recommended acute rehab.
Her course was further complicated by thrombocytopenia. Given a
4T score of 4, we sent for HIT antibodies which were positive at
2.1u/mL/ She was started on argatroban and switched to
___ prior to discharge. She had lower extremity
dopplers which were negative. The SRA assay is pending. She will
need to stay on ___ until we have this result back, and
we will be in touch with rehab for further recommendations.
Hematology follow-up is pending at the time of discharge.
CT torso was performed due to lymphadenopathy noted on MRI,
which was revealing for NSIP. Pulmonology was consulted at the
request of rheumatology and recommended pulmonary function
testing and repeat imaging in 3 months with outpatient
pulmonology appointment. We discussed with her the need for PET
or at least mammogram and colonoscopy as outpatient given some
association of NMO with malignancy. She declined PET in the
hospital, but this should be re-discussed as an outpatient.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Fondaparinux 7.5 mg SC DAILY
2. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
FINAL DIAGNOSIS
==================
Neuromyelitis optica
SECONDARY DIAGNOSES
====================
Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
WHY DID YOU COME TO THE HOSPITAL?
- You developed weakness in your legs and your neurologist, Dr.
___ that you come to the hospital.
WHAT HAPPENED WHILE YOU WERE HERE?
- We did an MRI scan of your brain and your spinal cord, which
showed a few spots in your brain and one long area in your
spinal cord that were not normal. Based on the imaging, and some
lab testing we believe you have a diagnosis called NMO.
- This is a disorder that is caused by demyelination from an
antibody that attacks the covering of nerves.
- We treated you with steroids, but you did not have much
improvement.
- We therefore treated you with plasma exchange, where we filter
out the protein in your blood that are attacking your brain and
spinal cord.
- You were improving after completing plasma exchange.
- As a complication of your plasma exchange, your platelets
started to go down which may be due to a reaction to heparin or
directly from the plasma exchange.
- We are treating you for this disorder, called HIT, with a
medication called Fondaparinux
- We will call you and your rehab when the final platelet
results come back, you need to remain on the injectable blood
thinner (Fondaparinux) until that returns
WHAT TO DO WHEN YOU LEAVE?
- Go to all your follow-up appointments as scheduled.
- Take all your medicines as prescribed.
MEDICATIONS WE ADDED
[ ] Fondaparinux -- do not stop this until we tell you to do so
Best wishes,
Your ___ Neurology Team
Followup Instructions:
___
|
10338508-DS-5 | 10,338,508 | 23,440,807 | DS | 5 | 2164-04-15 00:00:00 | 2164-04-09 14:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year-old woman who sustained a mechanical fall on
the day or presentation and now presents with R hip and R sided
back pain. The patient presented to the ED for evaluation and
the Orthopaedic Surgery service was consulted when imaging was
concerning for pubic ramus fracture and sacral fracture.
Past Medical History:
Anemia, COPD, Dementia, Multiple falls, R hip fracture ___ s/p
Short TEN for intertrochantor fracture
Social History:
___
Family History:
Non-contributory
Physical Exam:
Discharge Exam:
AFVSS
NAD
Light erythematous rash on back with no tenderness or itch
RLE exam:
SILT S/S/SP/DP
fires ___
WWP, 1+ DP pulses
Pertinent Results:
___ 09:50AM BLOOD WBC-9.4 RBC-4.94# Hgb-13.6# Hct-40.9#
MCV-83 MCH-27.5 MCHC-33.3 RDW-13.7 Plt ___
___ 09:50AM BLOOD Neuts-86.6* Lymphs-4.5* Monos-5.0 Eos-3.6
Baso-0.3
___ 09:50AM BLOOD Glucose-114* UreaN-21* Creat-1.2* Na-135
K-5.0 Cl-100 HCO3-23 AnGap-17
___ 09:50AM BLOOD Calcium-9.9 Phos-2.9 Mg-1.8
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R pubic ramus fracture and sacral fracture and was
admitted to the orthopedic surgery service. The patient was
nonoperatively. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with ___ and home ___ was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weightbearing as tolerated 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 TID
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth three times daily Disp #*42 Tablet
Refills:*1
2. Albuterol-Ipratropium ___ PUFF IH BID
3. Alendronate Sodium 70 mg PO QTUES
4. Donepezil 10 mg PO HS
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Sertraline 100 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
8. Tiotropium Bromide 1 CAP IH DAILY
9. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*62 Capsule Refills:*2
10. Senna 2 TAB PO HS
RX *sennosides [senna] 8.6 mg 2 TAB by mouth every night Disp
#*30 Tablet Refills:*2
11. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*2
12. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multiple] 1 tablet(s) by mouth daily
Disp #*61 Capsule Refills:*3
13. Wheel Chair
Dx: Pelvic Fracture
14. Cefpodoxime Proxetil 100 mg PO Q12H UTI Duration: 9 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth every 12 hours Disp
#*18 Tablet Refills:*0
15. Hospital Bed
Dx: Pelvic Fracture
16. Home Oxygen
Keep patient O2 sats between 92% and 100% at all times.
Dx: Hypoxia.
17. Enoxaparin Sodium 40 mg SC Q24H Duration: 2 Weeks
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
R pubic ramus fracture
Sacral fracture
Urinary tract infection
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
ANTIBIOTICS:
- On this admission, you were started on a new antibiotic for
your urinary tract infection. Please continue to take
Cefpodoxime upon discharge for a total of 10 days of antibiotic
coverage.
ACTIVITY AND WEIGHT BEARING:
- Weightbearing as tolerated in right lower extremity
Physical Therapy:
Weightbearing as tolerated in right lower extremity
Treatments Frequency:
None
Followup Instructions:
___
|
10338508-DS-6 | 10,338,508 | 28,527,648 | DS | 6 | 2165-04-03 00:00:00 | 2165-04-03 19:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
progressive confusion
Major Surgical or Invasive Procedure:
EGD on ___
History of Present Illness:
Ms. ___ is an ___ year old female with PMH significant for
dementia (mild/moderate memory impairement), COPD, multiple
falls s/p right hip fx (___) and pelvic fx (___) who presents
with confusion and gait unsteadiness with recent falls. Given
pt's mental status, she is unable to provide hx. As such, hx.
ascertained through ___, pt's daughter-in-law and
HCP.
Per Mrs. ___, pt. has had 1.5 to 2 week history of confusion.
Her usual state of health is with mild memory defecits and some
emotional stability issues with frequent outbursts of agitation
and anger. Her most signifiant issue as home has been safety
with recent falls. Within the last 2 weeks, pt. has had
increased confusion and has been intermittently oriented to
place. She also has had multiple falls within this time. Per
report, no evidence of head strike or loss of consciousness.
Pt. has had 24 hour care at her assisted living facility during
this time period. Per family, pt. has been hallucinating,
seeing things that are not there, confused with place/time,
constipated, and with ongoing weight loss. Unclear if pt. has
been having dysuria or changes in urinary frequency at this
time.
In the ED, initial vs were: 98.0, 80, 125/65, 16, 98% on RA.
Labs were remarkable for normal WBC, normal chem 10, UA grossly
positive for large leuks, and positive nitrites. CT head w/o
contrast negative for intracranial hemorrhage. CT spine
negative for acute fracture or other abnormality. Pt. was given
ceftriaxone.
Past Medical History:
# Hx. of UTIs
# Anemia
# COPD
# Dementia
# Hx. of GI Bleed with ___ tear (___)
# Multiple falls
# R hip fracture ___ s/p short TEN for intertrochantor fracture
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 98.0, 146/90, 90, 22, 93% on RA
General: Alert, partially oriented to place, not to time, no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated with inspiratory collapse, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds diffusely but otherwise clear to
auscultation bilaterally, no wheezes, rales, rhonchi
Abdomen: Soft, tender to palpation in suprapubic region,
fullness in LUQ/LLQ, hypoactive BS, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Interactive, seems to understand questions,
intermittently providing appropriate answers
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tmax 97.5 BP 103/62 P ___ 20 95% RA
General: thin ill-appearing female, awake and conversational
HEENT: anicteric sclera, MMM
Lungs: clear to ascultation bilaterally, no wheezes, rhonchi,
rales
CV: RRR, no m/r/g
Abdomen: soft, nondistended, mildly tender in epigastric region
on palpation but difficult exam due to pts dementia, +BS
Ext: Warm, well-perfused, 2+ pulses, no edema
Neuro: A&Ox1
Pertinent Results:
ADMITTING LABS
==============
___ 12:15PM BLOOD WBC-6.8 RBC-4.31 Hgb-11.7* Hct-37.6
MCV-87 MCH-27.1 MCHC-31.0 RDW-13.9 Plt ___
___ 12:15PM BLOOD Neuts-63.6 ___ Monos-6.4
Eos-10.3* Baso-0.6
___ 12:15PM BLOOD Glucose-85 UreaN-17 Creat-0.9 Na-142
K-4.2 Cl-107 HCO3-22 AnGap-17
___ 12:15PM BLOOD Albumin-4.0 Calcium-9.7 Phos-3.1 Mg-1.9
___ 12:15PM BLOOD ALT-15 AST-24 AlkPhos-94 TotBili-0.4
___ 04:56PM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:56PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 04:56PM URINE RBC-3* WBC-66* Bacteri-FEW Yeast-NONE
Epi-3
___ 04:56PM URINE Mucous-RARE
RELEVANT LABS
==============
___ 12:15PM BLOOD VitB12-647 Folate->20
___ 12:15PM BLOOD TSH-2.6
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ 12:55PM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:55AM BLOOD proBNP-371
___ 12:52PM BLOOD Type-ART pO2-61* pCO2-34* pH-7.48*
calTCO2-26 Base XS-2
___ 12:52PM BLOOD Lactate-1.1
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-8.8 RBC-3.37* Hgb-9.4* Hct-29.9*
MCV-89 MCH-27.9 MCHC-31.4 RDW-15.5 Plt ___
___ 07:00AM BLOOD Glucose-88 UreaN-13 Creat-0.7 Na-145
K-3.8 Cl-110* HCO3-27 AnGap-12
___ 07:00AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.0
PERTINENT MICRO/PATH
====================
Blood culture ___: neg
Blood culture ___ x 2: neg
Urine culture ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
Esophagus, biopsy (___):
1. Ulcerated mucosa with no intact epithelium present for
evaluation.
2. GMS and PAS stains are negative for fungi.
3. Immunostains for herpes simplex virus and cytomegalovirus are
negative (high background
staining only).
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
PERTINENT IMAGING
=================
CT head w/o contrast ___
No intracranial hemorrhage or calvarial fracture.
CT c-spine w/o contrast (___):
No acute cervical spine fracture, acute alignment abnormality,
or prevertebral soft tissue swelling.
CXR (___):
1. Increased opacity at the lateral left lung base, increased
from prior,
best seen on the frontal view. Findings could relate to
overlying soft
tissue, but consolidation due to infection is not excluded.
2. Unchanged prominence of the bilateral hila reflecting
enlarged pulmonary arteries as seen on prior CT of ___.
3. Emphysema.
KUB (___):
Unremarkable bowel gas pattern.
KUB (___):
Normal bowel gas pattern, unchanged as compared to the prior
examination. No evidence of pneumoperitoneum.
CXR (___):
As compared to the previous radiograph, there is now minimal
blunting of the right costophrenic sinus, likely caused by a
small right pleural effusion. Otherwise no changes are noted. No
normal size of the cardiac silhouette. No pulmonary edema.
Known moderately enlarged pulmonary arteries, as documented on
the CT examination from ___.
CT abd/pelvis w/o contrast (___):
1. No evidence of malignancy within the abdomen or pelvis.
However,
non-contrast CT is not the procedure of choice for assessment of
the colon
and, therefore, either colonoscopy or CT colonography is
recommended should
concerns persist.
2. Severe sigmoid diverticulosis without evidence of
diverticulitis.
3. Stable 3.6 x 3.5 cm cyst within the left adnexa.
4. Cholelithiasis.
5. Bilateral renal cysts, one of which appears hyperdense
within the lower pole right kidney and has slightly increased in
size since the previous CT.
6. Small-to-moderate right-sided pleural effusion.
EGD (___):
Impression:
Abnormal mucosa in the esophagus (biopsy)
Friability and erythema in the antrum compatible with gastritis
Duodenal ulcer
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
BRIEF SUMMARY
=============
Ms. ___ is a ___ y/o F with dementia, COPD, sp multiple falls
w/ R hip fx (___) and pelvic fx (___), who presented from
assisted living with confusion (2 weeks), hallucinations, and
gait unsteadiness. She was treated empirically UTI and ?PNA and
found to have peptic ulcer disease with a duodenal ulcer.
ACTIVE DIAGNOSES
================
# Altered mental status -
According to patient's daughter-in-law, patient has had
worsening mental status over last 8 months but increasing
confusion/gait unsteadiness especially over last ___ weeks
consistent with sub-acute delirium. Head CT showed no acute
intracranial process. Metabolic work-up showed normal TSH, B12,
folate. It was noted on her medication list that the patient had
started Seroquel recently on ___, which was likely contributing
to her altered mental status, and we discontinued this
medication. We consulted neurology on ___, who did not feel
that her hallucinations were consistent with ___ body dementia
and agreed with discontinuation of Seroquel. Additionally,
contributing factors to her acute change in mental status were
UTI, ?PNA, and constipation (see problems below). As we treated
these, the patient's mental status improved to her baseline.
# Peptic ulcer disease -
During her admission, the patient was noted to have nausea,
abdominal pain, anorexia, downtrending Hgb, and guaiac+ stools.
She was started on pantoprazole 40 mg BID and GI was consulted
for concern of upper GI bleed. She underwent EGD on ___, which
showed peptic ulcer disease with a duodenal ulcer with stigmata
of recent bleeding and severe esophagitis. H. pylori ab was
checked and neg on ___. Esophageal biopsies were taken and
pathology showed ulcerated mucosa with no intact epithelium
present for evaluation, neg fungi, neg HSV or CMV. The pt was
started on sucralfate slurry for a 14-day course (___) and
Maalox on ___ for her epigastric pain from ulcers. Since
sucralfate can cause hypophosphatemia and patient has required
daily supplementation of phosphorous, we have started her on
phos 250 mg daily. She was discharged on BID PPI. She has a
follow-up appointment with GI on ___.
# Constipation -
The patient had nausea and non-bloody, non-bilious brown emesis
starting on ___. It was unclear when her last bowel movement
was. She underwent manual disimpaction with minimal success. We
started an aggressive bowel regimen including senna, colace,
Miralax, and tap water enemas. KUB from ___ and ___ were neg
for obstruction and noncontrast CT abd on ___ was also
non-revealing. We attempted to place an NG tube but patient did
not tolerate this. However, on ___, patient had three large
loose bowel movements. We sent Cdiff and stool cx, which were
negative. She continued to have regular bowel movements for the
rest of her hospitalization.
# Aspiration pneumonitis -
On ___, the patient triggered twice for tachypnea to the 30's.
She improved with nebs and was started on prednisone 40 mg and
azithromycin 250 mg for COPD exacerbation. CXR showed known R
pleural effusion that has been stable during this admission and
no evidence of pulmonary edema or new infiltrates. EKG and
cardiac markers x 1 were neg for acute MI. ABG showed
respiratory alkalosis likely ___ hyperventilation. We sent a
Strongyloides ab due to patient's eosinophilia which is pending.
Though the patient did not have evidence of volume overload on
exam (except for mild crackles in rt lung base) and normal BNP,
she did receive 20 mg IV Lasix x 1. We considered PE, which we
felt was unlikely due to low Wells score (1.5 from
immobilization) and decided to defer getting a CTA. On ___, the
patient was back to her respiratory baseline. We believe that
the most likely etiology given the largely negative work-up is
aspiriation pneumonitis, which caused the patient's acute
presentation. Speech/swallow evaluation showed probable
aspiration with thin liquids and we modified her diet to
thickened liquids and soft/pureed solids with follow-up
speech/swallow eval when the patient is more able to
participate. The prednisone and azithromycin were d/c'd on ___.
# Urinary tract infection -
On admission, the patient's UA was positive for UTI (66 WBC, +
nitrites), but culture was unfortunately not sent prior to first
abx dose of ceftriaxone. We decided to treat empirically with
ceftriaxone (___). During this time of her constipation,
she developed a leukocytosis for which we decided to broaden her
to Zosyn (to cover abdominal bugs (___) and then switched
to Levofloxacin (___). Repeat culture performed ___
returned on ___ as mixed bacterial flora with skin
contamination.
# Possible pneumonia -
Review of CXR ___ showed increased opacity at the lateral left
lung base, consistent with possible pneumonia. She was treated
with abx (CTX ___ Zosyn ___ and Levofloxacin
___.
CHRONIC DIAGNOSES
=================
# COPD -
The patient has a history of COPD. We continued her on Advair,
and spiriva. We have d/c'd her Combivent and replaced with
albuterol, as ipratropium in combivent can displace long-active
tiotropium.
# Osteoporosis -
During her admission, we held her Alendronate and vitamin D
supplementation.
# Depression -
Patient is on sertraline at home, which we held during this
admission. Consider restarting as outpatient.
TRANSITIONAL ISSUES
===================
- Patient has follow-up appointment with GI.
- Patient had eosinophilia on labs during admission, will need
to f/u and ensure resolution as outpatient.
- Strongyloides ab NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Docusate Sodium 100 mg PO DAILY
3. Alendronate Sodium 70 mg PO QTUES
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Ranitidine 150 mg PO BID
6. QUEtiapine Fumarate 50 mg PO QHS
7. Tiotropium Bromide 1 CAP IH DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Sertraline 150 mg PO DAILY
10. Docusate Sodium 100-200 mg PO DAILY:PRN Constipation
11. Senna 8.6 mg PO BID:PRN Constipation
12. TraMADOL (Ultram) 25 mg PO Q8H:PRN Pain
13. Acetaminophen 650 mg PO Q8H:PRN Pain
14. Ipratropium-Albuterol Inhalation Spray 1 INH IH BID
Discharge Medications:
1. Hospital Bed
Please provide patient with a Hospital Bed.
ICD : 496
2. Acetaminophen 650 mg PO Q8H:PRN Pain
3. Docusate Sodium 100 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
Pain
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ ml
by mouth four times a day Refills:*0
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
7. Phosphorus 250 mg PO DAILY
RX *sod phos,di & mono-K phos mono [K-Phos-Neutral] 250 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
8. Alendronate Sodium 70 mg PO QTUES
9. Vitamin D 1000 UNIT PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Senna 8.6 mg PO BID:PRN Constipation
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
14. Sucralfate 1 gm PO QID Duration: 14 Days
RX *sucralfate 1 gram/10 mL 1 suspension(s) by mouth four times
a day Disp #*360 Milliliter Milliliter Refills:*0
15. Albuterol Inhaler 1 PUFF IH BID
RX *albuterol 1 puff inhaled twice a day Disp #*1 Inhaler
Refills:*0
16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, sob
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb inhaled q6h as
needed for wheezing Disp #*30 Vial Refills:*0
17. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze, sob
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb inhaled q6h
prn Disp #*30 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
ACTIVE DIAGNOSES
=================
# Altered mental status
# Peptic ulcer disease
# Constipation
# Aspiration pneumonitis
# Urinary tract infection
# Probably pneumonia
SECONDARY DIAGNOSES
===================
# Chronic obstructive pulmonary disease
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 meeting and caring for you during your most
recent hospitalization at ___.
You presented with confusion, likely from an infection. We have
stopped Seroquel, a medication that you started taking a week
prior to your hospitalization, because we believed it was making
you confused. We treated you for a urinary tract infection and a
possible pneumonia. You also had abdominal pain and dropping
blood counts, which were from an ulcer. You underwent an
endoscopy to diagnose this and we gave you new medications
(pantoprazole 40 mg twice a day; sucralfate four times a day,
through ___ to treat your ulcer and made an appointment for
you to follow-up with a Gastroenterologist. Additionally, you
were constipated during your hospitalization, which has
resolved. We were concerned that you were aspirating your food,
so you had a speech and swallow evaluation and we have modified
your diet to pureed solids and nectar thick liquids. Please see
below for further follow-up instructions.
All the best,
Your ___ Care Team
Followup Instructions:
___
|
10338661-DS-8 | 10,338,661 | 28,927,335 | DS | 8 | 2176-10-15 00:00:00 | 2176-10-18 19:11:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lovastatin / Niacin
Attending: ___.
Chief Complaint:
Fatigue and shortness of breath
Major Surgical or Invasive Procedure:
Colonoscopy x2
History of Present Illness:
Mr. ___ is a ___ with multiple medical problems including CAD
s/p multiple stents, CHF, DMII, and chronic GI bleeds ___ AVMs
who presents with fatigue and SOB. Pt states that this has been
going for a week or so, and his symptoms are typical of when his
HCT drops below 27. He has felt fatigued and notes that he has
been getting SOB with minimal exertion and even occasionally
while seated for the last few days. His stools have been dark
for the same period, but not frankly bloody. He suspected that
he had low hematocrit due to the symptoms and stopped his lasix
1 week PTA and his cilostazol ___ days PTA (for fear of "opening
up" his blood vessels.) He denies any F/C, cough or other URI
symptoms, chest pain, palpitations, N/V, abdominal pain, or
constipation; he did have three loose, but not liquid stools on
the morning of admission.
.
He was seen in urgent care on the day of admission, and his hct
was noted to be 24.5; this was similar to his hct of 25 noted on
___, when he had a ferraheme infusion. He was advised to go
to the hospital from urgent care.
.
In the ED, initial VS: 97.3 59 132/53 20 100%. A CXR showed no
acute process. He had labs significant for a HCT of 25.9,
creatinine 1.7 (below baseline) and guaiac positive dark brown
stool. He was given 1 unit of blood and transfered to the floor.
Vitals on transfer 98.4 58 163/60 19 100% RA.
.
On presentation to the floor, he was comfortable in bed, mildly
short of breath, but otherwise without complaints.
.
Overnight, he was transfused with an additional unit of PRBCs;
he reports that he feels much better this morning and denies any
respiratory difficulty or other symptoms, though he notes that
he has not yet been out of bed.
.
Past Medical History:
Recurrent GI bleeds secondary to AVMs (discovered in late ___,
s/p mult EGDs and a capsule study in ___
Diabetes Type II (on Insulin)
CAD s/p stents X 6
Hypercholesterolemia
Hypertension
Anemia
Hypothyroidism
Spinal stenosis, s/p 2 lumbar repairs and 1 cervical repair,
with persistent left foot drop
S/p Left hip replacement
Asthma (has PRN inhaler, no recent intubation or
hospitalization)
GERD
Cataracts s/p repair
Social History:
___
Family History:
CHF in mother and father, ___ in mother and brother, CAD in
brother. No family history of bradycardia.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS - Temp 97.5F, BP 124-161/60s, HR 58-64, R 20, O2-sat 98% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, surgical pupils, EOMI, MMM, OP clear
NECK - supple, no thyromegaly, no JVD this morning
LUNGS - minimal crackles bilaterally, wheezes L>R lung fields
HEART - Distant heart sounds, RRR, nl s1 and s2, no appreciable
murmurs
ABDOMEN - +BS, soft/NT/ND, no hepatosplenomegaly
EXTREMITIES - WWP, 1+ pitting edema to the mid shin on the right
leg, and pedally on the left
PHYSICAL EXAM ON DISCHARGE:
GENERAL - Elderly male in NAD, appears younger than stated age,
comfortable, appropriate
HEENT - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly
LUNGS - Left sided crackles in the middle-lower lung fields;
trace intermittent wheezes in all fields, good air movement; no
respiratory distress
HEART - Distant heart sounds, RRR; unable to appreciate any
murmurs
ABDOMEN - NABS, soft/NT, mildly distended without masses or HSM,
no rebound/guarding
EXTREMITIES - WWP, 1+ pitting edema to the mid shin, right >
left, some skin darkening / vascular changes also right > left
SKIN - no rashes or lesions noted
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact. Bilateral foot
drops with limited strength and movement of ankles/feet, left >
right; unchanged from previous exam.
Pertinent Results:
Admission Labs
___ 04:10PM WBC-5.4 RBC-2.67* HGB-9.1* HCT-25.9* MCV-97#
MCH-33.9*# MCHC-35.0 RDW-18.4*
___ 04:10PM NEUTS-69.6 ___ MONOS-4.4 EOS-5.4*
BASOS-0.6
___ 04:10PM PLT COUNT-165
___ 04:40PM GLUCOSE-125* UREA N-43* CREAT-1.7* SODIUM-138
POTASSIUM-4.6 CHLORIDE-110* TOTAL CO2-22 ANION GAP-11
.
.
Discharge Labs (s/p transfusion x 2 units PRBCs)
___ 06:00AM BLOOD WBC-5.1 RBC-3.37*# Hgb-10.1* Hct-30.7*
MCV-91 MCH-30.0# MCHC-33.0 RDW-19.5* Plt ___
___ 06:00AM BLOOD Glucose-100 UreaN-40* Creat-1.8* Na-142
K-4.2 Cl-108 HCO3-28 AnGap-10
___ 06:00AM BLOOD WBC-4.7 RBC-3.57* Hgb-10.8* Hct-32.7*
MCV-92 MCH-30.1 MCHC-32.9 RDW-19.3* Plt ___
.
.
CXR (___)
FINDINGS: Portable AP upright chest radiograph is obtained.
There are low
lung volumes which limit evaluation. Allowing for this, there is
no focal
consolidation, effusion, or pneumothorax. Cardiomediastinal
silhouette
appears grossly stable. Atherosclerotic calcifications along the
aortic knob noted. Bony structures appear intact.
IMPRESSION: No acute intrathoracic process on this limited chest
radiograph.
.
.
Colonoscopy (___)
Findings:
Contents: There was solid stool encountered in the
mid-ascending colon. The procedure was aborted at that point.
Other Multiple venous blebs were seen throughout the colon, but
unlikely to be the source of bleeding.
Impression: Multiple venous blebs were seen throughout the
colon, but unlikely to be the source of bleeding.
Stool in the colon
Otherwise normal colonoscopy to mid-ascending colon
.
.
Colonoscopy (___)
Findings:
Protruding Lesions A single sessile 6 mm polyp of benign
appearance was found in the ascending colon. A single-piece
polypectomy was performed using a cold snare. The polyp was
completely removed.
Impression: Polyp in the ascending colon (polypectomy)
Otherwise normal colonoscopy to cecum
Recommendations: Follow-up biopsy results
Colonoscopy in ___ years if polyp is an adenoma
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
Mr. ___ is a ___ with multiple medical problems including CAD
s/p multiple stents, CHF, DMII, and chronic GI bleeds ___ AVMs
who presented with fatigue and SOB typical of his episodes of GI
bleeding. Briefly, he was transfused 2 units PRBCs and had an
unrevealing colonoscopy. Due to inadequate prep, colonoscopy was
repeated the following day and was similarly unrevealing with
respect to sources of bleeding; the patient was discharged after
his colonoscopy in stable condition, off cilostazol. The
prescribing provider, Dr ___, was notified of the
discontinuation of this medication, planned at least
temporarily.
.
ACTIVE DIAGNOSES:
# GI bleed: Pt has Chronic GIB from known AVMs, and was having
symptoms typical of when his hematocrit drops. He was transfused
2 units PRBCs, with a Hgb/Hct bump from 9.1/25.9 to 10.1/30.7,
remaining stable at 10.8/32.7; he reported symptomatic
improvement in his shortness of breath. He had an unrevealing
colonoscopy performed on ___, which was aborted after stool
was visualized in the mid-ascending colon. Colonoscopy was
repeated on the morning of ___, with adequate prep, and showed
only a small, benign-appearing polyp, which was removed and sent
for biopsy. He was advanced to regular diet after his second
colonoscopy. Pt was monitored on tele throughout his admission
without events, and his home pantoprazole and ranitidine were
continued, with discontinuation of cilostazol, but continuation
of aspirin. Inpatient team communication with the patient's
outpatient providers, including Dr. ___, ___ and Dr.
___, ___ and Dr ___ his
admission.
# Acute on chronic systolic heart failure: History of heart
failure, initially with progression of symptoms and PE findings
(mild SOB, crackles, wheeze, JVP, ___ edema) consistent with
acute exacerbation (vol overload) while receiving volume with
his transfusion, in the setting of not taking his home lasix for
past week. He received a 60 mg IV lasix bolus prior to his
second unit of PRBCs, and a second bolus the following morning.
He improved clinically and appeared euvolemic, and was
subsequently continued on his home carvedilol, simvastatin,
lisinopril, and aspirin.
# Bradycardia: Pt was episodically noted to be bradycardic. His
HR generally remained in the 50-60 BPM range, but reached a low
of 38; he remained entirely asymptomatic. His carvedilol was
held for bradycardia < 55. We suspect that he normally has a
reduced HR, that became a bit more pronounced during the
prolonged prep for his endoscopy.
# HTN: Had increasing BPs in the ED and was hypertensive on
arrival to the floor, likely because of missed doses of HTN
medications and diuretics while receiving volume from blood
transfusion. He was diuresed with lasix, as described above,
and then continued on his home meds (CHF meds as above +
isosorbide and HCTZ); he remained within an acceptable BP range
for the remainder of his admission.
CHRONIC DIAGNOSES:
# DM: Stable. Continued glargine 30 units HS, with insulin
sliding scale. He had an episode of hypoglycemia in the setting
of the preparation, and noted his BGs were significantly lower,
which was attributed to limited PO intake in the 48 hours prior
to admission, as well as during his effectively 2-day prep.
# CAD: Maintained medical regimen as above, with PRN SL nitro
for angina.
# Asthma: initially wheezy on exam, possibly due to cardiac
wheeze; improved on subsequent examinations. He was given
albuterol, ipratropium nebs PRN.
TRANSITIONAL ISSUES:
1. Vascular - recommend consideration of temporal relationship
between GI bleed and relatively recent initiation of cilostazol.
2. GI - Colon polyp removed on ___ and sent for biopsy;
results pending at time of discharge.
3. Anemia - The patient is aware to see his internist for a Hct
check, and continue to follow closely, given the multiple
contributing factors.
Medications on Admission:
carvedilol 25 mg Tab 1 (One) Tablet(s) by mouth twice a day
pantoprazole 40 mg Tab, 1 Tablet(s) by mouth twice a day
Lantus 100 unit/mL Sub-Q 30 units at bedtime
Vitamin B-12 250 mcg Tab 1 Tablet(s) by mouth once a day
Vitamin D-3 1,000 unit Chewable Tab 1 Tablet(s) by mouth twice a
day
aspirin 81 mg Tab, Delayed Release Tab PO daily
albuterol sulfate 0.63 mg/3 mL Neb Solution
furosemide 20mg Tab; 2 Tabs PO daily, 1 tab at 1300 on MWF
hydrochlorothiazide 25 mg Tab; 1 Tab by mouth once a day
lisinopril 2.5 mg Tab by mouth once a day
simvastatin 80 mg PO every other day; 40 mg every other day
isosorbide dinitrate ER 40 mg Tab by mouth three times a day
levothyroxine 125 mcg Tab by mouth once a day
ranitidine 300 mg Tab by mouth once a day
fluticasone 50 mcg/Actuation Nasal Spray, Susp
fluticasone 44 mcg/Actuation Aerosol Inhaler
cilostazol 50 mg Tab; 2 Tabs PO Daily
nitroglycerin 0.4 mg Sublingual 1 Tab, SL prn
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
4. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
6. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO once a
day.
7. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet,
Chewable PO twice a day.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation twice a day as needed for shortness of
breath or wheezing.
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): plus 1 tab @ 1300 on MWF.
11. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
12. simvastatin 40 mg Tablet Sig: ___ Tablets PO DAILY (Daily):
80 mg PO every other day; 40 mg every other day
.
13. isosorbide dinitrate 40 mg Capsule, Extended Release Sig:
One (1) Capsule, Extended Release PO three times a day.
14. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO once a
day.
15. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Anemia
Secondary Diagnoses:
Gastrointestinal Bleeding
Arteriovenous Malformations
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted with a low blood level due to
gastrointestinal bleeding from known arteriovenous
malformations. While you were here, you received 2 units of
blood transfusions, and 2 colonoscopies. You were found to have
a sessile polyp that was biopsied. Your medications were
changed. You should follow-up with another colonoscopy in ___
years, and you should follow-up with Dr. ___ the
results of your biopsy.
Please note the following changes have been made to your
medications:
- Please STOP taking cilostazol
Please follow up with a colonoscopy in ___ years. Please
follow-up with Dr. ___ the results of your biopsy.
Followup Instructions:
___
|
10338661-DS-9 | 10,338,661 | 26,968,890 | DS | 9 | 2178-01-06 00:00:00 | 2178-01-06 23:01:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lovastatin / Niacin
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
Blood transfusions
History of Present Illness:
___ h/o DM, CAD (s/p 7 stents), hypothyroid, and small bowel AVM
presents with several days of exertional chest pain and frequent
dark stools. ___ PTA he noticed being more fatigued. This
progressed over the next two days until the day of admission he
was very tired. He also noticed dark stools during this time and
by ___ they were watery. He was also becoming SOB with
minimal exertion. His last bleed was in ___ with similar
symptoms. He reports having a capsule endoscopy 3 weeks ago and
an EGD 2 weeks ago with thermal cauterization. He denies fevers,
chest pain, headaches, or palpitations. He does report some
chills which is common for his when he has a bleed.
In the ED, initial VS: 98 62 162/55 18 97% ra. His Hct was 26
(from a reported b/l ~30) with guaiac positive brown stool and
he was transfuse 1 unit. He also had a Trop .04 and a Cr 2.3.
EKG showed sinus brady w/ lateral TWI c/w prior. He was given
80mg IV Pantoprazole and he was transferred to the floor for GI
bleed management.
Past Medical History:
Recurrent GI bleeds secondary to AVMs (discovered in late ___,
s/p mult EGDs and a capsule study in ___
Diabetes Type II (on Insulin)
CAD s/p stents X 6
Hypercholesterolemia
Hypertension
Anemia
Hypothyroidism
Spinal stenosis, s/p 2 lumbar repairs and 1 cervical repair,
with persistent left foot drop
S/p Left hip replacement
Asthma (has PRN inhaler, no recent intubation or
hospitalization)
GERD
Cataracts s/p repair
Social History:
___
Family History:
CHF in mother and father, ___ in mother and brother, CAD in
brother. No family history of bradycardia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:97.9 BP:150/70 P:53 R:16 O2:98RA
General: Alert, oriented, no acute distress
HEENT: Sclera pale, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Back: Mild tenderness in R and L flank
Ext: Warm, delayed cap refill, 2+ pulses, no clubbing, cyanosis
or edema
Skin: R ___ toe with 1mm Macule
DISCHARGE PHYSICAL EXAM:
Vitals: T:98.0 ___ P:53-62 R:18 O2:98RA
General: Alert, oriented, no acute distress
HEENT: Sclera pale, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, minimal scattered
wheezes, rales, rhonchi
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
Back: Mild tenderness in R and L flank
Ext: Warm, delayed cap refill, 2+ pulses, no clubbing, cyanosis
or edema
Skin: R ___ toe with 1mm Macule
Pertinent Results:
ADMISSION:
___ 01:20PM BLOOD WBC-5.3 RBC-2.89* Hgb-8.0* Hct-26.7*
MCV-92 MCH-27.5# MCHC-29.7*# RDW-15.5 Plt ___
___ 01:20PM BLOOD Neuts-68.4 ___ Monos-5.0 Eos-6.3*
Baso-0.4
___ 01:20PM BLOOD ___ PTT-38.3* ___
___ 01:20PM BLOOD Glucose-164* UreaN-54* Creat-2.3* Na-138
K-4.6 Cl-107 HCO3-20* AnGap-16
___ 01:20PM BLOOD cTropnT-0.04*
___ 05:55AM BLOOD cTropnT-0.02*
___ 05:55AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.9
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 05:00PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
___ 09:47PM URINE Hours-RANDOM UreaN-568 Creat-55 Na-76
K-23 Cl-77
___ 05:50AM BLOOD WBC-4.8 RBC-3.18* Hgb-9.1* Hct-28.5*
MCV-90 MCH-28.6 MCHC-31.9 RDW-15.7* Plt ___
DISCHARGE:
___ 05:50AM BLOOD Glucose-75 UreaN-37* Creat-2.0* Na-140
K-4.4 Cl-111* HCO3-21* AnGap-12
___ 05:50AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9
STUDIES:
CXR ___:
FINDINGS: No pleural effusion or pneumothorax. Given the low
lung volumes, no consolidations concerning for pneumonia.
Cardiac size is top normal.
IMPRESSION: No evidence of pneumonia.
The study and the report were reviewed by the staff radiologist.
EKG: Sinus brady with TWI consistent with prior.
___ EGD:
Subtle evidence of prior cautery in the duodenal bulb
Diverticulum in the proximal jejunum
Otherwise normal EGD to proximal jejunum
Brief Hospital Course:
___ with pmHx of DM, CAD (s/p 7 stents), and known AVM's with
multiple bleeding episodes p/w drop in Hct, SOB, and guaiac +
stools
ACTIVE ISSUES:
# Acute on Chronic Anemia: Patient with Hct drop to 26 from
baseline 30. Strong hx of AVM's and guaiac + stool make this the
most likely etiology. Does report flank pain but with no reason
currently to suggest RP bleed. Patient symptomatic with this
anemia (DOE). He received 1 unit pRBCs in the ED with plan to
scope in the AM. Required another transfusion o/n to avoid
symptomatic anemia (Hct goal >29). EGD showed no active areas of
bleeding. Hct was stable upon discharge. He will continue to
require Iron transfusions as an outpatient as well as
intermittent pRBC transfusions. For blood transfusions, he can
return to ___. He will need to follow with his GI doctor, ___.
___.
# ___ on CKD: Cr 2.4 from b/l 1.8-2.0. Likely in setting of GI
bleed patient became prerenal. Resolved with RBC repletion.
# CAD: Patient with significant hx of CAD, s/p 7 stents. Trop
.04 on admission likely represents demand ischemia in setting of
anemia. Trended to .02. Continued on ASA 81mg daily and
restarted on anti-hypertensives on discharge. Transfusion goal
>29.
# HTN: Patient at home on significant anti-hypertensive regimen
including Carvedilol, Lisinopril, Imdur, and Lasix. Given GI
bleed and ___, only started Imdur originally and then added back
Carvedilol when Hct stable. Other anti-hypertensives added on
discharge.
CHRONIC ISSUES:
# HLD: Continued Atorvastatin 40mg
# Hypothyroid: Continued home Synthroid 25mcg daily
# Asthma: Continued prn Albuterol
# Allergic Rhinitis: Continued Fexofenadine and Fluticasone
TRANSITIONAL ISSUES:
- Iron levels and transfusions
- Likely will require intermittent blood transfusions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO EVEN DAYS
2. Atorvastatin 60 mg PO ODD DAYS
3. Carvedilol 25 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Furosemide 40 mg PO QAM
6. Furosemide 20 mg PO Q1PM
7. Glargine 30 Units Bedtime
8. Lisinopril 2.5 mg PO DAILY
9. Loratadine *NF* 10 mg Oral daily
10. Pantoprazole 40 mg PO Q12H
11. Ranitidine 300 mg PO DAILY
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Cyanocobalamin 250 mcg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q4-6PRN SOB
16. Fluticasone Propionate 110mcg 8 PUFF IH BID:PRN SOB
17. Nitroglycerin SL 0.6 mg SL PRN chest pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4-6PRN SOB
2. Atorvastatin 40 mg PO EVEN DAYS
3. Carvedilol 25 mg PO BID
4. Cyanocobalamin 250 mcg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Glargine 30 Units Bedtime
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Loratadine *NF* 10 mg Oral daily
9. Nitroglycerin SL 0.6 mg SL PRN chest pain
10. Ranitidine 300 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Isosorbide Dinitrate ER 40 mg PO TID
13. Atorvastatin 60 mg PO ODD DAYS
14. Fluticasone Propionate 110mcg 8 PUFF IH BID:PRN SOB
15. Furosemide 40 mg PO QAM
16. Furosemide 20 mg PO Q1PM
17. Lisinopril 2.5 mg PO DAILY
18. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Gastrointestinal bleed
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___ ___. You were admitted with a GI bleed
likely due to your known Atrio Venous Malformations. EGD showed
no active area of bleeding. You required two transfusions of
blood initially. Your blood count remained stable upon
discharge.
You will continue to receive Iron transfusions as an outpatient.
You will also likely need intermittent blood transfusions which
you can receive at ___. Please follow up with Dr. ___
this.
Followup Instructions:
___
|
10338774-DS-3 | 10,338,774 | 22,641,490 | DS | 3 | 2127-07-02 00:00:00 | 2127-07-02 18:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Visual Field Deficit
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Chief complaint:
Left Visual Field Deficit
HPI:
Mr. ___ is a ___ year old right handed man with past medical
history remarkable for anuric end stage renal disease on
hemodialysis (MWF), and multiple vascular risk factors who
presented twice to ___ over the past three days with
symptoms concerning for stroke v. TIA. On ___, the patient
noted having some general ill feelings including subjective
feverishness and chills. He presented at 0600hrs to his
dialysis
unit for HD and afterwards he rested as usual.
Later that afternoon, he noted a headache which was sharp in
character along the occipital extending to the vertex which was
about ___ in severity, non-throbbing, not associated with any
photophobia. He noted that shortly after this began, he
experienced sensory change in his right arm which became numb
both to light touch and also to pinching (which he tested by
pinching both arms and noting significant decrease in sensation
on the right arm). Of note, his AV Fistula for HD is placed in
his right arm and was functioning normally earlier that day. He
lifted the arm above his head and noted feeling some weakness.
At ___, in the ED the symptoms had resolved, workup
was negative per report and the patient was discharged.
On ___, the patient noted some progression of his
illness with multiple episodes of emesis and nausea but no
further sensorimotor abnormalities. The next ___
the patient underwent HD again with similar post-HD fatigue.
After his nap, he again noted the same headache, however this
time he reports some visual blurring which after covering his
eyes seemed to be more localized to the left eye, and on further
assessment he noted some loss of peripheral vision in the
lateral
field of the left eye exclusively. This persisted, causing the
patient to again present to ___. A NCHCT was
performed and although significantly motion degraded per report,
the patient appeared to have a hypodense area in the right
occipital lobe. This finding prompted transfer to ___ for
further evaluation.
On neuro ROS, the pt endorsed vertex/occipital bilateral
headache, and blurred vision in left greater than right eye.
Denies diplopia, dysarthria, dysphagia. Noted lightheadedness
non-vertiginous on both ___ and ___ s/p dialysis which
resolved. Denies tinnitus or hearing difficulty, but notes
sensation of fullness in the ears bilaterally. Denies
difficulties producing or comprehending speech. Endorsed
episode
of right arm focal weakness, numbness which resolved. No bowel
incontinence or retention. Anuric. Notes some unsteadiness
earlier with gait.
On general review of systems, the pt noted some transient
subjective fever and chills. Denies night sweats or recent
weight loss or gain. Denies cough, shortness of breath. Denies
chest pain or tightness, palpitations. Notes some nausea,
vomiting over past two days. Endorsed constipation at baseline.
Did have some mild abdominal pain during admission. No recent
change in bowel or bladder habits. Anuric. Denies arthralgias
or myalgias. Denies rash.
Past Medical History:
PMHx:
- ESRD on HD (anuric since ___ MWF
- Hypertension
- Hyperlipidemia
- Borderline Diabetes
- Hepatitis C Virus
- Heroin/Cocaine Abuse (last ___ yrs ago)
- Active Marijuana Use
- Hyperparathyroidism
- Constipation
- Folliculitis s/p furuncle resection on left face c/b sensory
changes
Social History:
___
Family History:
Family Hx:
- No neurologic illness reported.
Physical Exam:
ADMISSION EXAM:
Pain=7 (headache in vertex to occiput) which reduced to 0 with
0.5mg Dilaudid IV; T=97.3F, BP=124/87, HR=93, RR=18, SaO2=100%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs, referred fistula sound pan-thoracic
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated; right arm fistula with
positive thrill and audible bruit
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. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Attentive with good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF tested with wiggling fingers demonstrated no
evident field cut in either left or right eye to any specific
quadrant. Funduscopic exam revealed some irregular vasculature
but no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Saccadic intrusions.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Tandem attempted with significant ataxia to both sides.
Romberg absent.
DISCHARGE EXAM:
VITAL SIGNS: T 98.1 BP 110/60 HR 98 RR 18 O2 sat 98% RA FSG 117
General: Awake, cooperative, NAD.
HEENT: NC/AT. MMM.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: diffuse wheezes throughout. No rales or rhonchi.
Cardiac: RRR, no murmurs, referred fistula sound pan-thoracic
Abdomen: soft, nondistended, some mild tenderness
Extremities: no edema, pulses palpated; right arm fistula with
positive thrill and audible bruit
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Language is fluent with
intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt was able to name both high and low frequency objects.
Able to read without difficulty. Speech was not dysarthric.
Able to follow both midline and appendicular commands. Attentive
with good knowledge of current events. There was no evidence of
apraxia. No neglect on description of images or bifurcating line
drawing.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consenual; brisk
bilaterally. VFF tested with wiggling fingers demonstrated left
inferior quadrantanopia.
III, IV, VI: EOMI without nystagmus. Saccadic intrusions.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ 4+ 4+ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Toes were downgoing bilaterally
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
Pertinent Results:
LABS:
___ 07:30AM BLOOD WBC-9.1 RBC-4.32* Hgb-14.4 Hct-43.1
MCV-100* MCH-33.4* MCHC-33.4 RDW-14.4 Plt ___
___ 12:10PM BLOOD WBC-9.4 RBC-4.02* Hgb-13.1* Hct-38.9*
MCV-97 MCH-32.7* MCHC-33.7 RDW-14.6 Plt ___
___ 07:30AM BLOOD ___ PTT-34.0 ___
___ 10:00PM BLOOD Glucose-89 UreaN-43* Creat-10.8*# Na-139
K-5.8* Cl-89* HCO3-30 AnGap-26*
___ 07:30AM BLOOD Glucose-91 UreaN-53* Creat-12.1*# Na-135
K-4.9 Cl-86* HCO3-30 AnGap-24*
___ 12:10PM BLOOD Glucose-92 UreaN-81* Creat-16.0*# Na-135
K-4.9 Cl-82* HCO3-34* AnGap-24*
___ 07:30AM BLOOD ALT-23 AST-29 LD(LDH)-228 AlkPhos-341*
TotBili-0.2
___ 07:30AM BLOOD Albumin-4.5 Calcium-10.7* Phos-7.1*
Mg-1.9 Cholest-148
___ 12:10PM BLOOD Calcium-9.2 Phos-7.2* Mg-2.0
___ 07:30AM BLOOD %HbA1c-5.5 eAG-111
___ 07:30AM BLOOD Triglyc-135 HDL-46 CHOL/HD-3.2 LDLcalc-75
___ 07:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CT HEAD ___: FINDINGS: There is no acute hemorrhage, edema
or shift of the normally midline structures. The ventricles and
sulci are of normal size and configuration. The basal cisterns
remain patent. The gray-white matter differentiation is
preserved. In particular, the area of concern within the right
occipital lobe is unremarkable on this exam. Calcifications are
seen along the falx and tentorium. The imaged paranasal sinuses
and mastoid air cells are well-aerated. The image lenses and
globes are normal. There is no fracture. Heterogeneous
appearance of the calvarium is compatible with renal disease.
IMPRESSION: No acute intracranial process.
MR/MRA HEAD AND NECK ___: FINDINGS:
MRI BRAIN: There is slow diffusion in the right paramedian
inferior occipital lobe with a corresponding smaller region of
faint FLAIR-hyperintensity, consistent with an infarct with a
combination of acute and late acute/early subacute components.
There is no evidence of hemorrhagic transformation.
There is no evidence of midline shift, mass effect, or
hydrocephalus.
There is mild asymmetric prominence of all components of the
left lateral
ventricle, likely developmental or congenital.
There is fluid-opacification of the mastoid air cells, right
more than left. There is mild prominence of the nasopharyngeal
soft tissues, with a
mucus-retention cyst on the left.
An old fracture of the right lamina papyracea, with slight
herniation of the medial right orbital fat is visualized.
Otherwise, the visualized
extracranial soft tissues and globes are unremarkable.
MRA BRAIN: The intracranial internal carotid arteries are
patent. There is a hypoplastic A1 segment of the right ACA;
otherwise, the anterior and middle cerebral arteries are patent
with normal branching pattern.
The vertebral arteries are patent with a dominant left vertebral
artery. The basilar tip is "patulous" with conjoint origin of
its terminal branches, including infundibular origins of the
superior cerebellar arteries, variant anatomy. Specifically,
the right posterior cerebral artery appears patent. There is no
evidence of aneurysm larger than 3 mm or other vascular
abnormality involving the intracranial anterior or posterior
circulation.
MRA NECK: Due to the patient's ESRD, on hemodialysis, the MRA of
the neck was performed as a 2D-TOF study, without IV
contrast-enhanced coronal VIBE
sequence; the study also appears degraded by motion. Allowing
for these significant limitations, there is a three-vessel
aortic arch. The origins of the common carotid and vertebral
arteries appear patent.
There is no significant mural irregularity, flow-limiting
stenosis, or
dissection in the neck vessels.
IMPRESSION:
1. Right paramedian inferior occipital lobar infarct with a
combination of acute and late acute/early subacute components,
accounting for the patient's clinical presentation.
2. No evidence of hemorrhagic transformation.
3. No evidence of steno-occlusive disease, aneurysm larger than
3 mm, or
other vascular abnormality involving the intracranial anterior
or posterior circulation.
3. No significant mural irregularity, flow-limiting stenosis,
or dissection in the neck vessels.
Brief Hospital Course:
A/P: ___ w hx of ESRD on HD, HTN, HLD, HCV, borderline DM,
prior substance abuse ___ yrs ago), and smoking history who
developed seveer R occipital HA on ___ in setting of malaise,
and then developed left visual field cut and subjective
weakness. Head CT at ___ on ___ concerning for
right occipital lobe hypodensity, transferred to ___ for
further evaluation. MRI/MRA on ___ demonstrated acute right
occipital infarct in setting of cerebral atherosclerosis. Plan
by system as follows:
1) Neuro - Per MRA, it was felt that Posterior Cerebral artery
atherosclerosis was the most likely explanation for this acute
right occipital infarct, especially given significant vascular
risk factors. Lesion explains his left visual field cut. HA
resolved since admission. Started atorvastatin 20mg on HD1 for
treatment of visualized cerebral vasculopathy. Alternative
etiologies, such as septic emboli less likely given lack of
cardiac murmur or fevers. TTE ___ showed no ASD/PFO, normal
EF, and no intracardiac source of thromboembolism. Patient
passed bedside swallow exam on ___. Performed well with ___
on ___, to be discharged home eventually with outpatient ___
prescription. Modifiable stroke risk factors including DM and
HLD evaluated. HbA1c equal to 5.5. LDL 75 with total cholesterol
of 148. An outpatient TEE ___ be scheduled to complete work up.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 75) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (X) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A
2) CV: Hx of HTN, controlled with clonidine, labetalol, and
lisinopril at home. ___ provide home meds, though liberalize BP
to sBP 130-160 goal. ___ monitory on tele for possible source
of putative thromboembolism. Pt ___ likely need outpatient
followup to adjust BP regimen given periods of systolic <100.
3) GI: Passed speech/swallow evaluation at bedside prior to
initiation of diet. Tolerating heart healthy/diabetic diet.
4) Endo: RISS for prevention of hyperglycemia in the
post-cerebral infarct setting.
5) Renal: Hx of GN leading to ESRD, now on ___ HD. ___ control
BP as above, and continue routine dialysis schedule. Patient has
failed a renal transplant in the past, but is not on
immuonsuppressive medications for unclear regimen. Has
previously taken CellCept and tacrolimus, states he has not
taken these or corticosteroids in several years. Pending
evaluation in Nephrology Transplant Clinic on ___.
Attempting to obtain OSH records regarding prior renal history.
TRANSITIONAL ISSUES:
- Outpatient Nephrologist: Dr. ___ at ___, phone ___.
Patient has previously been non-compliant with providers, has
also been followed by Dr. ___ at ___,
phone ___.
- Outpatient neurology followup scheduled with Dr. ___ at 2:00
pm on ___
- Outpatient TEE scheduling in process
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloniDINE 0.2 mg PO BID
2. Lisinopril 40 mg PO DAILY
3. Labetalol 200 mg PO DAILY
4. Cinacalcet 180 mg PO DAILY
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Omeprazole 20 mg PO DAILY
7. Clonazepam 1 mg PO TID
Discharge Medications:
1. Outpatient Physical Therapy
Outpatient Physical Therapy
ICD-9: 434.91
Fax Questions or Results to: Dr. ___, fax
___, ___
2. Cinacalcet 180 mg PO DAILY
3. Clonazepam 1 mg PO TID
4. CloniDINE 0.2 mg PO BID
5. Labetalol 200 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
10. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Right occipital infarct
SECONDARY:
- end stage renal disease on dialysis
- hypertension
- smoking history
- prior history of drug abuse
- hyperlipidemia
- chronic hepatitis C
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 medical care. You were
admitted to the Neurology Stroke service after presenting with
visual difficulties. You had an MRI of your brain which revealed
an ACUTE ISCHEMIC STROKE. A stroke is a condition where a blood
vessel providing oxygen and nutrients to the brain is blocked by
a clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- plaque buildup in your arteries in your brain. We have started
you on atorvastatin to help correct this.
Please take your other medications as ___
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these ___
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the ___
- sudden drooping of one side of the ___
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of
___
- sudden blurring or doubling of ___
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
10338774-DS-7 | 10,338,774 | 29,910,399 | DS | 7 | 2130-08-23 00:00:00 | 2130-08-23 17:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen / Benadryl
Attending: ___
Chief Complaint:
Auditory hallucinations
Major Surgical or Invasive Procedure:
LP ___
History of Present Illness:
Mr ___ self presented to ___ today for worsening AH and
paranoia. He has had these symptoms for some months, seeming
corresponding with the onset of his BK viremia. He has no prior
episodes of psychiatric disease. Mr ___ describes auditory
hallucination with a voice making comments about his life, some
of which are in context and some that are not. He believes the
voices are coming through the TV and radio. He also reports
ongoing fatigue symptoms and the feeling that something isn't
right and that he is being watched. He denies SI/HI. He overall
is tired and feels down. He reports compliance with his
medications and does report that he has had a tough time keeping
medical appointments.
He states that he was hospitalized at ___ in ___ last week for the same issue. He states
that he was monitored and kept for about 4 days. He was told
that his symptoms were due to marijuana use.
This AM patient states that he continues to hear voices, but
they do not command him. No VH. He states that he thinks that
the police have done this.
Past Medical History:
PMHx:
- ESRD on HD (anuric since ___ MWF
- Hypertension
- Hyperlipidemia
- Borderline Diabetes
- Hepatitis C Virus
- Heroin/Cocaine Abuse (last ___ yrs ago)
- Active Marijuana Use
- Hyperparathyroidism
- Constipation
- Folliculitis s/p furuncle resection on left face c/b sensory
changes
- BK nephropathy
- Psychosis
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
General: Anxious-appearing, awake, alert in NAD
HEENT: Sclera anicteric. Dry mucous membranes,
CV: RRR, no m,r,g. Normal S1 and S2.
Lungs: CTAB with faint end exp wheeze in bases, no r/r. equal
movement b/l Abdomen: Renal transplant in LLQ non-tender.
ABdomen otherwise soft, NT/ND. NABS Ext: No ___ edema, no c/c
Neuro: Moving all extremities with purpose, no facial asymmetry,
normal gait. Skin: Multiple keloid scars. WWP
Discharge Physical exam:
VS: 98.1 ___ 18 95%RA
General: Anxious-appearing, pleasant, alert in NAD
HEENT: NCAT.
CV: RRR, + murmur
Lungs: CTAB
Abdomen: Renal transplant in LLQ non-tender. Abdomen otherwise
soft, NT/ND.
Ext: No ___ edema, no c/c
Neuro: Moving all extremities with purpose, no facial asymmetry,
normal gait.
Skin: Multiple keloid scars. WWP
Pertinent Results:
Admission labs:
___ 01:10AM BLOOD WBC-7.8 RBC-4.68 Hgb-13.4* Hct-43.1
MCV-92 MCH-28.6 MCHC-31.1* RDW-16.0* RDWSD-54.2* Plt ___
___ 01:10AM BLOOD Neuts-74.5* Lymphs-13.3* Monos-9.8
Eos-1.0 Baso-0.6 Im ___ AbsNeut-5.78 AbsLymp-1.03*
AbsMono-0.76 AbsEos-0.08 AbsBaso-0.05
___ 07:00AM BLOOD ___ PTT-31.6 ___
___ 01:10AM BLOOD Glucose-166* UreaN-24* Creat-2.2* Na-138
K-4.0 Cl-108 HCO3-20* AnGap-14
___ 07:00AM BLOOD ALT-44* AST-30 LD(LDH)-224 AlkPhos-209*
TotBili-0.5
___ 07:00AM BLOOD Albumin-4.2 Calcium-9.5 Phos-3.2 Mg-1.7
___ 07:00AM BLOOD VitB12-480 Folate-9.0
___ 07:00AM BLOOD TSH-0.88
___ 07:00AM BLOOD PTH-458*
___ 07:00AM BLOOD Cortsol-13.5
___ 07:00AM BLOOD ___
___ 07:00AM BLOOD CRP-0.6
___ 05:05AM BLOOD HIV Ab-Negative
___ 01:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs:
___ 05:50AM BLOOD WBC-6.6 RBC-4.28* Hgb-12.4* Hct-39.5*
MCV-92 MCH-29.0 MCHC-31.4* RDW-16.3* RDWSD-54.9* Plt ___
___ 05:50AM BLOOD Glucose-128* UreaN-34* Creat-2.3* Na-139
K-3.9 Cl-104 HCO3-21* AnGap-18
___ 04:50AM BLOOD ALT-47* AST-30 AlkPhos-203* TotBili-0.6
___ 05:50AM BLOOD Calcium-9.8 Phos-3.3 Mg-1.9
CSF results:
Test Name Flag Results Unit
Reference Value
--------- ---- ------- ----
---------------
Herpes Simplex Virus PCR
Specimen Source ___
HSV 1, PCR Negative
Negative
HSV 2, PCR Negative
Negative
___ 04:20PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
___ ___ 04:20PM CEREBROSPINAL FLUID (CSF) TotProt-32 Glucose-94
Imaging:
EKG ___:
Sinus rhythm. Left atrial abnormality. Leftward precordial R
wave transition point. Compared to the previous tracing of
___ there is no significant diagnostic change. QTc 410.
MRI Head ___:
IMPRESSION:
1. No acute infarction or intracranial abnormality.
2. Chronic infarction in the right occipital lobe.
3. Diffuse T1 hypointense signal in the calvarial bone marrow,
which may be seen in the setting of anemia, obesity, or
processes involving hematopoietic bone marrow reconversion.
Brief Hospital Course:
Mr ___ is a ___ year old man with a PMH notable for ESRD
secondary to glomerulonephritis, status post failed LRT (___)
graft failure (___) who underwent HLA high-risk kidney
re-transplant (___) with post-operative course c/b BK
nephropathy and ongoing BK viruria/viremia who is admitted for
auditory hallucinations and paranoia.
ACUTE ISSUES
# AH/Psychosis: Patient has a history of fixed paranoid
delusions since at least ___, with 2 months of AH and command
AH. Age on onset atypical and suggests an underlying medical
issue for these symptoms. Continued to hear voices and
experience paranoia while inpatient. Brain MRI showed no acute
abnormality. Tox screen was negative although patient does admit
to recent marijuana use. ALT and Alk Phos elevated but down from
previous. TSH, B12, Folate, ceruloplasmin, CRP/ESR, cortisol
within normal limits. ___ negative. HIV and treponemal
antibodies negative. UA negative. CSF HSV negative. BK viral
load ___ serum, ___ urine. Per psych, there are case
reports of BK viremia in kidney transplant pts that cause NMDA
encephalopathy. Patient has psych follow up at ___
___ set up as well as psych ___. He was started on
risperidone 1mg qAM 2mg qHS. NMDA Abs and ___ virus are pending
on discharge.
# ___/ ESRD: s/p DDRT (High risk HLA donor ___ following
failed LRDRT, Creatinine has been rising over months
post-transplant. Has known DSAs and BK nephropathy. Had some
improvement with fluids. Deferring bx for now as likely
progression of BK nephropathy.
# Immunosuppresion: s/p DDRT (High risk HLA donor ___
re-transplant). Continued home everolimus 2mg BID & prednisone.
Goal everolimus levels of ___
# Prophylaxis: S/p valganciclovir course, continued home Dapsone
# BK viremia/viuria/ BK nephropathy: BK viral load ___ serum,
___ urine. On everolimus immunosuppression as above. Has
IVIG set up as outpatient.
# Anemia: Had acute drop ___ of 1pt Hgb. No signs/sx bleeding.
Remained stable, patient may have been dry.
CHRONIC ISSUES:
# DM: Patient reportedly should be on insulin, but is not taking
of his own choice. He was managed on insulin sliding scale.
Fasting blood sugars remained in 100s.
# Hypertension: Continued home amlodipine, hydralazine and
labetalol.
# HCV (+): followed by Hepatology. Plan for Harvoni/ribavirin
following resolution of BK virus treatment.
TRANSITIONAL ISSUES:
=====================
- NMDA receptor antibody, paraneoplastic panel, ___ virus from
PCR pending at time of discharge
- Patient will need follow up labs checked on ___.
- patient started on risperidone 1mg qAM and 2mg qPM daily
during hospitalization
- patient to follow up with ___, first
appointment ___ at 4pm.
- Biologic company contacted, they will contact patient to
resume IVIG week of ___
- Evaluate if patient would benefit from diabetes medications.
AM BGs in 100s during this admission.
# CODE: Full (confirmed)
# CONTACT: ___ (mother) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amlodipine 5 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Dapsone 100 mg PO DAILY
4. Everolimus 2 mg PO BID
5. HydrALAzine 25 mg PO Q6H
6. Labetalol 800 mg PO TID
7. Omeprazole 20 mg PO DAILY
8. PredniSONE 7.5 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Sodium Bicarbonate 1300 mg PO TID
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Dapsone 100 mg PO DAILY
4. Everolimus 2 mg PO BID
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. HydrALAzine 25 mg PO Q6H
7. Labetalol 800 mg PO TID
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 7.5 mg PO DAILY
10. Sodium Bicarbonate 1300 mg PO TID
11. RisperiDONE 2 mg PO QHS
RX *risperidone 1 mg 2 tablet(s) by mouth every evening Disp
#*60 Tablet Refills:*0
12. RisperiDONE 1 mg PO QAM
RX *risperidone 1 mg 1 tablet(s) by mouth every morning Disp
#*30 Tablet Refills:*0
13. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
14. Vitamin D ___ UNIT PO DAILY
15. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 ___ to clean area on skin every
morning Disp #*14 Patch Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
paranoia
renal transplant
BK viremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you were hearing voices. We
did a medical work-up, which was reassuring. You were also seen
by psychiatry while you were here and were started on a new
medication. It is important that you continue to take this
medication every day as prescribed. Please also follow up with
psychiatry. ___ has set up an appointment for
you. The information for the appointment is below.
You also will need labs checked on ___. Please get them
checked at ___ as you usually do. You will also getting a call
about IVIG from the infusion company.
It has been a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
10338774-DS-8 | 10,338,774 | 21,037,991 | DS | 8 | 2131-10-24 00:00:00 | 2131-10-24 20:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen / Benadryl / latex / iodine
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
LEFT HEART CATHETERIZATION ___ and ___
PERCUTANEOUS CORONARY INTERVENTION
History of Present Illness:
___ with HLD, HTN, CKD s/p s/p failed LRKT ___, re-txp ___,
CVA, Hep C who presented with chest pain to OSH.
Patient reports that he had been feeling chest pain for about a
week, on and off, which would last for minutes at a time.
Endorses shortness of breath, but this did not really accompany
the chest pain specifically and was more in line with his
baseline asthma. Reports no decreased urine output but does say
that urine looks darker. Denies cough, sputum production,
fevers/chills, palpitations, orthopnea, decreased exercise
tolerance.
AT OSH, was noted to be hypoxic to 94% on 2L NC. Had EKG with
downsloping STEs in I, aVL, new from prior. Also found to have
troponin elevation to 6.2. Was started on nitro gtt with
subsequent resolution of his chest pain, as well as heparin gtt,
full dose ASA, Benadryl, and 60 solumedrol. patient also had CXR
with increased lung volumes without acute process, and US of RLE
without DVT, as patient initially endorse RLE swelling.
Patient was transferred to ___ for further evaluation. Initial
vitals:
T 98.1 HR 63 BP 124/76 RR 18 O2 sat 94% NC. In ___ ED, noted
to
have trop elevation 0.72 without evolving changes. Remained
chest
pain free. Seen by renal transplant team and cardiology; started
on heparin gtt and admitted to cardiology for evaluation of
NSTEMI.
Past Medical History:
PMHx:
- ESRD on HD (anuric since ___ MWF
- Hypertension
- Hyperlipidemia
- Borderline Diabetes
- Hepatitis C Virus
- Heroin/Cocaine Abuse (last ___ yrs ago)
- Active Marijuana Use
- Hyperparathyroidism
- Constipation
- Folliculitis s/p furuncle resection on left face c/b sensory
changes
- BK nephropathy
- Psychosis
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
============================
VS: T 97.8 BP 133/85 HR 59 RR 18 O2 sat 92%RA
GENERAL: Patient lying in bed, not in acute distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Moist mucus
membranes.
NECK: Supple without visibly elevated JVP
CARDIAC: Normal S1S2, RRR, no murmurs
LUNGS: No respiratory distress. Diffusely wheezy and
rhonchorous.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm, well-perfused, no lower extremity edema.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAMINATION:
============================
VS: T 98.0 PO BP 144/88 HR 85 RR 18 O2 92 RA
GENERAL: Patient lying in bed, NAD
HEENT: NCAT. Sclera anicteric. EOMI. Moist mucus membranes.
NECK: no JVP
CARDIAC: regular rate and rhythm, no rubs murmurs or gallops
LUNGS: clear to auscultation bilaterally
ABDOMEN: 2 scars bilaterally lateral abdomen from kidney
transplants, Soft, non-tender over transplant site. L groin
dressing in place. No evidence of hematoma. DP pulse 2+
EXTREMITIES: Warm to touch. no cyanosis, clubbing, edema
Pertinent Results:
ADMISSION LABS:
==============
___ 01:02AM BLOOD WBC-9.7 RBC-4.33* Hgb-12.6* Hct-40.0
MCV-92 MCH-29.1 MCHC-31.5* RDW-16.2* RDWSD-55.7* Plt ___
___ 06:00AM BLOOD Neuts-86.5* Lymphs-3.9* Monos-8.5
Eos-0.3* Baso-0.1 Im ___ AbsNeut-9.92*# AbsLymp-0.45*
AbsMono-0.98* AbsEos-0.03* AbsBaso-0.01
___ 07:00PM BLOOD ___ PTT-107.4* ___
___ 07:00PM BLOOD Glucose-183* UreaN-25* Creat-2.5* Na-136
K-5.5* Cl-101 HCO3-13* AnGap-22*
___ 07:00PM BLOOD CK(CPK)-954*
___ 07:00PM BLOOD CK-MB-62* MB Indx-6.5*
___ 07:00PM BLOOD cTropnT-0.72*
___ 01:02AM BLOOD CK-MB-56* cTropnT-0.74*
___ 06:00AM BLOOD CK-MB-49* cTropnT-0.71*
___ 07:00PM BLOOD Calcium-10.2 Phos-2.6* Mg-1.7
___ 01:02AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:20AM BLOOD Lactate-2.5*
___ 07:00PM BLOOD EVEROLIMUS, 8.2
___ 04:00AM BLOOD EVEROLIMUS, 11.8
DISCHARGE LABS:
==============
___ 05:40AM BLOOD WBC-10.9* RBC-3.90* Hgb-11.3* Hct-36.0*
MCV-92 MCH-29.0 MCHC-31.4* RDW-16.1* RDWSD-54.4* Plt ___
___ 05:40AM BLOOD Glucose-195* UreaN-37* Creat-2.2* Na-138
K-4.6 Cl-103 HCO3-22 AnGap-13
___ 05:45AM BLOOD CK-MB-4 cTropnT-1.73*
___ 09:50PM BLOOD cTropnT-1.40*
___ 05:30AM BLOOD Calcium-10.0 Phos-2.8 Mg-1.9
IMAGING RESULTS:
==============
CHEST AP ___:
AP portable upright view of the chest. Metallic stent is seen
in the right
upper arm. The heart remains moderately enlarged. There is no
focal
consolidation concerning for pneumonia. No large effusion or
pneumothorax.
No signs of congestion or overt edema. Mediastinal contour
appears stable and
within normal limits. Bony structures are intact.
RENAL TRANSPLANT ULTRASOUND ___:
The left iliac fossa transplant renal morphology is within
normal limits. The
cortical echogenicity, pyramids, and hilar fat are within normal
limits.
There is no hydronephrosis and no surrounding fluid collection.
Again seen is a rounded focus of turbulent to and fro flow at
the
corticomedullary junction, inferiorly consistent with an
arteriovenous
fistula, unchanged from prior. The resistive index of
intrarenal arteries
ranges from 0.67 to 0.76, within the normal range. The main
renal artery
shows a normal waveform, with prompt systolic upstroke and
continuous
antegrade diastolic flow, with peak systolic velocity of 88
cm/s. Vascularity
is within normal limits throughout transplant. The transplant
renal vein is
patent and shows normal waveform.
A small bladder diverticulum is noted.
ECHOCARDIOGRAM ___:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe basal
inferior hypokinesis. Quantitative (3D) LVEF = 47%. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation.
CORONARY ANGIOGRAM ___:
Right dominant
LM: No disease.
LAD: Mid LAD focal 50% stenosis.
LCx: No signficant disease.
RCA: Proximal hazy lesion concerning for thrombus. Distal hazy
lesion also concerning for bulky thrombus (? embolic from
proximal lesion).
CORONARY ANGIOGRAM ___:
Dominance: Right
The RCA lesions in the proximal and distal vessel were unchanged
compared with prior and were each 80% and 90% respectively.
Impressions:
1. Successful PCI of RCA with DES.
Recommendations
1. Secondary prevention CAD. 2. ___. 3.
ASA81mgaday.
Brief Hospital Course:
Key Information for Outpatient ___ with HLD, HTN, CKD
s/p s/p failed LRKT ___, re-txp ___, CVA, Hep C who presented
with chest pain to OSH with trop elevation concerning for
NSTEMI, also noted to have ___ of unclear etiology. He underwent
a coronary angiogram on ___ that showed RCA irregularities,
did not pursue intervention due to concern of high contrast load
for his kidney transplant. He was returned to the floor for
medical management and taken back to the cath lab on ___
where he received 2 stents to the RCA. He was discharged to home
with close follow up with his primary care provider, Dr. ___
___ for cardiology, and Dr. ___ nephrology.
ACTIVE ISSUES:
=================================
#NSTEMI
Patient presented with chest pain, possible ischemic ST changes
on EKG, and trop/MB of 0.72/62 concerning for ACS; He was loaded
with aspirin and placed on a heparin drip. He underwent a
coronary angiogram on ___, where a RCA thrombus visualized.
However it was planned for him to have intervention after
further medical management so that there would be less risk to
his transplanted kidney. He was placed on an eptifibitide gtt
x24 hrs. On ___ he was taken back to the cath lab for 2
stents in the RCA, and was started on Plavix and taken off the
heparin drip. He was given both pre- and post-procedural
hydration, and his creatinine remained stable following both
procedures. He should continue taking Plavix 75 daily, ASA 81 mg
daily, carvedilol 25 mg BID, atorvastatin 80 mg QHS, and
sublingual nitro as needed. TTE showed mild regional left
ventricular systolic dysfunction LVEF = 47% and mild mitral
regurgitation.
# ___: Renal following. Cr peaked at 2.7, downtrended slightly
and now back to baseline (2.2) upon discharge. Unclear etiology.
Followed by renal transplant. BK virus ___. Creatinine did
not show any major elevation in response to either of patient's
cath procedures. He will have follow up as listed below for his
kidney transplant.
# Hyperkalemia:
# metabolic acidosis: Seen by renal transplant. Likely secondary
to kidney injury. His K peaked at 5.5 twice during
hospitalization but required no intervention. For his acidosis,
he was recommended to start on sodium bicarbonate. Follow up
with kidney transplant as noted below.
#Positive UTox for amphetamines and opioids. Utox was noted to
be positive for amphetamines and opiates although patient denies
any drug use. Opiates may be from morphine given at prior
hospital, but amphetamines are unlikely related to any
administered or prescribed medications.
# Hyperglycemia: Noted on BMP; has also been present during
prior admissions. A1C normal in ___. Was placed on an insulin
sliding scale, but did not require much insulin. ___ consider
re-checking A1c as an outpatient.
# Hypoxia: Patient had 2 L O2 requirement at OSH, then was
weaned off O2, noted to have wheezing on exam that improved with
albuterol. CXR clear.
CHRONIC/STABLE ISSUES:
=================================
#ESRD s/p LRKT: Complicated by BK viremia and nephropathy in
past, with high risk HLA donor. His everolimus level was noted
to be high so his dose was decreased to 1.5 mg BID. He should
continue his everolimus at 1.5 mg twice daily, prednisone 5 mg
daily, and dapsone 100 mg daily. He should have a lab check to
ensure his everolimus level is therapeutic. His calcium was
slightly elevated so his calcitriol was discontinued.
#HTN: His home hydralazine and labetalol were discontinued to
start carvedilol. His carvedilol was uptitrated as tolerated by
his heart rates to 25 mg PO BID. His amlodipine was increased
from 5 to 10 mg daily for further blood pressure management.
-amlodipine 10mg daily
-Carvedilol 25 mg PO BID
#Insomnia/Anxiety
-Klonopin 1 mg q8h PRN
#History of psychosis
-risperidone 2 mg BID
#GERD
-omeprazole 20 daily
> 30 minutes spent on discharge planning/coordination of care
TRANSITIONAL ISSUES:
====================
[ ] Re-check A1c given elevated fasting sugars seen during
hospitalization.
[ ] Please follow up with Dr. ___, on ___ with a lab
check on ___ to check an everolimus trough (before AM dose) and
creatinine.
[ ] Ensure patient compliant with aspirin and Plavix regimen.
[ ] Check blood pressure, heart rates to assess response to
carvedilol 25 mg BID.
[ ] Please follow up with Dr. ___ on ___ from cardiology.
# CODE STATUS: Full
# CONTACT: ___, Mother, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. amLODIPine 5 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Dapsone 100 mg PO DAILY
5. Everolimus 2 mg PO BID
6. HydrALAZINE 25 mg PO Q6H
7. Labetalol 800 mg PO TID
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 5 mg PO DAILY
10. RisperiDONE 2 mg PO BID
11. Vitamin D ___ UNIT PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO BID:PRN constipation
14. Sodium Bicarbonate 650 mg PO BID
15. ClonazePAM 1 mg PO QHS:PRN insomnia
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually q5minPRN Disp
#*1 Package Refills:*0
6. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Everolimus 1.5 mg PO BID
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
9. ClonazePAM 1 mg PO QHS:PRN insomnia
10. Dapsone 100 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. PredniSONE 5 mg PO DAILY
14. RisperiDONE 2 mg PO BID
15. Senna 8.6 mg PO BID:PRN constipation
16. Sodium Bicarbonate 650 mg PO BID
17. Vitamin D ___ UNIT PO DAILY
18.Outpatient Lab Work
ICD 9 code: ___
check: everolimus level (before morning dose), Chem 10; fax
results to: ___ MD-- ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
================
NON-ST ELEVATION MYOCARDIAL INFARCTION
CORONARY ARTERY DISEASE
ACUTE ON CHRONIC KIDNEY INJURY
SECONDARY DIAGNOSIS:
===================
HYPERTENSION
HYPERLIPIDEMIA
END STAGE RENAL DISEASE STATUS POST KIDNEY TRANSPLANT
HEPATITIS C VIRUS
CORONARY ARTERY DISEASE
HISTORY OF CEREBROVASCULAR ACCIDENT
INSOMNIA
ANXIETY
GASTROESOPHAGEAL REFLUX DISEASE
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 at the ___
___.
Why was I admitted to the hospital?
-You were admitted because you had chest pain at an outside
hospital. You were found to have a heart attack and were
transferred to ___ to see if you needed a procedure to
treat the heart attack.
What happened while I was in the hospital?
-You were given medications to treat your heart attack.
-You underwent a procedure called a "catheterization", where
doctors looked at your heart and then placed a "stent" into your
heart which improves blood flow and helps prevent another heart
attack.
-You were seen and evaluated by our kidney transplant doctors
who made some changes to your medications.
What should I do after leaving the hospital?
-It is very important to take your aspirin and clopidogrel (also
known as Plavix) every day.
-These two medications keep the stents in the vessels of the
heart open and help reduce your risk of having a future heart
attack.
-If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents and you may have
another heart attack.
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below, including your
kidney transplant doctors
- Have lab check on ___ to check your everolimus and
creatinine level
- Seek medical attention if you have new or concerning symptoms
or you develop chest pain, swelling in your legs, abdominal
distention, or shortness of breath at night.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Cardiology Team
Followup Instructions:
___
|
10338774-DS-9 | 10,338,774 | 29,831,175 | DS | 9 | 2132-11-27 00:00:00 | 2132-11-27 16:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen / Benadryl / latex / iodine
Attending: ___
Chief Complaint:
Nausea, vomiting, abdominal pain, constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a history of ESRD ___
glomerulonephritis s/p failed living-related renal
transplantation in ___ (graft failed in ___, who was
re-transplanted on ___ C diff colitis, CAD s/p stenting
to
RCA ___, transferred from OSH for pyuria and leukocytosis.
Patient reports 2 days of non-bilious vomiting, with difficulty
keeping down PO. Has been able to take meds, only missed dose
was
evero last night in the ED. Reports he was in his usual state of
health previously. Denies diarrhea, denies fevers or chills.
Last
BM 2 days ago, thinks he hasn't been passing gas since
yesterday.
No dysuria, hematuria. Urine output relatively unchanged
although
darker in the setting of taking in less fluid. No CP, SOB. OSH
CT
showing multiple dilated fluid filled small bowel loops and
distal ileum small bowel wall thickening. OSH Cr 2.33, WBC 13.5.
In the ED, patient not hypotensive, tachycardic, satting well on
RA. Afebrile. Cr 2.2, 2.1 which is at recent baseline. Bicarb
slightly low at 20. CT with e/o possible SBO, subtle perinephric
stranding. Transplant US unremarkable, although with trace
ascites noted. CXR unremarkable. UA without e/o infection or
inflammation but w/ elevated protein. Patient given LR, Lasix,
Zofran, MS.
___ the ED initial vitals:
T 98.0, HR 81, BP 143/96, RR 18, SpO2 95% RA
Exam notable for: Diffusely wheezy, normal work of breathing,
RRR, Abdomen soft, non-distended, mild periumbilical and
suprapubic tenderness w/o rebound, mild bilateral CVA tenderness
Labs notable for:
CBC: WBC 12.5, Hgb/Hct 14.5/44.5, Plt 129
Chem7: BUN/Cr ___
LFTs: AST 61, Lipase 109
Coags: Not measured
Imaging notable for:
___ CXR PA/Lat: No acute cardiopulmonary process.
___ Renal Transplant U/S:
1. Grossly similar appearance of AV fistula in the left lower
quadrant renal transplant.
2. Otherwise, unremarkable renal transplant ultrasound with
resistive indices within normal limits. No hydronephrosis.
3. Trace ascites inferior to the spleen.
___ CT A/P w/o Contrast:
1. Mildly distended loops of small bowel without distal
decompression or transition point is suggestive of ileus. As
oral
contrast has not yet reached the large bowel, repeat radiograph
in ___ hours can be obtained to assess for passage into the
colon.
2. Segmental small bowel wall thickening and mesenteric edema is
suggestive of enteritis, likely infectious or inflammatory.
However, given its segmental nature and the degree of the
patient's atherosclerosis, ischemia cannot be excluded.
3. Subtle perinephric stranding about the transplant kidney is
nonspecific and could be related to mesenteric free fluid
elsewhere or suggest infection or less likely rejection.
4. Punctate nonobstructing stone in the renal transplant.
5. Diffuse osseous sclerosis may suggest renal osteodystrophy.
Consults: Renal transplant. Recommended admission to ET. Check
CMV, Urine Pr:Cr ratio, bowel rest.
Patient was given: Morphine sulfate 4 mg IV x6, 3 L LR IVF,
Ondansetron 4 mg IV x4, Furosemide 20 mg PO, Ceftriaxone 1 g IV,
Everolimus 1.5 mg, Prednisone 5 mg, ASA 81 mg PO, Clopidogrel 75
mg PO, Risperidone 4 mg PO
ED Course: CT A/P showed perinephric stranding and concern for
partial SBO. He received CTX 1 g IV. Renal transplant evaluated
and recommended admission to ET for management of partial SBO
and
did not recommend further Abx.
Upon arrival to the floor, patient reports his abdominal pain
has
greatly improved. He is interested in trying to eat dinner.
Denies fevers, chills.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
PMHx:
- ESRD previously on HD now s/p 2 renal xplants (___)
- Hypertension
- Hyperlipidemia
- Borderline Diabetes
- Hepatitis C Virus
- Heroin/Cocaine Abuse (last ___ yrs ago)
- Active Marijuana Use
- Hyperparathyroidism
- Constipation
- Folliculitis s/p furuncle resection on left face c/b sensory
changes
- BK nephropathy
- Psychosis
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION:
==========
VS: T 98.1 | BP 150/96 | HR 70 | RR 18 | SpO2 93% RA
GENERAL: Alert, well appearing, walking around patient room. In
no acute distress.
HEENT: NC/AT, Anicteric sclera, pink conjunctiva. MMM
NECK: Supple, no JVD
HEART: Normal rate and rhythm. Normal S1 and S2. No murmurs,
rubs, gallops.
LUNGS: Diffuse wheezes bilaterally. No rhonchi or rales. No
increased work of breathing.
ABDOMEN: Normal bowel sounds throughout. Soft. Mildly distended.
Tympanitic to percussion. Mildly tender in RLQ and suprapubic
regions without rebound or guarding. Renal transplant palpable
in
LLQ, nontender.
EXTREMITIES: Warm. No cyanosis, clubbing, or edema. 2+ pedal
pulses bilaterally.
NEURO: AAOx3. Motor and sensory function grossly intact
throughout.
DISCHARGE:
===========
Vitals: ___ 2313 Temp: 98.3 PO BP: 153/84 HR: 78 RR: 18 O2
sat: 95% O2 delivery: RA
General: Alert, oriented, no acute distress
HEENT: No pallor or icterus, conjunctiva and sclera clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally except for faint wheeze
Abdomen: Soft, non-tender, non-distended; high pitched bowel
sounds; no tenderness over allograft
Ext: No clubbing, cyanosis or edema
Neuro: No focal deficits, normal speech
Pertinent Results:
ADMISSION LABS:
===============
___ 03:16PM WBC-9.3 RBC-4.79 HGB-13.6* HCT-43.9 MCV-92
MCH-28.4 MCHC-31.0* RDW-15.7* RDWSD-52.8*
___ 03:16PM NEUTS-80.3* LYMPHS-6.8* MONOS-11.1 EOS-0.6*
BASOS-0.4 IM ___ AbsNeut-7.46* AbsLymp-0.63* AbsMono-1.03*
AbsEos-0.06 AbsBaso-0.04
___ 03:16PM PLT SMR-VERY LOW* PLT COUNT-59*
___ 07:02AM GLUCOSE-117* UREA N-28* CREAT-2.1* SODIUM-139
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-21* ANION GAP-18
___ 05:02AM GLUCOSE-118* UREA N-28* CREAT-2.1* SODIUM-135
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-20* ANION GAP-16
___ 01:37AM URINE HOURS-RANDOM CREAT-207 TOT PROT-272
PROT/CREA-1.3*
___ 01:37AM URINE UHOLD-HOLD
___ 01:37AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 01:37AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-600*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 01:37AM URINE RBC-5* WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 01:37AM URINE MUCOUS-RARE*
___ 12:54AM LACTATE-1.0 K+-5.7*
___ 12:45AM GLUCOSE-109* UREA N-30* CREAT-2.2*
SODIUM-134* POTASSIUM-6.2* CHLORIDE-101 TOTAL CO2-20* ANION
GAP-13
___ 12:45AM estGFR-Using this
___ 12:45AM ALT(SGPT)-35 AST(SGOT)-61* ALK PHOS-84 TOT
BILI-0.9
___ 12:45AM LIPASE-109*
___ 12:45AM ALBUMIN-3.7
___ 12:45AM WBC-12.5* RBC-5.07 HGB-14.5 HCT-44.4 MCV-88
MCH-28.6 MCHC-32.7 RDW-15.9* RDWSD-51.1*
___ 12:45AM NEUTS-76.7* LYMPHS-9.2* MONOS-12.0 EOS-1.0
BASOS-0.4 IM ___ AbsNeut-9.55* AbsLymp-1.15* AbsMono-1.50*
AbsEos-0.12 AbsBaso-0.05
___ 12:45AM PLT COUNT-129*
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-7.9 RBC-4.57* Hgb-12.8* Hct-40.1
MCV-88 MCH-28.0 MCHC-31.9* RDW-15.4 RDWSD-49.5* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-70 UreaN-23* Creat-2.0* Na-142
K-3.8 Cl-102 HCO3-24 AnGap-16
___ 06:50AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.7
___ 06:50AM BLOOD EVEROLIMUS, BLOOD-PND
MICROBIOLOGY:
=============
___ 1:37 am URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 12:45 am BLOOD CULTURE Site: ARM
Blood Culture, Routine (Pending): No growth to date.
IMAGING STUDIES:
================
CXR:
No acute cardiopulmonary process.
RENAL TRANSPLANT US:
1. Grossly similar appearance of AV fistula in the left lower
quadrant renal
transplant.
2. Otherwise, unremarkable renal transplant ultrasound with
resistive indices
within normal limits and similar to prior. No hydronephrosis.
3. Trace ascites inferior to the spleen.
CTAP:
1. Mildly distended loops of small bowel without distal
decompression or
transition point is suggestive of ileus. As oral contrast has
not yet reached
the large bowel, repeat radiograph in ___ hours can be obtained
to assess for
passage into the colon.
2. Segmental small bowel wall thickening and mesenteric edema is
suggestive of
enteritis, likely infectious or inflammatory. However, given
its segmental
nature and the degree of the patient's atherosclerosis, ischemia
cannot be
excluded.
3. Subtle perinephric stranding about the transplant kidney is
nonspecific and
could be related to mesenteric free fluid elsewhere or suggest
infection or
less likely rejection.
4. Punctate nonobstructing stone in the renal transplant.
5. Diffuse osseous sclerosis ___ suggest renal osteodystrophy.
Brief Hospital Course:
___ PMH ESRD ___ glomerulonephritis status post failed
living-related kidney transplantation in ___ (graft failed in
___, who was re-transplanted on ___ C.diff colitis,
HTN, HLD, CAD s/p stenting to RCA ___, transferred from OSH
for pyuria and leukocytosis.
ACUTE ISSUES:
=============
#Ileus of unclear etiology
Presented with nausea and vomiting in the setting of no bowel
movements for 2 days, CTAP more consistent with ileus than with
mechanical bowel obstruction. Segmental small bowel wall
thickening and mesenteric edema was also noted, suggesting that
the ileus may have been an atypical manifestation of infectious
enteritis. This would be consistent with the patient's mild
leukocytosis upon transfer (WBC 12.5), which resolved as he
began to feel better. He was never febrile but he is on systemic
immunosuppression. He was kept NPO for ___ hours for bowel
rest, did not receive any antibiotics, and ultimately had a
bowel movement prior to discharge after receiving a Bisacodyl
suppository.
# Perinephric stranding
# Report of pyuria
The OSH from which he was transferred had reported pyuria, but
his UA was notable only for proteinuria here and his urine
culture was negative except for skin contamination. His Cr was
at his baseline, and he had no renal graft tenderness on exam.
Our CT abdomen did reveal subtle perinephric stranding around
the renal allograft, but in light of the above this was thought
more likely to represent surrounding inflammation from enteritis
rather than a primary renal process.
CHRONIC ISSUES
===============
# ESRD ___ glomerulonephritis status post failed living-related
kidney transplantation in ___ (graft failed in ___, who was
re-transplanted on ___: Postoperative course has been
complicated by BK nephropathy and ongoing BK viremia. Prior high
level DSAs noted, but Post-tx specimen ___ with low-level
DSA. Baseline Cr ___ The patient was at this baseline during
his hospital stay. He continued everolimus 1.5mg q12h,
prednisone 5mg daily for immunosuppression.
TRANSITIONAL ISSUES:
====================
- no medication changes
- f/u CMV VL
- f/u everolimus trough & titrate dosage accordingly
- f/u pending blood culture (although do not suspect it will
grow)
- CTAP with small bowel wall thickening & mesenteric edema may
require further workup if patient's enteritis symptoms recur
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 37.5 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Dapsone 100 mg PO DAILY
7. Everolimus 1.5 mg PO BID
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
9. Omeprazole 20 mg PO DAILY
10. PredniSONE 5 mg PO DAILY
11. RisperiDONE 4 mg PO BID
12. Aspirin 81 mg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Sodium Bicarbonate 650 mg PO BID
15. ClonazePAM 0.5 mg PO BID
16. OXcarbazepine 300 mg PO BID
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Carvedilol 37.5 mg PO BID
5. ClonazePAM 0.5 mg PO BID
6. Clopidogrel 75 mg PO DAILY
7. Dapsone 100 mg PO DAILY
8. Everolimus 1.5 mg PO BID
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
10. Omeprazole 20 mg PO DAILY
11. OXcarbazepine 300 mg PO BID
12. PredniSONE 5 mg PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN wheezing
14. RisperiDONE 4 mg PO BID
15. Sodium Bicarbonate 650 mg PO BID
16. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ileus of unclear etiology, possibly atypical gastroenteritis of
unknown pathogen
Secondary:
End stage renal disease ___ glomerulonephritis s/p 2 renal
transplants (most recent ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had abdominal pain
and nausea.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We got a CT scan of your abdomen showing that you were
constipated
- We gave you a suppository and you had a bowel movement and
felt better
- Your kidneys were working just fine
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
- Seek medical attention if you have more nausea and abdominal
pain, or other concerning symptoms
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10339317-DS-21 | 10,339,317 | 26,032,056 | DS | 21 | 2174-10-16 00:00:00 | 2174-10-16 17:35:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / Flomax / gemcitabine
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with PMH presumed
COPD,
stage IV bladder cancer s/p cystectomy, bilateral DVT, HTN
presenting to OSH with 2 weeks of dyspnea progressively
worsening
over the past 48 hours, transferred from ___ with
concerns of new onset heart failure and possible pulmonary
embolus.
At ___ he was hypoxic on room air when he arrived. His symptoms
were thought possibly due to COPD exacerbation (though patient
denied diagnosis, has significant smoking history). He was given
nebulizers for wheezing, 125 mg IV Methylpred, and BiPAP and had
initial improvement, but then had worsening shortness of breath
and nausea. ED team was concerned his symptoms may also be
related to pulmonary embolism given patient's known history of
iliac vein thrombosis. Bedside TTE was done which showed
"bilateral B-lines. Left and right heart with decreased EF. No
definite right heart strain. No pericardial effusion." He was
given 20 mg IV Lasix. Case was discussed with cardiology.
Patient
requested transfer to ___. He was also hypertensive and
started
on nitro, heparin drip, given azithromycin for concern for CAP.
He reported intermittent compliance with Lovenox, which was
being
used to treat a recently diagnosed iliac vein thrombosis.
___ notable for:
INR: 1.13 ___: 14.6 PTT: 46
NTproBNP: 4517
WBC 8.4 Hb 8.5 Plt 239
Na 136 BUN 85 Cr 3.26 HCO3 18 AGap=15 ___
Ca: 8.5
ALT: 41 AP: 80 Tbili: 0.8 Alb: 3.4
AST: 53 LDH: Dbili: Tprot: 6.1
Troponin I: 0.16
Upon transfer to ___ ED, patient denied fevers, chills, cough,
chest pain.
Renal was consulted, reported:
"He reports he has had slowly increasing shortness of breath for
the past 2 weeks, with significant orthopnea. Has also been
intermittently nonadherent to his Lovenox for his iliac vein
thrombosis. Otherwise has been in relatively usual state of
health. Has been on carboplatin and gemcitabine, which was
started ___ C5 week 1 started ___. Not on any other
nephrotoxic medications. Denies any OTC painkillers. Has had
edema in his ankles since ___, unchanged until last week when
he noted increased swelling in the LLE. No new rashes. No change
in output from urostomy, no discolored urine. No herbal
medications. No fevers/chills. Has required multiple RBC
transfusions for anemia over the past several months; review of
___ records also with multiple episodes of
thrombocytopenia."
Additionally, he was recently seen ___ by oncology at ___
and reported lymphedema of the left leg, had an u/s showing a
partially occlusive thrombus in the proximal to mid femoral
vein.
He had been on 100 mg Lovenex daily (1.5 mg/kg for 70 kg) with
slight thrombus forming per the note and was instructed to
increase to 80 mg BID (1.5 mg/kg at 80 kg), but it seems that
the
patient did not do this.
In the ED,
Initial Vitals: 97.3 90 169/85 18 96% bipap
Exam:
Airway: Airway is patent BiPAP in place
Breathing: Breath sounds bilaterally are rhonchorous and wheezy
throughout, with equal rise and fall of the chest
Circulation: Palpable radial pulse
Disability: GCS 15, pupils are ___ on the right ___ on the left,
extremity movements are equal in all extremities
Exposure: Evidence of trauma none, evidence of rash none
Pertinent secondary exam findings are:
Extensive 2+ pitting edema to the posterior thigh, JVD to the
earlobe
Labs:
Hb 7.3
proBNP: >35000
Cr 3.3, BUN 86, HCO3 17, P 6.9
Trop T 0.10 -> 0.09
UA with ___, Sm bld, Neg Nit, 21 WBC, Mod Bact
Urine:
UreaN 565
Creat 60
Na 42
K 39
Osmolal 408
blood gas (ordered as arterial, unclear how collected)
___
Imaging: see below
Consults: renal
Interventions: Received Ceftriaxone 1g, Nitro drip, Heparin
drip
VS Prior to Transfer: 98 91 147/90 15 97% bipap
Upon arrival to MICU, patient feels tired and not interested in
talking, but he does tell me he has had a productive cough and a
few days to a week of dyspnea. His breathing feels better with
the mask on. He asks me to speak with his partner ___ for
further information. She tells me he has only had a few days of
dyspnea. He has been sleeping sitting up. He has had no
fevers/chills or other infectious symptoms that she knows of.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
metastatic bladder cancer (to pelvic LNs) s/p palliative
cystectomy in ___onduit, s/p
pembrolizumab
(___?), cisplatin/radiation, cycle #5, week 1 of
carboplatin and gemcitabine
Transfusion dependent anemia (He has required transfusion nearly
monthly)
DVT ___ s/p a/c
DVT ___
perineal abscess drainage
TURBT.
Hypertension
Social History:
___
Family History:
Per OMR:
His brother had prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: reviewed in metavision
GEN: NAD
HEENT: on BiPAP
NECK: JVP elevated
CV: RRR, S1/S2, no obvious murmur
RESP: diffuse end-expiratory wheeze
GI: NABS, soft, ND/NT, ileal conduit RLQ
MSK: ___ pitting edema b/l LEs, legs lukewarm, feet mottled,
cold
SKIN: no major rash
NEURO: alert, oriented, follows commands
PSYCH: initially somnolent, then anxious appearing
DISCHARGE PHYSICAL EXAM:
=======================
___ 98.2 PO 142 / 73
L Sitting 69 18 98 Ra, wt 180 lbs
GENERAL: sitting in recliner, NAD.
HEENT: NCAT. MMM.
CARDIAC: RRR. Normal S1/S2. No murmurs, rubs, or gallops. No JVD
appreciated.
PULMONARY: Diffuse rhonchi, inspiratory wheeze, No increase
work of breathing.
ABDOMEN: Soft, non-tender, nondistended. Urostomy present.
Umbilical, ventral, right inguinal hernia are soft, compressible
EXTREMITIES: 1+ pitting edema in BLEs, 2+ pulses in upper and
lower extremities.
NEURO: A&Ox4. Grossly intact.
Pertinent Results:
ADMISSION LABS:
==============
___ 01:15PM BLOOD WBC-8.5 RBC-2.32* Hgb-7.3* Hct-23.1*
MCV-100* MCH-31.5 MCHC-31.6* RDW-20.1* RDWSD-71.8* Plt ___
___ 01:15PM BLOOD ___ PTT-122.6* ___
___ 01:15PM BLOOD Glucose-152* UreaN-86* Creat-3.3*# Na-139
K-5.2 Cl-104 HCO3-17* AnGap-18
___ 01:15PM BLOOD Albumin-3.9 Calcium-8.5 Phos-6.9* Mg-2.5
___ 01:33PM BLOOD pO2-88 pCO2-38 pH-7.28* calTCO2-19* Base
XS--7 Comment-SAMPLE TYP
___ 01:33PM BLOOD Lactate-1.7
IMAGING:
========
TTE ___:
IMPRESSION: Moderate to severe regional left ventricular
systolic dysfunction, c/w multivessel CAD or a non-coronary
process. Mild regional right ventricular systolic dysfunction.
Mild aortic regurgitation. Mild mitral regurgitation. Moderate
pulmonary hypertension. Small pericardial effusion.
RENAL U/S ___
IMPRESSION:
No hydronephrosis.
CXR ___
In comparison with the study of ___, there has been
substantial increase
in the diffuse bilateral pulmonary opacifications. This most
likely
represents acute pulmonary edema associated with bilateral
pleural effusions
and compressive basilar atelectasis. Nevertheless, in the
appropriate
clinical setting, it would be impossible to exclude superimposed
aspiration/pneumonia, especially in the absence of a lateral
view.
Renal US ___:
IMPRESSION:
Patient is status post cystectomy. No evidence of renal calculi
or
hydronephrosis.
DISCHARGE LABS:
===============
___ 01:39PM BLOOD WBC-6.0 RBC-2.35* Hgb-7.1* Hct-22.2*
MCV-95 MCH-30.2 MCHC-32.0 RDW-18.4* RDWSD-59.7* Plt ___
___ 07:00AM BLOOD WBC-6.0 RBC-2.18* Hgb-6.6* Hct-20.9*
MCV-96 MCH-30.3 MCHC-31.6* RDW-17.9* RDWSD-59.1* Plt ___
___ 01:39PM BLOOD PTT-49.6*
___ 07:00AM BLOOD Glucose-105* UreaN-112* Creat-5.5*
Na-132* K-4.0 Cl-90* HCO3-24 AnGap-18
___ 06:15AM BLOOD Glucose-111* UreaN-109* Creat-6.1*
Na-132* K-4.0 Cl-89* HCO3-23 AnGap-20*
___ 04:34AM BLOOD ALT-9 AST-10 AlkPhos-54 TotBili-0.3
___ 07:00AM BLOOD Calcium-8.0* Phos-7.6* Mg-2.0
Brief Hospital Course:
PATIENT SUMMARY:
================
___ with metastatic bladder cancer s/p cystectomy, multiple
DVTs, transferred from ___ to the ___ MICU for hypoxic
respiratory failure in the setting of new reduced ejection
fraction heart failure, which was improved with aggressive
diuresis and complicated by hemolytic anemia and renal failure,
most likely secondary to gemcitabine-associated thrombotic
microangiopathy.
ACUTE ISSUES:
=============
# ACUTE HYPOXIC RESPIRATORY FAILURE
# ACUTE SYSTOLIC HEART FAILURE
Presented with dyspnea which was suspected primarily from
pulmonary edema, pleural effusions thought likely from acute
systolic heart failure. TTE showing regional wall motion
abnormality and EF 30% with moderate to severe regional left
ventricular systolic dysfunction, c/w multivessel CAD or a
non-coronary process, mild regional right ventricular systolic
dysfunction, mild aortic regurgitation, mild mitral
regurgitation, moderate pulmonary hypertension, small
pericardial effusion, concerning for possible drug induced
cardiotoxicity. Differential for acute onset HFrEF included
multivessel coronary artery disease vs immune checkpoint
inhibitor (pembrolizumab)-associated myocarditis. He may
consider cardiac catheterization after renal function improves
but this was not pursued during this hospitalization as his
creatinine remained above 3 for the duration of the
hospitalization. ICI-induced myocarditis is less likely given
timing (last dose pembro ___ and given lack of rapid
clinical deterioration typical for ICI-induced myocarditis. Iron
studies and SPEP/UPEP not indicative of other non-ischemic
cardiomyopathy.
He was initially admitted to MICU for BiPAP, which was weaned to
NC shortly after arrival. Respiratory failure likely driven by
volume overload in setting of acute decompensated HFrEF (EF
30%), with rapid improvement in respiratory status with
diuresis. He initially required a lasix gtt but was transitioned
to 100 mg IV boluses. Unfortunately, his renal function worsened
with diuresis despite remaining clinically volume overloaded. He
was briefly trialed on PO Torsemide 80mg then 100mg but had poor
urine output. IV Furosemide was then restarted but ultimately
discontinued ISO continued worsening of kidney function.
Decision was made to give him a diuretic holiday with modest
improvement in Cr to 5.7 but with ongoing ___ edema. He remained
on room air. Mr. ___ was not prescribed a diuretic at
discharge and will follow-up with nephrology and cardiology as
an outpatient to restart diuresis. For afterload reduction, he
obtained adequate control on hydrazine and isosorbide dinitrate.
He was started on carvedilol for neurohormonal blockade.
___ antagonist were not started because
of the degree of renal dysfunction. If renal function improves,
these medications could be started. ***Discharge wt 180 lbs (dry
wt in 160s per pt)
# GEMCYTABINE INDUCED THROMBOTIC MICROANGIOPATHY
Labs notable for hemolytic anemia with significant renal
dysfunction, schistocytes on smear, concerning for
gemcitabine-induced TMA. Hematology was consulted and
recommended that optimal management of likely drug induced TMA
is withdrawal of the offending agent (gemcitabine) and
supportive care. Transfused PRN for HGB <7 (patient received 1
unit RBCs) on ___ and ___. Patient was noted to have a HgB
of 7.1 at discharge with plan to recheck on ___ at ___
___ and transfusion if needed. The patient's
oncologist notified and will seek infusion as an outpatient.
# ___
Per renal, urine microscopy consistent with ATN, with granular
casts including some muddy brown casts, mucus, calcium phosphate
crystals. Etiology likely TMA as above with contribution from
HTN urgency. Renal U/S without evidence of obstruction or renal
vascular abnormalities. The further decline in renal function
was initially attributed to transient hypotension in the setting
of afterload reduction for heart failure. Patient's
antihypertensives were decreased and renal function stabilized
temporarily; however, he became significantly fluid overloaded
with a concomitant rise in creatinine, all concerning for
cardiorenal physiology. He was diuresed with Lasix 100-120 mg IV
boluses but his creatinine remained unstable in the 5 ranges
with fluctuating volume status. Nephrology briefly discussed
dialysis and goals of care with him and his partner given his
worsening kidney function. There was no indication for
initiation of HD this admission. Will have follow-up chemistry
panel ___.
# Hypertension
Patient was hypertensive in the setting of essential
hypertension and TMA. Became hypotensive to SBP ___ in setting
of restarting home medications so backed off initially; however,
blood pressure became and unstable and climbed to 180s. He was
ultimately discharged on Imdur 120mg daily and hydralazine 50mg
TID with care to maintain MAP >65.
# DVT
Known DVT prior to admission. Patient was on heparin gtt
awaiting platelet plateau, then started on warfarin for
anticoagulation. He became supratherapeutic on initial dosing
and remained supratherapeutic despite dose reduction and
cessation. He then became subtherapeutic and was restarted o na
heparin bridge. In discussion with pharmacy, patient's
anticoagulation requirements are confounded by poor nutritional
status making warfarin difficult to manage. Given patient's
strong desire to be at home, we were unable to determine a
warfarin regimen prior to discharge. He was given vit K 10mg PO
and prescribed apixaban 2.5 mg at discharge in the setting of
severely reduced GFR.
# THROMBOCYTOPENIA
Most likely secondary to gemcitabine induced TMA.
Anticoagulation plan as above. Will have follow-up CBC ___.
# URINARY TRACT INFECTION
Patient was febrile overnight to 100.5 F and found to have UA
consistent with urinary tract infection. Treated empirically
with Ceftriaxone. Urine culture grew Enterobacter Aerogenes.
Transitioned to ciprofloxacin for ___t discharge.
# Nutritional Deficiency
Patient was found to have evidence of muscle wasting/ fat
wasting on exam consistent with prolonged nutritional deficiency
and poor PO intake. Initiated on Nepro supplements TID and
encouraged PO as tolerated.
CHRONIC ISSUES:
===============
#Back pain:
He was continued on home Oxy 30, and supportive care. Morphine
SR was discontinued due to renal dysfunction and replaced with
long acting oxycontin.
TRANSITIONAL ISSUES:
====================
[] check hgb ___ at ___, transfuse for hgb <7
[] check chemistry panel on ___ at ___ renal
function and electrolyte imbalances in the setting of holding
diuretic, may need to restart torsemide vs Lasix with metolazone
depending on renal function and volume status
[] Discuss further treatment with oncologist as thrombotic
microangiopathy is attributed to gemcitabine toxicity
[] Patient was not discharged with a diuretic and requires
prompt follow-up with cardiology for new heart failure with
reduced ejection fraction
[] Follow-up with nephrology regarding worsening kidney function
[] Palliative care discussion while inpatient, was referred to
___ to establish care
[] Patient discharged on apixiban 2.5 mg for anticoagulation
[] For UTI, prescribed 5 day course of ciprofloxacin 250mg q12
[] ___ antagonist were not started
because of the degree of renal dysfunction. If renal function
improves, these medications should be started.
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. Prochlorperazine ___ mg PO Q6H:PRN Nausea/Vomiting - First
Line
2. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain -
Moderate
3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
4. NIFEdipine (Extended Release) 60 mg PO ONCE
5. Enoxaparin Sodium 80 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
6. Morphine SR (MS ___ 30 mg PO Q12H
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. CARVedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Ciprofloxacin HCl 250 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
4. HydrALAZINE 50 mg PO Q8H
RX *hydralazine 50 mg 1 tablet(s) by mouth three times a day
Disp #*56 Tablet Refills:*0
5. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
RX *isosorbide mononitrate 120 mg 1 tablet(s) by mouth qAM Disp
#*30 Tablet Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD QAM back pain
RX *lidocaine [Lidocaine Pain Relief] 4 % apply to back qAM Disp
#*14 Patch Refills:*0
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [Senna Lax] 8.6 mg 1 tablet(s) by mouth BID prn
Disp #*28 Tablet Refills:*0
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth three times
a day Disp #*56 Tablet Refills:*0
9. Sodium Bicarbonate 650 mg PO TID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth three times a
day Disp #*56 Tablet Refills:*0
10. Morphine SR (MS ___ 30 mg PO Q12H
11. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
12. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain -
Moderate
13. Prochlorperazine ___ mg PO Q6H:PRN Nausea/Vomiting - First
Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACUTE SYSTOLIC HEART FAILURE
ACUTE HYPOXIC RESPIRATORY FAILURE
GEMCITABINE-ASSOCIATED THROMBOTIC MICROANGIOPATHY
THROMBOCYTOPENIA
HYPERTENSIVE URGENCY
METASTATIC BLADDER CANCER
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___.
WHY WAS I IN THE HOSPITAL?
==========================
You came to the hospital because you had shortness of breath and
were found to be in heart failure.
WHAT HAPPENED TO ME IN THE HOSPITAL?
====================================
In the hospital, you were found to have HEART FAILURE. You
received a medication called FUROSEMIDE (LASIX) to remove the
excess fluid in your lungs and body, which helped with your
breathing. You were also started on a few other medications to
treat the heart failure, including HYDRALAZINE, ISOSORBIDE
DINITRATE, and CARVEDILOL. You will to follow-up with an
outpatient cardiologist to discuss the management of your heart
failure and determine a home diuretic.
You had labs drawn that showed that your blood counts were low,
and you received blood transfusions. Your blood count is low
most likely because one of your cancer treatments, GEMCITABINE,
is causing your red blood cells to be destroyed (THROMBOTIC
MICROANGIOPATHY). You also were found to have low levels of a
component of your blood called PLATELETS, which are important in
forming blood clots in your body. We believe that this was also
a side effect of the GEMCITABINE. Finally, your kidney function
was impaired during this hospitalization, which was also likely
a result of the GEMCITABINE.
You had a blood clot (DEEP VEIN THROMBOSIS) prior to this
hospitalization, and you were initially taking a medication
called LOVENOX. Your kidney function is too slow to take lovenox
right now. During your hospitalization, you were on a similar
medication called HEPARIN, which was delivered through an IV,
which prevented blood clots from forming. You have been
prescribed APIXIBAN for home anticoagulation.
You were found to have a URINARY TRACT INFECTION. We have
prescribed a 5 days course of CIPROFLOXACIN to take at home.
WHAT HAPPENS AFTER I LEAVE THE HOSPITAL?
========================================
- Please weigh yourself daily; if you gain more than 3 lbs in
one day, contact your primary care doctor immediately; your
discharge wt is 180 lbs.
- Please follow-up at the ___ at 8am on
___ for blood transfusion
- Please follow-up with your primary care/nephrologist the week
of discharge
- Please follow-up with your new cardiologist to continue to
manage your new diagnosis of heart failure
- You will need to follow up with your oncologist to discuss the
treatment for your cancer going forward.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10339460-DS-17 | 10,339,460 | 28,646,532 | DS | 17 | 2190-07-12 00:00:00 | 2190-07-14 18:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
decompression and hardware revision on ___, Dr. ___
___ of Present Illness:
This is a ___ with Hx breast cancer metastatic to bone, recently
s/p T12 and L1 laminectomy for bone met, presented 4 days postop
with cord compression, now s/p decompression and hardware
revision on ___, found to have fever, leukocytosis, and
hypotension concerning for sepsis.
The patient was readmitted on ___ with abdominal distension,
leg weakness and fecal incontinence, found to have cord
compression and emergently taken to the OR for decompression. On
admission noted to be afebrile with BP 109/54. During the day on
___ started to have fever to 100 with SBPs 95-105 (of note, her
baseline BPs are in systolics 95-105). She was also noted by
nursing to have some loose stools. Mid-day ___ she was febrile
to 102, and in the mid-afternoon around 3pm was again febrile
with SBP low ___, also accompanied by leukocytosis to ___. She
received a total of 2L IVF boluses for SBP persistently < 90
with low 70/40. Blood culture and stool studies sent. She also
was started empirically on vanco/cipro/flagyl. During this
period she remained asymptomatic, without headache,
lightheadedness, or confusion. Due to her persistent hypotension
despite fluid boluses, as well as concern for multiple potential
sources of infection, she was transferred to the ICU for closer
monitoring.
Patient was mentating well and had normal urine output at the
time. She had no specific symptoms asisde from some
lightheadedness. She was noted to have some diarrhea and
abdominal tenderness on exam. While in the SICU her blood
pressures improved and remained in the 90's to low 100's. She
continued to have normal urine output and without specific
compolaints besides some lightheadedeness. She also remained
afebrile on broad coverage. Blood cultures and urine cultures
were negative to date. There was a left lower lobe opacitiy
noted on chest x-ray however could be atelectasis but could not
rule out pneumonia. Patient is without cough or respiratory
symptoms. She refused to have a CT of her abdomen and refused
repeat chest x-ray. Due to inability to locate source of likely
infection, a transfer to medicine was requested.
On evaluation for transfer, patient is doing overall well but
tearful about her course. She says repeatedly that she believes
she simply needs rest to get better, but that she has not been
allowed to do that here. She is not eager to undergo any further
diagnosic studies.
Review of systems:
(+) Per HPI
Past Medical History:
Breast cancer, bilateral, both ER/PR+,HER-2 amplified,
metastatic to bone (spine) and possibly lungs
HTN
HLD
Social History:
___
Family History:
Her father had prostate cancer in his ___. There is no stated
history of breast or ovarian cancer. It is not clear that she
has ever had a breast biopsy or regular mammogram before the
recent evaluation.
Physical Exam:
admission:
Vitals: 99.6 98.7 64 105/51 12 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur RLSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: + foley draining clear ___: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3. CNs, motor, senstation grossly intact. Dressing on
lower back with drain, c/d/i.
discharge:
Vitals: 98.1 BP 111/54 HR 66 RR 16 02 98%RA
I/O 24 hr: 2750/2550
General: Alert, oriented, no acute distress
HEENT: MMM
Neck: JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur RLSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
___: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: A&Ox3. CNs, motor, senstation grossly intact.
Skin: Blanching erythematous rash on back in a geographic
distribution, mid-line back with sutures.
Pertinent Results:
ADMISSION LABS
___ 02:30AM BLOOD WBC-16.6* RBC-4.21 Hgb-10.9* Hct-32.8*
MCV-78* MCH-25.9* MCHC-33.3 RDW-15.9* Plt ___
___ 02:30AM BLOOD Neuts-80.5* Lymphs-14.8* Monos-3.4
Eos-1.0 Baso-0.4
___ 02:30AM BLOOD Glucose-116* UreaN-14 Creat-0.6 Na-134
K-4.1 Cl-96 HCO3-25 AnGap-17
___ 02:30AM BLOOD ALT-117* AST-81* AlkPhos-1051*
TotBili-0.3
___ 02:30AM BLOOD Albumin-3.0*
___ 02:40AM BLOOD Lactate-1.0
DISCHARGE LABS
___ 06:33AM BLOOD WBC-8.5 RBC-4.18* Hgb-11.0* Hct-34.3*
MCV-82 MCH-26.3* MCHC-32.0 RDW-16.4* Plt ___
___ 06:33AM BLOOD Glucose-102* UreaN-6 Creat-0.5 Na-128*
K-4.0 Cl-97 HCO3-23 AnGap-12
___ 10:20AM BLOOD Na-139 K-3.9 Cl-106
___ 06:33AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.2
___ 06:33AM BLOOD TSH-PND
IMAGING
___ CHEST (PORTABLE AP): No previous images. Cardiac
silhouette is within normal limits. There is indistinctness of
engorged pulmonary vessels, consistent with elevated pulmonary
venous pressure. Left basilar opacification could merely
reflect atelectasis, though in view of the clinical history,
supervening pneumonia must be seriously considered. Small
nodular opacification at the right base laterally was better
evaluated on prior CT scan.
/___ CT L/T SPINE: The patient is status post posterior rod
and transpedicular screw fusion from T11-L3 with the lower half
of T12 through L3 seen on these images without evidence of
hardware loosening or fracture. Partial corpectomy at L1 with
mixed lytic and sclerotic destruction of the vertebral body,
likely pathologic fracture and posterior soft tissue mass is
better assessed on the accompanying MRI but results in narrowing
of the spinal canal in this location despite posterior partial
laminectomies at T12 and L1. Minimal air and fluid
in the posterior soft tissues is consistent with the recent
surgery. Bones are diffusely demineralized consistent with
osteoporosis. No additional bony lesions are identified with
mild L5-S1 and bilateral sacroiliac joint degenerative changes,
slightly more pronounced on the right. Mild atherosclerotic
calcification of the aorta is seen with normal aortic caliber.
Calcified fibroid uterus is better assessed on the prior CT of
the abdomen/pelvis.
IMPRESSION: Posterior rod and screw fusion from T11-L3 without
evidence of hardware related complication including loosening or
fracture. Destructive L1 lesion status post partial corpectomy
with persistent soft
tissue mass resulting in narrowing of the spinal canal, better
assessed on the recent MRI.
___ MR ___ SPINE: Since the previous MRI examination, there
has been laminectomy at the T12 and L1 level with decompression
of central canal. The previously seen severe narrowing of the
spinal canal at the L1 level is no longer visible although
evaluation is limited secondary to artifact from the metallic
implant Pedicle screws seen at T11 T12 to L1 L2 level. There is
no evidence of a intraspinal hematoma is seen. There is no cord
compression identified. Small signal abnormality in T11
vertebra from focus of metastasis again identified unchanged.
No other pathologic fractures are seen. Degenerative changes in
the lumbar spine are again identified as before without
high-grade thecal sac compression.
IMPRESSION: Postoperative changes are identified for fixation of
L1 pathologic fracture. Although the retropulsion of the L1
vertebral body is unchanged, laminectomy has resulted in
decompression of the spinal canal. No intraspinal hematoma is
seen. Although evaluation of the surgical area is limited
secondary to metallic artifact, no obvious high-grade thecal sac
compression seen or spinal cord compression seen in this area.
MICRO:
___ Blood Culture, Routine (Final ___: NO GROWTH.
___ C. difficile DNA amplification assay (Final ___:
Negative
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
This is a ___ with a history of breast cancer metastatic to
bone, recently s/p T12 and L1 laminectomy for bone met, who
presented 4 days postop with cord compression on ___, now s/p
decompression and hardware revision, found to have fever,
leukocytosis, and hypotension concerning for sepsis.
# SIRS/ Suspected Sepsis: The patient was readmitted and taken
to the OR on ___ (see below). On ___ she had abdominal
pain/tenderness and loose stools and was febrile to 102. BPs
were as low as the ___ accompanied by leukocytosis to the
___, though she was asymptomatic. She was resuscitated with IVF
and started on vanco/cipro/flagyl. She was transferred to the
SICU where her BPs stabilized and she remained afebrile. Blood,
urine, and cultures were negative, as was a C.Diff assay. On CXR
there was a LLL opacity (atelectasis vs. pneumonia) but the
patient declined further imaging and she did not have symptoms
suggestive of pneumonia. An infectious source was not
identified, but given her abdominal symptoms an undifferentiated
colitis was suspected. After transfer to the medicine floor she
continued to clinically improve with stable BPs. She was
transitioned to PO cipro/flagyl, and completed a ___onus medullaris syndrome: The patient presented with leg
weakness, fecal incontinence, and urinary retention. Emergent
imaging showed cord compression and she was emergently taken to
the OR for decompression. She underwent the following
interventions:
1. Removal of posterior segmental instrumentation.
2. Revision instrumentation, T11-L2.
3. Thoracolumar corpectomy, L1.
4. T12 laminectomy, biopsy of intraspinal neoplasm.
5. Lateral extracavitary fusion, T12-L1, and L1-2.
6. Posterior fusion, T11-L2.
7. Transpedicular decompression, L1.
8. Open treatment, lumbar fracture.
9. Repair of cerebrospinal fluid leak.
10. Application of wound VAC device
Post-op, she regained fecal continence (with some subjective
urgency) and lower extremity strength but still had a neurogenic
bladder with absent bladder reflex and at discharge was still
requiring an indwelling foley. It is unclear what bladder
function she will regain. The wound vac was removed post-op and
the incision was healing well at discharge. The orthospine team
followed her post-op and they recommended a TLSO brace for
ambulation. Her pain was well-controlled with APAP. She worked
with physical therapy during her admission, and her diet was
advanced to full without incident. At discharge she still
requires a TLSO brace for ambulation.
# Metastatic bilateral breast cancer: Recent diagnosis of left
breast w/ invasive ductal carcinoma, histologic grade 3, ER
positive, PR positive, and HER-2/neu amplified by FISH. Right
breast with invasive carcinoma with ductal and lobular features,
histologic grade 1, measuring at ER positive, PR positive,
HER-2/neu amplified by FISH. Metastatic to bone and possibly
lungs as well. Pending chemotherapy planning. She had rad-onc
___ on ___. She will follow-up with Dr. ___ on ___.
# Rash on back: Geographic in distribution. Erythematous,
blanching papules that are coalescent. Likely miliaria rubra in
the setting of lying on her back for long periods. At discharge
was improving with keeping the skin on her back dry and
application of lotions.
# Polyuria: Pt has been experiencing polyuria, initially ~4L/24
hrs, then to 3L/24hrs, and then has been putting out around
2.5L/24 hrs. Her electrolytes and renal function remained
normal. Uosms >400 so DI less of a concern but if continues
could consider working this up. Given the large amounts of urine
output, her electrolytes and renal function labs should be
repeated on ___.
# Loose stools: At discharge she reported having some loose
stools. Her CDiff was negative earlier in the hospitalization
but if this were to continue and/or WBCs began to rise then
recheck CDiff.
Transition issues:
- She was discharged off heparin prophylaxis as the plan is for
her to ambulate at rehab with ___. If she becomes bed-bound,
consult a physician for SQ heparin vs. pneumoboots for DVT
prophylaxis
- Will have first RT session on ___.
- She should have repeat electrolytes and renal function checked
on ___.
- She will need orthopedic follow-up - an appointment has been
arranged.
- She will need urology follow-up for the urinary retention and
so should see the NP for neurogenic bladder, and for teaching of
self-catheterization if needed - an appointment has been
arranged
- She will need to follow up with Dr. ___ medical
oncologist - an appointment has been made.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO QID
2. Vitamin D 800 UNIT PO DAILY
3. Acetaminophen 1000 mg PO Q8H
<4g/day
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC BID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please hold for RR<10, sedation
9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
Please hold for RR<10, sedation
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 1 TAB PO BID
12. Diazepam 2.5-5 mg PO Q6H:PRN spasms
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Diazepam 2.5-5 mg PO Q6H:PRN spasms
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. Vitamin D 800 UNIT PO DAILY
5. Calcium Carbonate 500 mg PO QID
6. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Cord compression
Presumed sepsis
Secondary diagnosis:
Metastatic breast cancer
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:
Ms. ___:
It was a pleasure to take care of you. You were admitted to the
___ because of urinary retention, abdominal distension, and
back pain. There was concern for spinal cord compression, so you
returned to the operating room on ___ for a decompression
and hardware revision procedure, which went well. After the
procedure, however, you developed fevers, hypotension (low blood
pressure), and leukocytosis (elevated white count), all of which
indicated that you were likely to have an infection. We
monitored you closely, treated you with antibiotics, and gave
you intravenous fluids. We also drew cultures and performed
studies to evaluate for potential causes of the fevers, but this
did not reveal a source. You have completed your course of
antibiotics, and will not need to take them on discharge.
After the surgery your bladder function has not yet returned,
for which you still have a foley catheter in place and should
see the urology specialists.
You will have follow-up with the (1) orthopedic surgeon (Dr.
___, (2) medical oncologist (Dr. ___, (3) radiation
oncologist (Dr. ___, and (4) urologist nurse practitioner.
Please review your medication list closely.
Please follow up with your doctors as below.
Followup Instructions:
___
|
10339460-DS-20 | 10,339,460 | 21,928,991 | DS | 20 | 2196-07-11 00:00:00 | 2196-07-11 19:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Tegaderm / seasonal allergies
Attending: ___.
Chief Complaint:
L hand weakness
Major Surgical or Invasive Procedure:
Radiation Therapy
History of Present Illness:
Ms. ___ is a ___ year old female with metastatic breast cancer
who
presents from ___ clinic to expedited work up of left
arm weakness.
About 3 weeks ago, the patient began to notice the gradual onset
of dull pain and discomfort in her ___ finger on her left had
with proximal radiation to her elbow and scapula. Over the next
few weeks, she has noticed progression of the intensity of her
symptoms and noted that it is exacerbated at night. In addition,
she has noticed subjective weakness in her left hand. She was
seen by Dr. ___ today in ___ clinic for evaluation
who felt that her symptoms were c/w a brachial plexopathy. He
therefore referred her to ___ ED for further work up.
In the ED, the initial vital signs were:
T 98.3 HR 86 BO 145/69 R 16 SpO2 100% RA
Laboratory data was notable for:
Cr ___
Ca 9.8 Mg 1.9 Phos 4.9
Hgb 7.4 MCV 84
The patient received:
___ 19:05 PO/NG Calcium Carbonate 500 mg
___ 19:49 IVF LR 1000 mL
Upon arrival to 11R, the patient endorses the above history. She
is without headaches or vision changes. No fevers or chills. No
neck pain. No history of trauma. No dyspnea, chest pain or
palpitations. No abd pain. no n/v/d. No dysuria. No diarrhea or
constipation. No other paresthesias. No bowel/bladder
incontinence.
ROS: 10 point review of systems discussed with patient and
negative unless noted above
Past Medical History:
PAST ONCOLOGIC HISTORY:
She initially presented with bilateral breast cancer in ___.
On
the left side, she had a high-grade cancer that was HER-___s estrogen receptor positive. She had a
synchronous smaller grade I, double hormone receptor positive,
HER-2/neu negative cancer on the right side.
At the time of our initial evaluation, she was found to have
spinal metastases and spinal cord compression. She underwent
emergency laminectomy followed by radiation therapy to the low
thoracic spine. She had a transient interference with bladder
functioning, but gradually recovered both bladder control and
lower extremity strength. She still walks with a walker for
security, but her gait is quite competent and she has no
residual
bladder dysfunction.
She continues to have discomfort in her back at the area where
she has had decompression and stabilization surgery. However,
there has never been imaging evidence of disease progression at
this site following her initial surgery and radiation.
After her initial surgery and radiation, she began weekly
paclitaxel for 12 weeks with trastuzumab in ___. She
continued on trastuzumab and letrozole after the 12 weeks of
paclitaxel were completed. In addition to daily letrozole and q
3 week trastuzumab, she received periodic treatment with
zoledronic acid.
After an extended period of disease control until ___,
but then developed increasing lesions in her left breast as well
as progression in her lungs and elevated tumor markers. She had
not wished to return to paclitaxel at that point because of
alopecia. Accordingly, she was switched to vinorelbine plus
pertuzumab and trastuzumab. Letrozole was discontinued.
After a relatively short exposure to double antibody +
vinorelbine, she showed further disease progression. We stopped
that regimen and initiated T-DM1 therapy. She again had
evidence
of progression during five cycles of therapy with this agent.
In ___, we attempted therapy with capecitabine and
trastuzumab. She progressed rapidly on this regimen and at that
point, I convinced her to resume paclitaxel with trastuzumab.
This regimen was restarted on ___ and she exhibited
a good response to resumption of the paclitaxel. This continued
until ___, when her local disease again showed evidence
of progression.
At that point, we initiated low dose doxorubicin without
trastuzumab given the potential complications to the heart of
overlapping therapy. She responded well initially to
doxorubicin
at 20mg/M2 given for 2 weeks with a one week break. Her left
breast lesions regressed quite significantly and she remained
well until ___ when subcutaneous nodules in the lower
central left breast were again enlarging. She was otherwise
asymptomatic, and her ECOG PS was 0.
She began therapy with carboplatin and trastuzumab on ___.
She received a day 8 dose of carboplatin on ___.
PAST MEDICAL HISTORY:
Breast Cancer metastatic to bone, skin, lung and liver, as above
GERD
Social History:
___
Family History:
Her father had prostate cancer in his ___. There is no stated
history of breast or ovarian cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.9 BP 135/73 HR 77 R 16 SpO2 97 RA
GENERAL: NAD
HEENT: clear OP, no lesions, moist membranes
EYES: anicteric, PERRL
NECK: supple, no pain on palpation of spinous processes
RESP: CTAB, no wheezing, rhonchi or crackles
___: Regular, no murmurs
GI: soft, non-tender, no rebound or guarding
EXT: warm, no edema
SKIN: dry, no rashes
NEURO: alert, fluent speech. CN II-XII intact. Negative tinel's
sign over ulnar tunnel. Sensation intact in hands b/l. No
decreased muscle bulk in hands. ___ grip strength L hand ___
right hand. Decreased pinky to thumb strength left hand
ACCESS: POC c/d/I
DISCHARGE PHYSICAL EXAM:
VS: 98.0 PO 125 / 80 L Sitting 92 18 98 RA
GENERAL: NAD
HEENT: clear OP, no lesions, moist membranes
EYES: anicteric, PERRL
NECK: supple, no pain on palpation of spinous processes
RESP: CTAB, no wheezing, rhonchi or crackles
___: Regular, no murmurs
GI: soft, non-tender, no rebound or guarding
EXT: warm, no edema
SKIN: dry, no rashes
NEURO: Alert, fluent speech. CN II-XII intact. Negative tinel's
sign over ulnar tunnel. Sensation intact in hands b/l. No
decreased muscle bulk in hands. ___ grip strength L hand ___
right hand. Decreased pinky to thumb strength left hand
ACCESS: PORT c/d/I
Pertinent Results:
LABS:
___ 11:16AM BLOOD WBC-5.4 RBC-2.70* Hgb-7.5* Hct-23.0*
MCV-85 MCH-27.8 MCHC-32.6 RDW-17.3* RDWSD-52.9* Plt ___
___ 05:58PM BLOOD WBC-5.8 RBC-2.70* Hgb-7.4* Hct-22.8*
MCV-84 MCH-27.4 MCHC-32.5 RDW-17.5* RDWSD-52.9* Plt ___
___ 04:44AM BLOOD WBC-6.5 RBC-2.86* Hgb-7.8* Hct-24.0*
MCV-84 MCH-27.3 MCHC-32.5 RDW-17.2* RDWSD-52.0* Plt ___
___ 10:00AM BLOOD WBC-6.0 RBC-3.02* Hgb-8.1* Hct-25.8*
MCV-85 MCH-26.8 MCHC-31.4* RDW-17.6* RDWSD-54.3* Plt ___
___ 05:18AM BLOOD WBC-4.2 RBC-2.44* Hgb-6.6* Hct-20.9*
MCV-86 MCH-27.0 MCHC-31.6* RDW-17.3* RDWSD-53.7* Plt ___
___ 12:49PM BLOOD WBC-5.8 RBC-2.88* Hgb-7.8* Hct-24.7*
MCV-86 MCH-27.1 MCHC-31.6* RDW-17.6* RDWSD-54.7* Plt ___
___ 05:58PM BLOOD Neuts-63.7 ___ Monos-7.4 Eos-0.2*
Baso-0.2 Im ___ AbsNeut-3.70 AbsLymp-1.61 AbsMono-0.43
AbsEos-0.01* AbsBaso-0.01
___ 11:16AM BLOOD UreaN-27* Creat-1.3*
___ 05:58PM BLOOD Glucose-94 UreaN-23* Creat-1.3* Na-141
K-4.3 Cl-99 HCO3-23 AnGap-19*
___ 04:44AM BLOOD Glucose-103* UreaN-21* Creat-1.3* Na-143
K-4.2 Cl-103 HCO3-23 AnGap-17
___ 05:05AM BLOOD Glucose-95 UreaN-26* Creat-1.4* Na-144
K-4.2 Cl-107 HCO3-25 AnGap-12
___ 05:18AM BLOOD Glucose-95 UreaN-33* Creat-1.4* Na-145
K-4.1 Cl-108 HCO3-23 AnGap-14
___ 05:58PM BLOOD ALT-48* AST-60* AlkPhos-652* TotBili-0.3
___ 05:18AM BLOOD ALT-42* AST-66* LD(LDH)-266* AlkPhos-504*
TotBili-0.2
___ 05:18AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.8 Iron-68
___ 05:18AM BLOOD calTIBC-256* Hapto-<10* Ferritn-336*
TRF-197*
IMAGING:
MRI CERVICAL AND THORACIC ___:
IMPRESSION:
1. Metastatic osseous involvement of the C7 vertebral body; with
a moderate
compression deformity of C7 likely reflecting a pathologic
fracture.
2. Metastatic osseous involvement of the right aspect of the T1
vertebral
body. No pathologic fracture of T1.
3. Signal abnormality in the left T3 pedicle may simply
represent stress
reaction however additional metastasis is difficult to exclude.
Attention on
follow-up.
4. No epidural extension of tumor. No leptomeningeal disease.
5. Moderate wedge deformity of T10 with slight retropulsion of
the buckled
posterior, superior vertebral body cortex 5 mm into the spinal
canal; although
new since ___, this is likely chronic.
6. Unchanged postoperative changes in the lower thoracic and
upper lumbar
spine.
7. Degenerative changes in the cervical spine cause moderate
spinal canal
narrowing from C4-5 through C6-7, with slight contact and
remodeling of the
spinal cord. Degenerative neural foraminal narrowing is worst
(moderate to
severe) on the right at C5-6 and bilaterally at C6-7.
8. Mild thoracic spine degenerative changes. No thoracic spinal
canal or
neural foraminal narrowing.
9. Multiple liver and renal lesions were better assessed on
prior dedicated
abdominal imaging studies. Other incidental findings, as above.
CT ABDOMEN ___:
A metastasis in segment V which had measured about 33 x 26 mm in
axial
___ on the prior study has markedly increased. It is
difficult to
measure due to many satellite lesions with which it is
confluent, but the mass
could be considered to measure at least 87 x 86 mm with
extensive new lesions
throughout most of the right lobe. A new left lobe lesion
measures up to 31 x
23 mm (05:55) in the addition to a few additional smaller ones.
The gall
bladder appears normal. There is no biliary dilatation. The
pancreas is
unremarkable. Spleen is normal in size. Adrenals are
unremarkable. No
evidence for stones, solid masses or hydronephrosis involving
either kidney.
Small cyst again noted in the left kidney with increased
density. Moderate
multifocal and global volume loss of the left kidney, also
stable.
Stomach and small bowel appear normal. Large bowel is also
unremarkable.
Appendix appears normal.
Fibroid uterus. No adnexal mass. Bladder appears normal.
Major vascular
structures appear widely patent. Atherosclerotic changes are
moderate in
severity. No lymph adenopathy or ascites.
Spinal findings are stable and described in the separate chest
report.
IMPRESSION:
Marked increase in hepatic metastatic disease. Stable spinal
Findings.
CT CHEST ___:
IMPRESSION:
New suspicious mediastinal lymphadenopathy. Increased lingular
nodule. Few new small pulmonary nodules. Stable spinal
findings.
MRI BRACHIAL PLEXUS ___:
-Osseous metastasis replacing a majority of the C7 vertebral
body with tumor extending into the C7-T1 neural foramina, and
infiltrating the C7 nerve roots.
There is probable involvement of the C8 nerve roots, left
greater than right.
-Additional osseous metastases at C6, T1, and right second rib.
-Possible pathological fracture of the T3 left transverse
process where there
is metastatic involvement.
-Lingular nodule appears slightly larger compared to the prior
chest CT in
___, although this may be due to differences in
technique.
Recommend correlation with a dedicated chest CT for accurate
assessment of
interval change.
-Known mediastinal adenopathy and left breast nodules, better
assessed on
prior CT.
Brief Hospital Course:
Ms. ___ is a ___ with metastatic breast cancer who presented
with progressive L arm/hand pain and weakness and found to have
osseous metastasis replacing a majority of the C7 vertebral body
with tumor extending into the C7-T1 neural foramina, and
infiltrating the C7 nerve roots.
#LEFT ARM WEAKNESS AND PAIN
#Osseous metastatsis infiltrating C7 nerve roots
#NEUROPATHY:
Pain and weakness is in an ulnar distribution localizing to
inferior brachial plexus. Found to have metastatic disease to
cervical spine likely contributing to symptoms at presentation.
MRI showed tumor involvement in the C7-T1 neural foramina, and
tumot infiltrating the C7 nerve roots and possibly C8 nerve
roots. MRI C and T spine showed metastatic osseous involvement
of the C7 vertebral body; with a moderate compression deformity
of C7 likely reflecting a pathologic fracture and metastatic
osseous involvement of the right aspect of the T1 vertebral
body. She had degenerative changes in the cervical spine cause
moderate spinal canal narrowing from C4-5 through C6-7, with
slight contact and remodeling of the spinal cord. Degenerative
neural foraminal narrowing is worst (moderate to
severe) on the right at C5-6 and bilaterally at C6-7. Radiation
oncology was consulted and she received raditional simulation
mapping and went initial fraction of 5 planned fractions on
___.
#ANEMIA:
Patient with anemia most consistent with anemia of chronic
disease. She had spurious lab draws which were likely
dilutional. Haptoglobin, however, was undetectable and raised
concern for possible hemolytic process. Her hemoglobin was
stable on repeat blood draw. Her CBC should be repeated at her
next oncology appointment next week.
#BREAST CANCER
#SECONDARY MALIGNANCY OF LUNG AND LIVER:
Restaging imaging with CT torso on ___ showed marked increase
in hepatic metastatic
disease. Stable spinal Findings. New medistainal adenopathy. She
is due to follow up with Dr. ___ in ___ clinic.
#CKD Stage 3B:
Mildly elevated Cr from baseline of 1.1, however, given
patient's age and weight, her Cr represents moderate decrease in
GFR. No electrolyte abnormalities or volume overload.
She received pre and post hydration in anticipation of CT scan
___.
#GERD: stable
-continued omeprazole
TRANSITIONAL ISSUES:
======================
[] Anemia on labs during admission most consistent with anemia
of inflammation. CBC should be repeated on ___ at next
appointment.
[] Transaminitis, could be secondary to metastatic disease to
liver. Remotely with Hepatitis B core and surface ab positivity
likely reflecting immunity due to native disease, could consider
repeating hepatitis B vl.
[] Scheduled for 5 fractions of radiation therapy, The Ride was
set up to help transport her to and from appointments, ensure
follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
CANCER RELATED NEUROLOGIC CHANGES
METASTATIC 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 weakness in your L hand
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received an MRI, imaging, of your neck and upper back
which showed metastatic cancer causing your hand weakness.
- You were seen by the radiation oncology team and you were
started on radiation treatment.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please call your doctor if you experience any of the warning
signs listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10339460-DS-22 | 10,339,460 | 27,378,668 | DS | 22 | 2196-11-28 00:00:00 | 2196-11-28 16:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tegaderm / seasonal allergies
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
___ 01:35AM BLOOD WBC-7.5 RBC-2.76* Hgb-7.9* Hct-25.6*
MCV-93 MCH-28.6 MCHC-30.9* RDW-20.6* RDWSD-70.2* Plt ___
___ 01:35AM BLOOD Neuts-91.9* Lymphs-2.9* Monos-2.8*
Eos-0.0* Baso-0.3 NRBC-0.5* Im ___ AbsNeut-6.91*
AbsLymp-0.22* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.02
___ 01:35AM BLOOD ___ PTT-71.7* ___
___ 01:35AM BLOOD Glucose-112* UreaN-28* Creat-1.0 Na-147
K-4.3 Cl-112* HCO3-22 AnGap-13
___ 01:35AM BLOOD ALT-84* AST-164* AlkPhos-907* TotBili-1.2
___ 01:35AM BLOOD Lipase-382*
___ 01:35AM BLOOD proBNP-6831*
___ 01:35AM BLOOD Albumin-2.8* Calcium-11.0* Phos-2.5*
Mg-2.2
___ 01:35AM BLOOD TSH-48*
___ 01:35AM BLOOD Free T4-0.3*
___ 05:48AM BLOOD PTH-9*
___ 05:48AM BLOOD 25VitD-60
___ 01:53PM BLOOD ___ pO2-49* pCO2-56* pH-7.30*
calTCO2-29 Base XS-0
___ 01:53PM BLOOD K-3.9
___ 02:21PM BLOOD Lactate-1.1
___ 05:47AM BLOOD freeCa-1.66*
IMAGING:
___ CXR
FINDINGS:
AP portable upright view of the chest. Right chest wall
Port-A-Cath
terminates in the low SVC. Hardware partially visualized within
the lower
thoracic and lumbar spine. Lung volumes are low. Pulmonary
vascular
congestion is suspected with likely mild edema. Bilateral lower
lung
opacities left greater than right raise concern for atelectasis
and effusion,
difficult to exclude pneumonia. The heart size cannot be
reliably assessed.
Prominence of the mediastinal contour is unchanged in the
setting of
mediastinal adenopathy. Bony structures appear grossly intact.
IMPRESSION:
Bibasilar opacities concerning for atelectasis and effusions,
difficult to
exclude underlying pneumonia/metastasis. Likely congestion with
mild edema.
___ CT HEAD W/O CONTRAST
FINDINGS:
No intra-axial or extra-axial hemorrhage, definite signs of
edema, shift of
midline structures, or evidence of acute major vascular
territorial
infarction. Imaged paranasal sinuses are well aerated as are
the mastoid air
cells and middle ear cavities. The bony calvarium is intact.
IMPRESSION:
No acute intracranial process. If there is concern for
metastatic disease,
consider MRI.
___ CXR
IMPRESSION:
Lungs are low volume with stable bilateral pleural effusions
right greater
than left. Cardiomediastinal silhouette is stable. Patchy
parenchymal
opacity in the right apex is unchanged. Right-sided Port-A-Cath
tip projects
to the ___. No obvious pneumothorax is seen.
Brief Hospital Course:
___ F with Metastatic Breast Cancer (on Gemcitabine), presented
to ED from ___ due to TSH 55. She was also found with
anemia, thrombocytopenia, Ca ___. She was admitted to ICU given
agonal breathing. Concern for mets to lung seen on CT and CXR.
Thorough goals of care discussion held with patient and family,
who elected for hospice and comfort care measures only. Risks
and benefits discussed, the patient and family verbalized
understanding and agreed to plan. NP from ___ office visited,
stated this was a reasonable decision. The patient was treated
with morphine and Ativan prn. The patient was discharged to
___ facility.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. LOPERamide 2 mg PO QID:PRN diarrhea
3. DiphenhydrAMINE 25 mg PO Q4H:PRN itching
4. Silver Sulfadiazine 1% Cream 1 Appl TP BID
5. Multivitamins W/minerals 1 TAB PO DAILY
6. calcium carbonate-vit D3-min 2 tabs oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN mild pain,tactile fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions
4. Haloperidol 0.5-2 mg IV Q4H:PRN nausea/vomiting
5. Hyoscyamine 0.125-0.25 mg SL Q4H:PRN excess secretions
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. LORazepam 0.5-2 mg IV Q2H:PRN anxiety
9. Morphine Sulfate ___ mg IV Q15MIN:PRN moderate-severe pain
or respiratory distress
10. OLANZapine (Disintegrating Tablet) 5 mg PO Q4H:PRN delirium
11. Senna 8.6 mg PO BID:PRN Constipation
12. Silver Sulfadiazine 1% Cream 1 Appl TP BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Breast cancer
Metastases to lung
Agonal breathing
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:
Reason for hospitalization:
1) Abnormal breathing
2) Abnormal lab values
Instruction for after discharge
1) Transition to ___ facility for continuing comfort
measures care.
Followup Instructions:
___
|
10339845-DS-10 | 10,339,845 | 26,407,956 | DS | 10 | 2144-11-14 00:00:00 | 2144-11-15 15:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / oxycodone
Attending: ___.
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
Flexible Sigmoidoscopy
MRI Enterography
History of Present Illness:
Ms. ___ is a ___ year-old female with SLE, on plaquenil,
prednisone and methotrexate, with multiple recent ED visits and
an inpatient stay over the past month for abdominal pain with
associated nausea, vomiting, and watery diarrhea.
Past Medical History:
- SLE
- Depression: requiring ___ hospital stay in ___
- Asthma
- Spondylolisthesis: s/p L5-S1 laminectomy and fusion
- Psoriasis with skin manifestations
- Hx multiple concussions with post-concussive syndrome leading
to 1.5 months off of grad school
- Pins in left thumb
- Breast reduction
Social History:
___
Family History:
Mom: ___, fibromyalgia, depression, hypothyroidism,
migraines, thyroid cancer.
Father with psychiatric problems, alcohol use disorder.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS:
___ 1130 Temp: 98.0 PO BP: 97/62 HR: 74 RR: 18 O2 sat: 98%
O2 delivery: Ra
GENERAL: Alert and interactive. Quiet, intermittently rubbing
her
abdomen during interview.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
Slightly dry mucus membranes.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Slightly hyperactive bowels sounds, non distended,
diffusely tender to palpation in all four quadrants. No rebound,
slightly guarded. More tender in suprapubic region
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill approximately 2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation to light touch in all extremities. A&Ox3
DISCHARGE PHYSICAL EXAM:
========================
VS ___ 98.6 PO 99 / 63 Lying 79 16 99 RA
GENERAL: Alert and interactive. Quiet, intermittently rubbing
her
abdomen during interview.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
Slightly dry mucus membranes.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Very thin, + bowels sounds, non distended,
diffusely tender to palpation in all four quadrants. No rebound,
slightly guarded. More tender in suprapubic region
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation to light touch in all extremities. A&Ox3
Pertinent Results:
ADMISSION LABS
===========================
___ 08:35PM PLT COUNT-240
___ 08:35PM NEUTS-53.4 ___ MONOS-10.6 EOS-1.3
BASOS-1.5* IM ___ AbsNeut-2.77 AbsLymp-1.70 AbsMono-0.55
AbsEos-0.07 AbsBaso-0.08
___ 08:35PM WBC-5.2 RBC-4.09 HGB-13.0 HCT-39.0 MCV-95
MCH-31.8 MCHC-33.3 RDW-12.3 RDWSD-42.5
___ 08:35PM tTG-IgA-5
___ 08:35PM IgA-384
___ 08:35PM CRP-0.6
___ 08:35PM CORTISOL-8.1
___ 08:35PM ALBUMIN-4.7 CALCIUM-10.4* PHOSPHATE-5.0*
MAGNESIUM-2.2
___ 08:35PM LIPASE-21
___ 08:35PM ALT(SGPT)-19 AST(SGOT)-26 ALK PHOS-44 TOT
BILI-0.4
___ 08:35PM GLUCOSE-96 UREA N-5* CREAT-1.1 SODIUM-141
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-10
___ 08:41PM LACTATE-0.7
___ 09:30PM URINE MUCOUS-MANY*
___ 09:30PM URINE HYALINE-93*
___ 09:30PM URINE RBC-2 WBC-9* BACTERIA-NONE YEAST-NONE
EPI-3
___ 09:30PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-300*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:30PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 09:30PM URINE UCG-NEGATIVE
___ 09:30PM URINE HOURS-RANDOM
DISCHARGE LABS
===================
___ 08:00AM BLOOD WBC-4.2 RBC-3.79* Hgb-12.0 Hct-35.1
MCV-93 MCH-31.7 MCHC-34.2 RDW-12.4 RDWSD-41.6 Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-68* UreaN-4* Creat-0.8 Na-145
K-3.8 Cl-106 HCO3-27 AnGap-12
___ 05:50AM BLOOD ALT-12 AST-17 Amylase-30 TotBili-0.3
___ 08:00AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.8
___ 05:45AM BLOOD WBC-3.9* RBC-3.30* Hgb-10.6* Hct-31.4*
MCV-95 MCH-32.1* MCHC-33.8 RDW-12.8 RDWSD-43.8 Plt ___
___ 05:45AM BLOOD Glucose-76 UreaN-5* Creat-0.8 Na-142
K-3.8 Cl-105 HCO3-29 AnGap-8*
___ 05:45AM BLOOD Albumin-3.6 Calcium-9.1 Phos-4.9* Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ year-old female with SLE, on plaquenil,
prednisone and methotrexate, with multiple recent ED visits and
an inpatient stay over the past month for abdominal pain with
associated nausea, vomiting, and watery diarrhea. She had an NPO
challenge, in which she did not have any diarrhea and much
reduced abdominal pain. She also had a flex sig and MRE while in
the hospital to further evaluate the etiology of her abdominal
pain, which were both unremarkable. Patient had no diarrhea in
the hospital even with resuming a diet, and reported that her
pain was slightly improved overall. She was evaluated by
psychiatry who believe that she does not have a somatic symptom
disorder. She was started on amitriptyline and dicyclomine to
help with the abdominal pain and cramping.
====================
ACUTE ISSUES:
====================
#Abdominal pain
#Diarrhea
#Nausea/Vomiting
The patient reports a lengthy history of her GI symptoms with
significant interference with her quality of life. Prior workup
for the cause of her abdominal pain has been un-revealing thus
far, with negative endoscopy biopsy results, CT scan,
ultrasound, and KUB, and negative TTG IgA for celiac disease. GI
recommended NPO test to differentiate osmotic vs. secretory and
the patient did not have any bowel movements when she was
fasting. She then had a flex sigmoidoscopy and MRE which were
unremarkable. Stool cultures and laxative studies were sent from
the ED, and are pending on discharge. At the time of discharge,
Ms. ___ had not had a bowel movement in 5 days, which is
normal for her. She was advised to take half a dose of mirilax
(OTC) if she does not have a BM in the next few days.
# PAIN
We had multiple conversations about the management of her
abdominal pain - visceral hypersensitivity etc. She was started
on amitriptyline which will also help with her depression and
she was given information for a nutritionist who specializes in
nutrition for patients with abdominal pain and diarrhea. Of
note, the MRE incidentally notes: 2 hemorrhagic cysts in the
left ovary which could represent hemorrhagic cysts versus
endometriomas. Her pain does not seem to be consistent with
history of endometriosis however, as she describes a relatively
unremarkable menstrual history and symptoms. In addition, there
has been no indication in her extensive imaging that she has
endometiromas elsewhere in the bowel, though it is known that
the severity of the symptoms do not correlate with imaging
findings. Further evaluation of endometriosis as the etiology of
her pain will be a transitional issue.
# Weight loss
The patient reports a weight loss of 40 pounds since ___
EMR shows weight loss of ~30 pounds since ___ to ___
(153.8--> 124.3lbs). This is likely multifactorial, with social
stressors of medical school, pain with eating, as well as
significant nausea/vomiting associated with eating and drinking
all contributing to her food aversion. Continue to encourage PO
intake, nutrient shakes, as well as outpatient nutrition
counseling. Her weight was essentially stable at 55.1 kg at
discharge.
# Orthostatic hypotension
The patient reports dizziness upon standing up. She had an
episode of orthostasis with HR increase to 160s during
admission. She received 2L IVF. Prior to discharge, she had
normal orthostasis. In addition, she has a significant history
of gastrointestinal losses, as well as decreased PO intake for
the past several months. Improvement of symptoms of dizziness
with improved hydration in house. She was tested for adrenal
insufficiency with a cortisol stim test which was normal.
CHRONIC ISSUES:
===============
# SLE
- Continue Methotrexate sodium 10mg ___
- Continue Hydroxychlorquine 200 mg QD
- follow up with her Rhuematologist
# Depression
- Continue home lamotragine
- Currently has outpatient psychiatrist. In addition, the new
prescription of amitriptyline may affect the depression as well
as the hypersensitivity which she describes.
====================
TRANSITIONAL ISSUES:
====================
[] if no BM in a few days after discharge, try Mirilax - OTC
(half a dose).
[] PCP ___
[] follow up with GYN re: incidental finding of ?endometrioma
vs. hemorrhagic cyst, patient will schedule the appointment
[] follow up with GI : GI department will call to schedule.
[] follow up with Rheum : patient has an appointment already
scheduled
[] patient will schedule an appointment with Nutrition, contact
information for nutritionists who specialize in GI issues was
given.
[] follow up laxative screen and Calprotectin pending at time of
discharge
PRIMARY CARE
Name: ___
___, MD, PC
Address: ___, ___
Phone: ___
Appt: ___ at 3:00PM
___ 02:00p ___ (RHEUM LMOB)
___ BUILDING (___), ___ FLOOR
RHEUMATOLOGY ___ (___)
- New Meds: amitriptyline 25 mg po, dicyclomine 10 mg PO/NG TID,
multivitamin, simethicone PRN, miralax PRN
- Stopped/Held Meds: none
- Changed Meds: none
- Post-Discharge ___ Labs Needed: none
- Discharge weight: 55.1 kg (___)
# CONTACT: ___ fiancé ___
# DISPO: Medicine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID:PRN anxiety
2. Hydroxychloroquine Sulfate 200 mg PO DAILY
3. LamoTRIgine 150 mg PO DAILY
4. Clobetasol Propionate 0.05% Gel 1 Appl TP PRN rash
5. FoLIC Acid 1 mg PO DAILY
6. metHOTREXate sodium 10 mg oral 1X/WEEK
7. TraZODone 50 mg PO QHS:PRN insomnia
8. dextroamphetamine-amphetamine 10 mg oral DAILY
9. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Amitriptyline 25 mg PO QHS
RX *amitriptyline 25 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
2. DICYCLOMine 10 mg PO TID
RX *dicyclomine 10 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth once a day
Disp #*30 Capsule Refills:*0
4. Simethicone 40-80 mg PO QID:PRN gas, bloating
RX *simethicone 80 mg 1 1 by mouth once a day as needed Disp
#*30 Tablet Refills:*0
5. Clobetasol Propionate 0.05% Gel 1 Appl TP PRN rash
6. ClonazePAM 1 mg PO TID:PRN anxiety
7. dextroamphetamine-amphetamine 10 mg oral DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Hydroxychloroquine Sulfate 200 mg PO DAILY
10. LamoTRIgine 150 mg PO DAILY
11. metHOTREXate sodium 10 mg oral 1X/WEEK
12. Omeprazole 20 mg PO DAILY
13. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Abdominal Pain
Diarrhea
SECONDARY DIAGNOSIS
====================
SLE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You came to ___ because you were having abdominal pain and
diarrhea.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- You had a flexible sigmoidoscopy and a MR ___ to
better visualize the lumen of the large intestine.
- You were started on a new medicine called amitriptyline to
reduce your abdominal pain and diarrhea
- You were started on Bentyl to help with the abdominal
cramping.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see below).
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10339845-DS-8 | 10,339,845 | 20,474,896 | DS | 8 | 2143-11-15 00:00:00 | 2143-11-17 20:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
pain in shoulders, elbows, hands, and toes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ diagnosed with SLE at age ___ presents
with acute flare of severe pain in shoulders, elbows, hands and
toes.
Pt states that her most recent flare began in the beginning of
___, for which she has been taking prednisone 40mg po qd
(decreased when pain more tolerable, recent 25mg) and plaquenil
x
6 weeks and started methotrexate yesterday. Pt states that she
developed ___ joint pain, redness, swelling, and fatigue. Pt
also noticed throat swelling on the right side making swallowing
difficult in addition to several oral ulcers, now healing. In
addition, in the last week pt reports having a couple days of
low
grade fever, blurry vision, nosebleeds, diarrhea, and joint
pain.
Pt denies chest pain, SOB, dysuria, hematuria, or blood in
stools. No sick contacts.
Per ED, pt has not been on any medication for SLE prior to ___,
no flare in several years. Per her rheumatologist Dr. ___ labs: CRP - 9.6mg/L, ___ - 1:160, DsDNA - 100.
In ED, pt was given IVF, 4 mg morphine x2, methylprednisone
sodium succ 125 mg. Labs showed negative UA, K 6.1 (hemolyzed)
repeat 3.8, WBC 6.3, Hgb 13.0. Urine cx pending. Physical exam
notable for no grossly swollen or erythematous joints,
tenderness
to palpation of shoulders/elbows/hands/fingers/toes, no rash,
and
lungs CTA.
Upon arrival to the floor, pt states that dilaudid has helped
her
pain and that she is able to move better than she was earlier
today. Pt also expresses significant frustration with joint pain
in context of beginning medical school in one week and becomes
tearful on exam.
Past Medical History:
- SLE: diagnosed age ___ at ___ when presented with
hallucinations, rash, hemolytic anemia, lymphadenopathy, fever;
initially treated with IV and then PO steroids, then on Cellcept
and Plaquinil, off immunosupression since ___ followed
by rheumatologist at ___ (Dr. ___ ___
- Depression: requiring ___ hospital stay in ___
- Asthma
- Spondylolisthesis: s/p L5-S1 laminectomy and fusion
- Psoriasis with skin manifestations
- Hx multiple concussions with post-concussive syndrome leading
to 1.5 months off of grad school
- Pins in left thumb
- Breast reduction
Social History:
___
Family History:
Mom: ___, fibromyalgia, depression, hypothyroidism,
migraines, thyroid cancer. Father with psychiatric problems,
alcohol use disorder.
Physical Exam:
Admission Physical Exam
===============
VITALS: HR: 98.3 BP: 122/78 HR: 62 RR: 18 O2: 99 RA
General: Alert, oriented, no acute distress, laying comfortably
HEENT: Sclerae anicteric, MMM, oropharynx clear without
erythema
or edema, EOMI, PERRL, neck supple, no LAD, pt unable to fully
open jaw due to pain
CV: Regular rate and rhythm, physiologic S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: tenderness to mild palpation in LUQ, otherwise soft,
non-tender in any other quadrant, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no erythema, clubbing,
cyanosis or edema
Neuro: moves all extremities with purpose, gait deferred.
Discharge Physical Exam
===============
VS: 99.2 PO 114 / 73 L Lying HR 52 RR 18 99 Ra
GEN: Well-appearing, appropriate
HEENT: Sclerae anicteric, MMM, oropharynx clear without erythema
or edema, EOMI, PERRL, neck supple, no LAD
CV: RRR, physiologic S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: soft, NDNT , normoactive bowel sounds present, no
organomegaly, no
rebound or guarding
Ext: Warm, well perfused, 2+ pulses
MSK: Minor tenderness to palpation of left ___ digit MCP and
PIP,
but no other tenderness to palpations on hands. No tenderness in
elbows, shoulders, knees, and toes. No erythema or edema.
Neuro: full strength throughout, sensation grossly intact, gait
deferred
SKIN: no rashes
Pertinent Results:
Admission Labs
===========
___ 03:18PM BLOOD WBC-6.3 RBC-4.29 Hgb-13.0 Hct-39.0 MCV-91
MCH-30.3 MCHC-33.3 RDW-12.1 RDWSD-40.1 Plt ___
___ 03:18PM BLOOD Neuts-70.4 ___ Monos-8.1 Eos-0.6*
Baso-0.5 Im ___ AbsNeut-4.45 AbsLymp-1.27 AbsMono-0.51
AbsEos-0.04 AbsBaso-0.03
___ 03:18PM BLOOD Plt ___
___ 03:18PM BLOOD Glucose-91 UreaN-9 Creat-1.0 Na-139
K-6.1* Cl-103 HCO3-20* AnGap-16
___ 03:18PM BLOOD
Discharge Labs
==========
___ 07:15AM BLOOD WBC-8.6 RBC-4.27 Hgb-13.0 Hct-39.0 MCV-91
MCH-30.4 MCHC-33.3 RDW-12.1 RDWSD-40.0 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-92 UreaN-6 Creat-0.6 Na-142 K-4.7
Cl-105 HCO3-24 AnGap-13
___ 07:15AM BLOOD ALT-9 AST-17 LD(LDH)-205 AlkPhos-53
TotBili-0.4
___ 07:15AM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.4 Mg-2.1
___ 07:15AM BLOOD ___ Titer-1:160*
dsDNA-POSITIVE*
___ 07:15AM BLOOD C3-94 C4-10
Imaging
======
Spleen US
Unremarkable echogenicity of the spleen, which measures 11.6 cm,
within normal
limits.
Microbiology
========
Urine culture negative
Brief Hospital Course:
___ with SLE presents with fatigue and severe pain in shoulders,
elbows, hands and toes. She has been managed as an outpatient by
her rheumatologist at ___. Recently she has been taking 40mg
po daily of prednisone, plaquenil for 6 weeks, and recently
start methotrexate. Here complement levels were normal, ___ was
positive, and ___ titer, dsDNA and parovirus were pending at
discharge. Aside from her symptoms, there were no objective
findings of systemic disease. UA, Cr, CBC WNL. Rheumatology was
consulted and in conjunction with her outpatient rheumatologist,
recommended IV methylprednisolone 125 mg x2d then PO
methylprednisolone 50mg with slow taper of 5 mg/wk. They also
recommended increase in plaquenil and continuing methotrexate.
She was started on atovaquone for PJP ppx and ranitidine for GI
ppx. For pain control, pt improved with steroids and NSAIDs.
ACUTE/ACTIVE ISSUES:
# Systemic lupus erythematosis:
Pt presented with fatigue, low-grade fever, polyarticular joint
pain with history of SLE is most consistent with uncontrolled
SLE, though the exam was largely unremarkable and no evidence of
renal, hematologic, or serous involvement. Recent labs by OP
Rheum show elevated CRP, dsDNA, and ___. Denies recent
infection. No weakness to suggest neurologic or myopathic
process and no hx or signs of renal failure. C3,C4 levels were
negative and ___, anti-DNA were pending at discharge. Rheum was
consulted and followed patient throughout stay. Patient was
transitioned to methylprednisolone 50mg and continued on
Plaquenil 400 mg PO QD. She will continue methotrexate on her
next dose ___ (last dose ___ and continue folic acid to
prevent MTX side effect
CHRONIC/STABLE ISSUES:
# LUQ tenderness:
Initial presentation with LUQ abdominal tenderness, fatigue.
LFTs, lipase, and spleen U/S unremarkable. Now without pain.
Improved somewhat with treatment of lupus.
# Anxiety/Depression:
Continued on home clonazepam, lamotrigine
=======================
TRANSITIONAL ISSUES:
=======================
MEDICATIONS:
- New Meds: Methylprednisolone (48mg x7d, 42mg x7d, 38mg x7d,
32mg x7d) ibuprofen, ranitidine, atovaquone,
- Stopped Meds: Prednisone
- Changed Meds: Plaquenil 400 mg
FOLLOW-UP
- Follow up: PCP and ___
- Tests required after discharge: As per outpatient
rheumatologist
- Incidental findings: None
OTHER ISSUES:
#CODE: Full (presumed)
#CONTACT: Father (___) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Methotrexate 10 mg PO 1X/WEEK (TH)
2. FoLIC Acid 1 mg PO DAILY
3. Hydroxychloroquine Sulfate 200 mg PO DAILY
4. ClonazePAM 1 mg PO BID anxiety
5. PredniSONE 10 mg PO BID
6. PredniSONE 5 mg PO DAILY
7. LamoTRIgine 150 mg PO QHS:PRN anxiety
8. ClonazePAM 0.5 mg PO Q24: PRN anxiety
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 1500 mg by mouth once a day
Refills:*0
3. Ibuprofen 800 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: d/c naproxen
4. Methylprednisolone 16 mg PO DAILY
RX *methylprednisolone 16 mg 3 tablet(s) by mouth once a day
Disp #*15 Tablet Refills:*0
5. Methylprednisolone 8 mg PO DAILY
RX *methylprednisolone 8 mg 5 tablet(s) by mouth once a day Disp
#*100 Tablet Refills:*0
6. Methylprednisolone 4 mg PO DAILY
7. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
8. Ranitidine 150 mg PO DAILY
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth once a day Disp
#*21 Tablet Refills:*0
9. ClonazePAM 1 mg PO BID anxiety
10. ClonazePAM 0.5 mg PO Q24: PRN anxiety
11. FoLIC Acid 1 mg PO DAILY
12. Hydroxychloroquine Sulfate 200 mg PO DAILY
13. LamoTRIgine 150 mg PO QHS:PRN anxiety
14. Methotrexate 10 mg PO 1X/WEEK (TH)
Discharge Disposition:
Home
Discharge Diagnosis:
1) Systemic lupus erythematosis
# Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you had worsening joint pains and
fatigue consistent with your lupus. Please see more details
listed below about what happened while you were in the hospital
and your instructions for what to do after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- Your steroids were changed and increased in strength and your
hydroxychloroquine was increased in strength
- You were seen by a rheumatologist who helped to manage your
medications.
- You were given pain medication to control your joint pain.
- You were checked for viruses which could have triggered your
flare which were negative
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and
rheumatologist within 2 weeks
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have fevers, chest pain,
shortness of breath, worsening joint pain, or other
lupus-related symptoms.
Followup Instructions:
___
|
10340105-DS-18 | 10,340,105 | 25,558,196 | DS | 18 | 2151-02-06 00:00:00 | 2151-02-06 19:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
codeine / latex
Attending: ___.
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
Cerebral Angiogram
History of Present Illness:
HPI: Ms. ___ is a ___ year old female who was transfered from
___. The patient reported new onset neck pain and
vertigo beginning at 9am. Head CT was obtained at OSH which
revealed a small R parietal SAH. She denies any hx of fall.
Patient is not taking any anticoagulants, no hx of bleeding
disorder. She denies any change in visual acuity, double vision,
blurry vision or overt headache.
Past Medical History:
Type II DM, Migraines, Melanoma
Social History:
___
Family History:
No family hx of aneurysms
Physical Exam:
PHYSICAL EXAM:
O: BP: 177/68 HR:73 R 12 O2Sats097%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2 mm bilaterally EOMs intact
Neck: supple
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. .
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
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
Pertinent Results:
___ CTA
NECT: No acute intracranial process.
CTA: No flow limiting stenosis or aneurysm greater than 3 mm.
___ MRI Brain with and without contrast
Developmental venous anomaly identified in the right parietal
region with underlying susceptibility changes, possibly
consistent with small cavernomas as described in detail above.
Two foci of restricted diffusion noted in the occipital lobes
with no evidence of hemorrhagic transformation, suggestive of
subacute ischemia. Multiple scattered foci of high signal
intensity are visualized on T2 and FLAIR sequences, distributed
in the subcortical white matter, which are nonspecific and may
reflect changes due to
small vessel disease.
___ CT torso
Enhancing hepatic lesion and a hypodense subcentimeter splenic
lesion, may
represent benign entities, such as hemangiomas or hepatic FNH,
but metastatic disease is also a differential consideration. An
MRI is recommended for further characterization.
No evidence for intrathoracic malignancy.
___ lumbar puncture
CSF 2 WBC, 48 RBC, protein 40, glucose 71
Brief Hospital Course:
Ms. ___ was admitted to the hospital for observation and to
undergo further testing. CTA of the head was negative for
aneurysm or a vascular disection. On ___ she underwent a
cerebral angiogram which was negative for any vascular
malformation.
On ___, Ms. ___ met with neurology whose initial
reccomendations including a CT of her torso as well as a lumbar
puncture. Her CT torso showed a 2.4 x 1.9 x 1.7 cm partially
exophytic lesion between segments III/IV b shows
hyperenhancement which likely represents a hemangioma. The
lesion was documented in her chart for follow up with her
primary care doctor.
On ___, Ms. ___ underwent a lumbar pucture the results of
which showed only 2 WBC and normal protein and glucose. Based
on the low WBC count, the suspicion for leptimengeal carncinoma
is low, but cytology is pending at time of discharge and we will
contact her with the final results of the CSF analysis when
done. She should have outpatient follow up with PCP to arrange
an MRI of the abdomen and an echocardiogram.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Subarrachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Dr. ___:
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.
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 (loss of vision, blurring, double vision,
half 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:
___
|
10340309-DS-22 | 10,340,309 | 26,809,865 | DS | 22 | 2137-09-13 00:00:00 | 2137-09-13 10:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Flexeril
Attending: ___.
Chief Complaint:
Wound erythema
Major Surgical or Invasive Procedure:
None on this admission
___: A left-sided common femoral artery to above-knee
popliteal artery with an 8 mm PTFE graft.
History of Present Illness:
___ M s/p Left CFA-AK pop bypass w/ 8mm PTFE on ___
presenting w/increased pain and erythema at the thigh incision
site. Patient had been recovering well although noted an
increase in the severity of his pain over the past
several days as well as small amount of blanching erythema near
the left thigh incision. He had been discharged on Bactrim
because of concern for infection at the left thigh site. At the
time of presentation, the patient was without significant
complaints, he had no chest pain, shortness of breath,
fever/chills/nightsweats, change in bladder habits.
Past Medical History:
PMH: PAD (left SFA occlusion), sciatica, chronic back pain
PSH: ___: left CFA-AK pop bypass w/PTFE,
LLE diagnositc angiogram ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Upon Discharge:
Gen - AAOX3, NAD
CV - RRR
Resp - CTAB no wheezes/crackles/rhonchi
Abd - soft, NT/ND, +BS
LLE - wound with minimal-to-no remaining erythema on thigh
incision; no erythema of groin incision; no drainage from either
incision, no induration, warm limb; Pulses: fem P, pop P, DP P,
___ P
RLE - warm, no cyanosis/clubbing, fem P, pop P, DP P, ___ P;
1-cm-diameter superficial non-draining, non-erythematous ulcer
on right great toe
Pertinent Results:
___ 07:14AM BLOOD WBC-9.5 RBC-5.00 Hgb-15.1 Hct-45.3 MCV-91
MCH-30.2 MCHC-33.4 RDW-13.9 Plt ___
___ 06:55PM BLOOD Neuts-63.5 ___ Monos-4.3 Eos-2.9
Baso-0.7
___ 07:14AM BLOOD Plt ___
___ 06:55PM BLOOD Glucose-78 UreaN-23* Creat-1.1 Na-140
K-5.0 Cl-104 HCO3-25 AnGap-16
CT SCAN (___):
1. Prominent fluid collection adjacent to the distal
anastomotic site of the
patient's left common femoral to popliteal artery PTFE bypass
graft which
measures close to simple fluid in attenuation.
This fluid collection is incompletely evaluated on this non
contrast
examination however a lack of significant surrounding
inflammatory changes
adjacent to this fluid collection suggests this finding likely
represents a
post operative seroma. However, superinfection can not be
excluded.
2. Multiple punctate foci of gas are also present superior to
this fluid
collection of indeterminant etiology.
3. Left common femoral to above-knee popliteal PTFE bypass
graft appears
grossly intact on this non-contrast-enhanced examination.
Expected
postoperative changes are present adjacent to the proximal
anastomotic site.
___ 05:01AM BLOOD WBC-8.9 RBC-4.79 Hgb-14.6 Hct-43.2 MCV-90
MCH-30.5 MCHC-33.7 RDW-14.0 Plt ___
___ 05:01AM BLOOD Vanco-15.8
___ 6:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ was admitted to ___ Vascular Surgical Service
after he visited the Emergency Deparmtent with erythema of his
incision site, from a left above-knee femoral-popliteal bypass
with PTFE on ___. He was admitted to the Vascular Surgical
floor, and placed on IV antibiotics (vancomycin, ciprofloxacin,
flagyl). His erythema was noted to improve signficantly. He was
given a regular diet, his home medications, and pain control. He
was encouraged to continue ambulating regularly and frequently.
On ___, a CT scan was performed, the results of which may be
found in the Pertinent Results section. On ___, a PICC line
was placed. It was decided he would continue on iv vancomycin
and oral cipro and flagyl through ___.
He was seen by chronic pain management as he was asking for
increased narcotics. They recommended tylenol ___ q8h
standing, dilaudid po 2mg q4h prn for pain. They recommended
that he decrease his dilaudid use as his wound improved, and
suggested a transition to tramadol 50mg q6h as needed.
At the time of discharge, the patient had minimal-to-no
remaining erythema. He was able to ambulate indepedently, had
good pain control, was tolerating a regular diet, and was on all
his home medications. He was explained and expressed agreement
with the discharge plan, and was discharged in good condition.
He is going to ___ ___ for continued medical
therapy. We recommend he follow up with podiatry and pain
managment. He has a vascular surgery appt in a week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
6. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Pravastatin 40 mg PO DAILY
3. Acetaminophen 1000 mg PO Q8H
4. Docusate Sodium 100 mg PO BID
5. urea *NF* 20 % Topical bid
apply to right ___ interdigital space on the medial aspect of
the ___ digit
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
7. Vancomycin 1000 mg IV Q 8H
8. Ciprofloxacin HCl 500 mg PO Q12H
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. MetRONIDAZOLE (FLagyl) 500 mg PO TID
12. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PAD
Left lower extremity surgical incision site erythema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, you were ___ with redness around your
surgical incision site. You were started on antibiotics and
monitored closely. You are being discharged on vancyomycin IV,
cipro and flagyl po. The IV vancomycin will be given through the
PICC intravenous line that was placed in the hospital. This can
be removed after you complete your antibiotic course on ___.
Chronic pain mgmt saw you and recommended dilaudid 2mg q4h prn
for pain. They recommend you be titrated off dilaudid and
transitioned to tramadol 50mg q6hprn for pain. They also
recommend tyelnol ___ q6h for pain (this should be a standing
dose). If you have continued pain , you should follow up in a
chronic pain clinic.
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
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
MEDICATION:
Continue to take your ASPIRIN as instructed
Please take the full course of antibiotics as prescribed
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over 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
over the area that is draining, as needed
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
OTHER
As discussed in the hospital, the MOST beneficial lifestyle
modification you can make is to stop smoking. We have many
resources available to assist you with this, and strongly urge
that you continue to try to quit. This is very important for
wound healing, for your vascular health, and to decrease the
risk of complications in the future.
Followup Instructions:
___
|
10340309-DS-25 | 10,340,309 | 24,400,309 | DS | 25 | 2138-01-16 00:00:00 | 2138-01-17 18:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Flexeril
Attending: ___.
Chief Complaint:
L thigh purulent drainage and fevers
Major Surgical or Invasive Procedure:
___: INCISION AND DRAINAGE/ WASHOUT OF LEFT THIGH WOUND
___
___: Excision of left common femoral to above-knee popliteal
polytetrafluoroethylene bypass graft and redo left common
femoral to above-knee popliteal bypass with left long reverse
greater saphenous vein graft.
History of Present Illness:
___ s/p L fem-AK pop bypass graft w/ PTFE ___ ___ c/b seroma
s/p I&D ___ ___, c/b occlusion s/p LLE angio/graft
thrombectomy/proximal stenting on ___, d/c'd home on
___, p/w fevers up to 102, myalgias, L thigh pain, and
purulent drainage from his prior L fem-AK pop (thigh) incision.
Felt well
until the morning of admission, when he felt like "he had the
flu." Reports the incision had drained clear yellow fluid
continuously since the original operation, but it changed to
creamy thick green drainage on day of admission. No n/v/d.
Given 1g vancomycin by ED.
Past Medical History:
PMH: PAD, sciatica, chronic back pain, hypercholesterolemia
PSH: LLE angio (___), L fem-AK pop bypass graft w/ PTFE
(___), I&D LLE graft site (___), LLE angio/graft
thrombectomy/proximal stenting (___)
Social History:
___
Family History:
non-contributory
Physical Exam:
PE: 102.8 113 122/86 20 99%RA
Gen: NAD, A&Ox3
___: tachy, reg rhythm
Pulm: CTA b/l
Abd: soft, NT, ND, +BS
Ext: L thigh incision with surrounding erythema, pinpoint hole
w/
turbid yellow drainage (dressings w/ green purulent drainage),
no
fluctuance/fullness, L groin incision well healed, palp
___ R groin access site well healed, palp ___
DISCHARGE
Vitals: afebrile, vitals stable
Gen: NAD, AAOx3, well appearing
Abd: soft, nontender, nondistended
Cardio: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Ext: left leg with healing incision on medial leg from groin to
knee; two quarter sized areas of nonfluctuant induration at
proximal incision; open wound anterior to distal incision above
knee on medial thigh, approximately 6cm x 3cm, no purulence, no
erythema, mildly tender, granulation tissue
Pertinent Results:
___ 05:57AM BLOOD WBC-4.7 RBC-5.29# Hgb-15.5# Hct-48.3#
MCV-91 MCH-29.4 MCHC-32.1 RDW-14.6 Plt ___
___ 05:38AM BLOOD Glucose-145* UreaN-6 Creat-0.7 Na-138
K-3.9 Cl-102 HCO3-27 AnGap-13
___ 8:13 am SWAB Source: L leg wound.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
CTA ___
Final Report
HISTORY: History of left femoral-popliteal bypass, now with
left leg pain and purulent drainage from the incision site.
Evaluate patency of the bypass graft.
TECHNIQUE: CT of the abdomen, pelvis, bilateral lower
extremities was
performed without administration of IV contrast, followed by
imaging after the administration of IV contrast using a CTA
technique. A total of 100 cc of Omnipaque was administered for
this examination.
COMPARISON: CT examination performed on ___.
FINDINGS:
CTA:
The celiac artery appears moderately narrowed at its origin,
with a large left gastric artery which is also supplying a
replaced left hepatic artery. There is also a prominent and
largely replaced right hepatic artery which arises from the SMA.
The SMA itself appears widely patent. The ___ appears widely
patent. The aorta demonstrates mild atherosclerotic changes
with some lobulation resulting ___ a maximal diameter of
approximately 2.4 cm, but no frank aneurysmal change. Similarly,
the right and left common and external iliac arteries
demonstrate atherosclerotic changes, but without evidence of
focal stricture or significant aneurysmal dilation.
Mild atherosclerotic disease is seen along the right common
femoral artery, without focal narrowing. The right superficial
femoral artery appear grossly patent without evidence of
flow-limiting stenosis. The right popliteal artery appears
widely patent as well. The right anterior tibial artery is well
seen, and the dorsalis pedis artery appear widely patent to the
most distal visualized aspects. There may be mild stenosis at
the origin of the right peroneal artery but beyond this, the
peroneal and posterior tibial arteries otherwise appear to be
widely patent as well. The plantar arch is patent.
The left-sided femoral-popliteal bypass graft appears widely
patent, with a proximal 8.2 cm stent, but appears to run largely
within the left sartorius muscle sheath. The left sartorius
muscle also appears diffusely edematous, particuarly ___
comparison to the right. The graft appropriate inserts onto the
superior aspect of the popliteal artery, and while slightly
narrowed or irregular ___ region, remains patent. Several
stenoses less than 50% are seen along the popliteal artery, with
regions of intervening dilation as well. The left-sided
anterior tibial, peroneal, and posterior tibial arteries, as
well as the dorsalis pedis artery and plantar arch are also
widely patent.
Loculated fluid is seen tracking medially to the skin from the
region the
popliteal anastomosis of the graft, between the sartorius and
vastus medialis muscles. A small amount of fluid is also seen
at the proximal anatomsis ___ the femoral region. The native
left superficial femoral artery is not enhancing.
CT of the Abdomen and Pelvis Without and With IV Contrast:
Allowing for the arterial phase technique, the liver appears
grossly
unremarkable. A 5 x 10 mm low-density focus is seen within the
right lobe of the liver (series 3, image 17) which may represent
a small hepatic hemangioma, but is not confidently characterize
on this study. The gallbladder, spleen, and right adrenal gland
are also unremarkable. The left adrenal gland may be slightly
thickened. The bilateral kidneys appear unremarkable. The
pancreas is unremarkable. There is no abdominal lymphadenopathy
or free fluid.
Examination of the pelvis demonstrates an unremarkable
appearance to the
bladder. The prostate may be minimally enlarged. Large bowel
loops are
grossly unremarkable.
There is no evidence of pancreatic ductal dilation or biliary
ductal dilation. The bilateral kidneys enhance ___ a symmetric
manner.
Assessment of osseous structures does not show suspicious
abnormalities.
3D reconstructions including maximum intensity projections and
volume rendered images were created on an independent
workstation and reviewed at the time of interpretation.
IMPRESSION:
1. Widely patent appearance of the left femoral-popliteal bypass
graft as well as proximal stent. The bypass graft appears to
run within the muscle sheath of the left sartorius muscle. This
was discussed by telephone with Dr. ___ for Dr.
___, at 4:00 pm on ___, at the time of dictation of
the study.
2. Fluid collection ___ the suprapatellar region of the left leg
adjacent to the distal anatomosis, traveling medially to the
skin between the sartorius and vastus medialis muscles. Small
amount of fluid about the left proximal anastomosis is also
noted ___ the femoral region. A small amount of fluid track over
a short length along the graft ___ the proximal and distal
extents.
Brief Hospital Course:
Patient was admitted to the Vascular Surgery service for
management of an infected PTFE bypass graft on the left leg.
Two surgical procedures were performed during this hospital
stay. The first was an I&D of the left leg at the site of the
bypass graft, which occurred on ___ and went without
complication (see operative report for details). The second
procedure was a PTFE graft excision and redo of the left common
femoral to above-knee popliteal bypass with reverse saphenous
vein graft, which occurred on ___ and went without
complication (see operative report for details).
.
The patient was initially started on broad spectrum antibiotics
after the debridement but the wound continued to show signs of
progressive infection so the graft was removed. ID was
consulted for recommendations on antibiotics. The patient was
put on Nafcillin ___ response to wound cultures that grew out
coagulase positive Staph. aureus. The patient stayed ___ house
for the entire 30 day course of his IV antibiotics because of
social issues (his insurance would not cover rehabilitation
facility, the patient lived at a homeless ___ and could not
have IV antibiotics arranged there, see social work note for
details).
.
The wound at the distal medial thigh from the I&D required a
wound vac during the hospital stay; that was discontinued as the
wound improved and the patient was discharged with a wet-to-dry
dressing over the wound.
.
The chronic pain service was consulted for management of the
patient's high narcotic pain medication requirement.
Ultimately, the patient was placed on MS ___ and weaned off
of high dose oral and IV dilaudid. He was discharged with a 10
day supply of the MS ___ and follow up with his PCP was
arranged to manage pain medication requirements as an
outpatient.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 325 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Gabapentin 300 mg PO TID
6. Pravastatin 40 mg PO DAILY
7. Warfarin 1 mg PO DAILY16
8. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
do not take more than 4000mg tylenol ___ any 24 hr period
RX *acetaminophen 325 mg 2 tablet(s) by mouth q8hrs prn Disp
#*60 Tablet Refills:*2
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*3
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
3. Pravastatin 40 mg PO DAILY
RX *pravastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
RX *pravastatin 40 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
4. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*2
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
6. Morphine SR (MS ___ 30 mg PO Q8H
RX *morphine 30 mg 1 tablet extended release(s) by mouth three
times a day Disp #*30 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl [Ducodyl] 5 mg 2 tablet,delayed release (___)
by mouth daily prn Disp #*60 Tablet Refills:*2
9. Calcium Carbonate 500 mg PO QID:PRN GERD
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet,
chewable(s) by mouth qid prn Disp #*60 Tablet Refills:*2
10. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*1
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
- Left common femoral to above-knee popliteal PTFE bypass graft
infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
WHAT TO EXPECT:
1. It is normal to feel tired, this will last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
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 ___ wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Take aspirin as instructed
Follow your discharge medication instructions
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride ___ a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over 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
over the area that is draining, as needed
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase ___ pain that is not controlled with pain
medication
A sudden change ___ the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
___
|
10340309-DS-27 | 10,340,309 | 25,644,297 | DS | 27 | 2138-03-13 00:00:00 | 2138-03-14 20:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Flexeril
Attending: ___.
Chief Complaint:
left lower extremity claudication
Major Surgical or Invasive Procedure:
None; noninvasive imaging only
History of Present Illness:
___ w hx L CFA to AK-pop bypass w PTFE ___ c/b occlusion s/p
PTA/S ___, infxn s/p excision/redo w RGSV ___, stenosis s/p
PTA ___ now presenting with claudication, mild LLE edema and
possible graft restenosis. Patient is well known to vascular
surgery service having had multiple LLE interventions over last
8 months. Patient initially had diagnostic angio ___ followed
by LLE bypass ___. Postop course has been complicated by
seroma requiring I&D ___, graft occlusion requiring
endovascular thrombectomy/proximal stenting ___, MSSA graft
abscess s/p I&D ___, graft excision redo w RGSV ___ and
graft stenosis s/p angioplasty ___. Now presents with LLE
claudication, mild edema x 10 days. States that LLE calf pain
is worse with ambulation, improved with rest. Denies additional
symptoms including fever, chills, chest pain, shortness of
breath, nausea, vomiting, dysuria, ___ wound drainage, skin
changes.
Past Medical History:
PMH: HTN, HLD, PVD, chronic back pain, sciatica Vascular Risk
Factors: HTN, HLD, PVD
PSH: R knee reconstruction (___), LLE diagnostic angiogram via
R CFA (___), L CFA to AK-pop bypass w PTFE
(___), I&D LLE graft site seroma (___),
Endovascular thrombectomy, proximal stenting LLE bypass graft
via R CFA (___), I&D LLE graft site abscess
(___), Excision L CFA to AK-pop PTFE bypass graft and
redo L CFA to AK-pop w RGSV (___), LLE graft
angioplasty via R CFA (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
P/E:
VS: 96.0 85 127/88 20 98%RA
GEN: WD, WN M in NAD
HEENT: NCAT, anicteric
CV: RRR
PULM: CTA B/L, no respiratory distress
ABD: soft, NT, ND
EXT: WWP, well healing LLE incisions at medial aspect w small
area ~1cm granulation tissue - no fluctuance/drainage/erythema,
1+ LLE edema to knee; no edema RLE, No varicosities, No skin
changes
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers
Pulse Exam
Right: femoral palpable, DP dopplerable, ___ dopplerable
Left: femoral palpable, DP dopplerable, ___ dopplerable
Brief Hospital Course:
Due to concern for stenosis or thrombosis of the graft, the
patient was admitted to the vascular surgery service. The next
day, noninvasive studies were ordered. They showed that the left
femoral-popliteal bypass graft was patent. They also showed that
pressures, Doppler, and pulse volume recordings were essentially
normal, just mildly reduced on the left, while the patient was
at rest. Because of this, it was decided that no intervention
should be performed, and the patient was discharged home, doing
well.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Clopidogrel 75 mg PO DAILY
4. HydrOXYzine 25 mg PO TID
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Pravastatin 40 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet,delayed release (___) by mouth
once a day Disp #*30 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every six hours as needed Disp #*30 Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. HydrOXYzine 25 mg PO TID
RX *hydroxyzine HCl 25 mg 1 tablet by mouth three times a day
Disp #*30 Tablet Refills:*0
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth once a day Disp #*30 Tablet Refills:*0
6. Pravastatin 40 mg PO DAILY
RX *pravastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Claudication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Followup Instructions:
___
|
10340309-DS-29 | 10,340,309 | 22,073,663 | DS | 29 | 2138-07-11 00:00:00 | 2138-07-11 08:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Flexeril
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
___: Left lower extremity angiogram - Cutting balloon
angioplasty of proximal in-stent stenosis with a 3.5 x 50 mm
cutting balloon. Stenting of the proximal graft into present
stent with a
6 x 80 mm Zilver PTX stent post dilated with a 5 mm balloon.
6. Closure of access with ___ Perclose device.
History of Present Illness:
___ with h/o L fem-AK pop bypass with PTFE complicated by
occlusion with PTA/stent in ___, complicated by infection s/p
excision/redo with RGSV in ___, complicated by stenosis s/p PTA
___ and again ___ s/p PTA/stent.
He was last seen in ___ clinic with Dr. ___ on ___ when
he reportedly was doing well. A duplex of the graft
demonstrated
some increased velocities in the proximal graft at that time
(317
cm/s); however, given his lack of claudication, he was scheduled
only for routine follow up at that time. ABIs were 1.15 (right)
and 0.78 (left).
Since then, he reports 2 weeks of increasing claudication
symptoms. At present the pain is so severe that he is limited
after only a few steps. He does not endorse rest pain or pain
at
night. He does, however, also complain of swelling in the left
leg and calf tenderness, which increases with dependence and
improves significantly with elevation.
Past Medical History:
HTN, HLD, PVD, chronic back pain, sciatica
PSH: R knee reconstruction (___), LLE
diagnostic angiogram via R CFA (___), L CFA to
AK-pop bypass w PTFE (___), I&D LLE graft site seroma
(___), Endovascular thrombectomy, proximal stenting
LLE bypass graft via R CFA (___), I&D LLE graft site
abscess (___), Excision L CFA to AK-pop PTFE bypass
graft and redo L CFA to AK-pop w RGSV (___), LLE
graft angioplasty via R CFA (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
Gen: WDWN male in NAD
CV: RRR
Lungs: CTA bilat
Abd: Soft no masses/tenderness
Ext: Warm, well perfused. No edema, no wounds.
Pulses: R fem/dp/pt - palp, L fem-palp, dp/pt-dopplerable,
graft-dopplerable
Pertinent Results:
Arterial Duplex LLE
14x step up lesion at the proximal stent
___ 06:36AM BLOOD Hct-43.5
___ 06:36AM BLOOD UreaN-8 Creat-0.8 Na-142 K-4.1 Cl-106
Brief Hospital Course:
Mr. ___ was admitted to the vascular floor from the ED. A
left lower extremity DVT study was negative. An arterial duplex
showed his proximal bypass graft with previous stenting had a
14x step up. He was taken for angiogram on ___ and had ballon
angioplasty of the stenosis, with placement of a zilver stent.
He did well, was perclosed and transfered back to the vascular
floor. He was monitored closely overnight and had stable lab
values on POD 1. He is discharged home in stable condition with
plans to follow up in 1 month with duplex. He should continue
aspirin and plavix for life, and should never stop these without
consulting his vascular surgeon .
Medications on Admission:
Plavix 75', hydroxyzine 25''', metoprolol succinate
ER 50', pravastatin 40', ASA 325'
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*3
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*3
3. HydrOXYzine 25 mg PO TID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Pravastatin 40 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Atherosclerosis - in stent stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin once daily - DO NOT STOP ASPIRIN without
permission from your vascular surgeon
Take Plavix (Clopidogrel) 75mg once daily - DO NOT STOP
ASPIRIN without permission from your vascular surgeon
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
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
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
ACTIVITIES:
When you go home, you may walk and use 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
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
CALL THE OFFICE FOR: ___
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
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
10340309-DS-31 | 10,340,309 | 26,547,620 | DS | 31 | 2139-03-22 00:00:00 | 2139-03-23 00:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Flexeril
Attending: ___.
Chief Complaint:
left lower extremity claudication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PVD with complex vascular history including L CFA to AK
pop bypass with PTFE (___) which was excised and replaced with
RGSV (___), s/p LLE graft angioplasty via R CFA (___) and
most recently LLE angiogram with PTA/stent of mid vein graft and
PTA of proximal vein graft (___) who presents with increasing
claudication. He reports that over the last several weeks his
claudication symptoms have worsened in severity and that he can
only walk ___ yards. He denies any rest pain,
erythema or drainage from the incision. He was last seen by Dr
___ in clinic in ___ at which time he could only walk ___
yards without symptoms. Lower extremity duplex at that time
showed a native right SFA stenosis as the level of ___
canal with a velocity of 313 with a 2.4x step up. The left
femoral to
AK-pop graft was widely patient with some areas of mild to
moderate velocity elevation which was improved when compared to
his pre-angioplasty study. It was thought at that time that his
bilateral lower extremity symptoms may have been related to
neurogenic claudication in light of his recent lower back pain.
He was subsequently referred to the chronic pain clinic. Of note
he has been homeless for the last week and was unable to get
into a shelter tonight. He continues to smoke tobacco.
Past Medical History:
HTN, HLD, PVD, chronic back pain, sciatica
PSH: R knee reconstruction (___), LLE
diagnostic angiogram via R CFA (___), L CFA to
AK-pop bypass w PTFE (___), I&D LLE graft site seroma
(___), Endovascular thrombectomy, proximal stenting
LLE bypass graft via R CFA (___), I&D LLE graft site
abscess (___), Excision L CFA to AK-pop PTFE bypass
graft and redo L CFA to AK-pop w RGSV (___), LLE
graft angioplasty via R CFA (___)
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission physical exam:
Vitals: 96.2 101 144/87 18 96 RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused, no evidence of
ischemia
Pulses: fem pop graft DP ___
R p p - p p
L p p p p p
Discharge physical exam:
Vitals: 97.9/97.9 74 122/77 16 93RA
GEN: A&Ox3, NAD
HEENT: EMOI, nonicteric, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, no respiratory distress
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused, no evidence of
ischemia
Pulses: fem pop graft DP ___
R p p - p p
L p p p p p
Pertinent Results:
Labs:
___ 02:49AM BLOOD WBC-8.4# RBC-4.82# Hgb-14.6# Hct-44.7#
MCV-93# MCH-30.4# MCHC-32.8 RDW-13.9 Plt ___
___ 02:49AM BLOOD ___ PTT-31.1 ___
___ 02:49AM BLOOD Glucose-143* UreaN-15 Creat-0.8 Na-143
K-3.7 Cl-106 HCO3-29 AnGap-12
Images:
Arterial duplex ___: 2.1x step up at distal graft
anastamosis with velocity ~300, AK-pop graft was widely patient
with some areas of mild to moderate velocity elevation
Rest and Exercise ABI/PVR ___: improvement in ABI when
walking
Brief Hospital Course:
Patient was admitted to the vascular surgery inpatient service
for further evaluation and management of left lower extremity
claudication. He received arterial graft duplex and
exercise/rest ABI/PVR exams. Arterial graft duplex showed ~2.1x
step up at the distal anastomosis and exercise ABI/PVR showed no
worsening of measurements during exercise. Of note, the patient
left the hospital floor multiple times to presumably smoke
cigarettes outside. No interventions was given during this
hospitalization. We recommend smoking cessation for the patient
prior to any consideration of further revascularization. The
patient was discharged in stable condition with 3 month
follow-up with Dr. ___.
Medications on Admission:
cilostazol 100 mg tablet BID
clopidogrel 75 mg tablet daily
gabapentin 300 mg capsule TID
metoprolol succinate ER 50 mg daily
pravastatin 40 mg tablet daily
acetaminophen 650 mg every six hours PRN
aspirin 325 mg daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every 6 hours Disp #*5
Capsule Refills:*0
6. Pravastatin 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
left lower extremity claudication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Please follow-up in Dr. ___ in 3 months. At that
time, we will duplex your left leg. Please continue your home
medications once you leave the hospital.
CALL THE OFFICE FOR: ___
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
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
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
10340786-DS-18 | 10,340,786 | 29,938,311 | DS | 18 | 2188-07-25 00:00:00 | 2188-07-26 16:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
mandibular fracture
Major Surgical or Invasive Procedure:
Open reduction, internal fixation right mandibular angle
fracture
History of Present Illness:
Mr. ___ is an ___ healthy male who presents for
evaluation after being struck in the jaw by a helmeted football
player during a game. He reports that he was struck by the other
player's head (helmeted) in the right jaw, with no other sites
of impact, no LOC, full recall, and no headstrike or neck pain.
The patient was also helmeted.
Prior to Trauma Service consultation, the patient underwent a CT
mandible/maxillofacial (full report below) showing a right
mandibular fracture. He was already seen by the ___ service,
please refer to their note for full recommendations (preliminary
recs: requesting a Panorex, BID peridex rinses, and plan for
ORIF on ___.
ROS:
(+) per HPI
(-) Denies fevers chills, night sweats, unexplained weight loss,
fatigue/malaise/lethargy, changes in appetite, trouble with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR, dysphagia, chest pain, shortness of breath, cough, edema,
urinary frequency, urgency
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam:
GCS 15 (E:4 V:5 M:6)
Gen: A&O, NAD, cooperative and interactive
Head: No scalp lacerations or tenderness to palpation
Eyes: PERRLA, EOMI
ENT: Bilateral external auditory canals clear, bilateral nares
clear, oral cavity exam restricted due to pain. There is visible
edema on the right mandible.
Neck: Trachea midline, no crepitus, no tenderness to palpation
Chest: Clavicle and bilateral ribs with no tenderness to
palpation, no crepitus
Resp: Lungs clear to auscultation bilaterally
CV: RRR, no murmurs
GI: soft, non-tender, non-distended
Pelvis: Stable, non-tender
GU: Deferred
Lymphatic: No groin or cervical lymphadenopathy bilaterally
Skin: Warm and well-perfused throughout, no rashes or
lacerations
Neuro: CN2-12 grossly intact, moving all extremities without
limitation, ___ motor throughout, sensory WNL, patellar DTR
intact
Brief Hospital Course:
Mr. ___ was admitted on ___ for management of his mandibular
trauma. CT Sinus/Mandible/Maxillofacial documented acute
minimally displaced fracture through the posterior body and
angle of the mandible on the right with extension to the right
third molar. On ___, he underwent open reduction and internal
fixation right
mandibular angle fracture. Reader referred to the operative
report for more information on the procedure. His early
post-operatory was uneventful.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
soft diet, ambulating, voiding without assistance, and pain was
well controlled. The patient was discharged home. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth Every 8 hours Disp
#*60 Tablet Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % Please rinse your mouth Two
times per day Refills:*0
3. Ibuprofen 600 mg PO Q8H
RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 8 hours Disp
#*10 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right mandibular angle fracture
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 ___ for
management of your right mandibular fracture. You underwent open
reduction, internal fixation right mandibular angle fracture.
You have recovered and you are ready to be discharged.
- Follow a soft diet that does not require you to chew until you
follow up with your surgeon.
- Maintain meticulous oral hygiene.
- Brush with soft tissue tooth brush.
- Use the prescribed mouth rinse two times per day.
- Resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
- Get plenty of rest.
- Continue to ambulate several times per day.
- Drink adequate amounts of fluids.
- Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*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.
Followup Instructions:
___
|
10340808-DS-31 | 10,340,808 | 29,431,676 | DS | 31 | 2136-05-08 00:00:00 | 2136-05-09 16:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cipro Cystitis / Tegretol / Bactrim / Aspirin /
Haldol / Ketorolac / Phenytoin / Morphine / Ibuprofen / Clinoril
/ Ssri's / Iodine-Iodine Containing / Iodinated Contrast- Oral
and IV Dye / gentamicin / doxycycline / loratadine / Celebrex /
Prozac / Levaquin / Wellbutrin / cephalexin / Mellaril / Motrin
/ Dilantin / Sulfa (Sulfonamide Antibiotics) / vancomycin /
cilostazol
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Right heart catheterization
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of scleroderma
w/ recently diagnosed pulmonary hypertension, Sjogren's disease,
T2DM, HTN, lymphedema, venous stasis ulcers, who presented with
shortness of breath, chest pain, and nausea. She was admitted to
___ at the end of ___, where she was found
to have a UTI and was discharged on a course of cefpodoxime and
also reported shortness of breath at that time, with a TTE that
demonstrated a PASP of 62 mmHg. She was planned for an
outpatient right heart catheterization. Since then, although the
shortness of breath has been ongoing for several months, it has
worsened over the past week and is worsened with exertion. She
also complains of chest pain with exertion, which she describes
as "an elephant sitting on her chest." She had similar chest
pain on a prior admission although refused a stress test at that
time. Moreover, she has been experiencing subjective fevers and
chills, a slightly worsening cough, and nausea without vomiting.
She has been having regular, non-bloody bowel movements.
On arrival to the ___ ED, her VS were T 101.3F, BP 168/82 mmHg
P ___ RR 15 O2 98% RA. Examination was notable for systolic
ejection murmur, clear lungs bilaterally, abdomen diffusely
tender (reportedly per baseline). Legs edematous without
pitting. LLE erythematous and weeping with question of
cellulitis. Labs were notable for negative troponin, lactate
1.0, normal chemistries with the exception of glucose of 112, Mg
1.4, and phosphorus of 2.5. Normal LFTs. proBNP 277. WBC 9.9k,
H/H 8.8/29.3, PLT 149,000. Coagulation parameters negative.
Influenza swab negative. UA with small leukocytes, positive
nitrites, few bacteria and 19 WBC. CXR was performed, which
demonstrated no focal consolidations or evidence of pulmonary
edema. ECG demonstrated sinus rhythm, rate 96, normal axis, and
no ST segment elevations/depressions or TWI. She was initiated
on antibiotics, but, because she stated that vancomycin has
"destroyed [her] kidneys multiple times" and refused the
medications, she was started on IV clindamycin 600 mg and IV
cefepime 2g. She was admitted to the medical service.
On arrival to the floor, she reported that she has been
experiencing itchiness when she urinates, dysuria, increased
frequency, fevers, abdominal pain, worsening leg swelling,
redness, pain, and shortness of breath. With respect to the
urinary symptoms, she reports that she stopped taking her
cefpodoxime two days ago because of an upset stomach. She has
been febrile at home to ___. With respect to her leg pain and
swelling, she has chronic lymphedema, and uses compression
stockings, although she has been having worsening redness
despite the use of stockings and elevation. The left leg is
chronically more swollen than the right. She also endorses some
ear fullness. With respect to her chest pain and shortness of
breath, this has been going on for several months, but the
shortness of breath appears to have worsened yesterday. She
endorses orthopnea and chest pain and shortness of breath with
exertion. She has been undergoing work-up for her pulmonary
hypertension, and she underwent V/Q scan at ___
in ___ that was low probability of PE.
Past Medical History:
Limited Scleroderma/CREST
Hypertension
Hyperlipidemia
Diabetes type 2
GERD
Hypothyroidism
IBS
Depression with prior suicide attempt
Osteoporosis
MVA in ___ (s/p numerous orthopedic surgeries of the lower
extremities)
Recurrent osteomyelitis of LLE requiring explantation of
hardware
h/o CCY
Social History:
___
Family History:
Her father died at ___- his autopsy noted cerebral palsy.
Physical Exam:
ADMISSION EXAM:
==============
VS: T 100.9F BP 154/63 mmHg P ___ RR 20 O2 94% RA
General: Hard of hearing, kyphotic, NAD.
HEENT: Anicteric sclerae; EOMs intact. MMM, OP clear.
Neck: Supple, 1 cm tender left submandibular lymph node.
CV: Tachycardic, II/VI systolic murmur best heard over LUSB. No
rubs or gallops.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, diffuse abdominal tenderness, worst over suprapubic
region. No rebound or guarding.
Ext: Bilateral swelling L>R, erythema and warmth with tenderness
to palpation over left shin, with healing ulcerations.
Neuro: A&Ox3. CNs II-XII intact.
DISCHARGE EXAM:
==============
VS: ___ 0405 Temp: 98.5 PO BP: 103/58 HR: 63 RR: 18 O2 sat:
97% O2 delivery: 2L
General: Hard of hearing, kyphotic, NAD.
HEENT: Anicteric sclerae; EOMs intact. MMM, OP clear.
CV: Tachycardic, II/VI systolic ejection murmur best heard over
LUSB. No rubs or gallops.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended. No rebound or guarding.
Ext: Bilateral trace edema L>R, erythema and warmth with
tenderness to palpation over left shin, with healing
ulcerations.
Erythema not extending beyond delineated line.
Neuro: A&Ox3. CNs II-XII intact.
Pertinent Results:
ADMISSION LABS:
==============
___ 10:31PM BLOOD WBC-9.9# RBC-3.38* Hgb-8.8* Hct-29.3*
MCV-87 MCH-26.0 MCHC-30.0* RDW-15.9* RDWSD-50.5* Plt ___
___ 10:31PM BLOOD Neuts-85.5* Lymphs-6.7* Monos-6.7
Eos-0.2* Baso-0.4 Im ___ AbsNeut-8.48*# AbsLymp-0.67*
AbsMono-0.67 AbsEos-0.02* AbsBaso-0.04
___ 10:31PM BLOOD ___ PTT-26.1 ___
___ 10:31PM BLOOD Glucose-112* UreaN-12 Creat-1.0 Na-141
K-3.9 Cl-103 HCO3-24 AnGap-14
___ 10:31PM BLOOD ALT-7 AST-14 AlkPhos-71 TotBili-0.5
___ 10:31PM BLOOD Albumin-4.2 Calcium-9.5 Phos-2.5* Mg-1.4*
DISCHARGE LABS:
==============
___ 05:16AM BLOOD WBC-5.6 RBC-3.07* Hgb-7.9* Hct-26.4*
MCV-86 MCH-25.7* MCHC-29.9* RDW-15.7* RDWSD-49.3* Plt ___
___ 05:16AM BLOOD Glucose-99 UreaN-18 Creat-1.1 Na-142
K-5.0 Cl-104 HCO3-27 AnGap-11
___ 08:51AM BLOOD ALT-6 AST-13 LD(LDH)-146 AlkPhos-63
TotBili-0.5
___ 08:51AM BLOOD cTropnT-<0.01
___ 05:16AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.9
PERTINENT IMAGING:
=================
___ Pulm/Sleep Pulmonary/PFT
Impression:
Although spirometry results are consistent with a restrictive
ventilatory defect the FVC may be underestimated due to an early
termination of exhalation. Gas exchange is normal. There are no
prior studies available for comparison.
___ Cardiovascular Cath Physician ___
___ pulmonary hypertension.
Responsive to 100% O2 and NO.
___HEST W/O CONTRAST
No evidence of interstitial lung disease. No acute process
within the chest.
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with a PMH of scleroderma
w/ recently diagnosed pulmonary hypertension, Sjogren's disease,
T2DM, HTN, lymphedema, venous stasis ulcers, who presented with
shortness of breath, chest pain, and nausea.
# DYSPNEA
# PULMONARY HYPERTENSION
# SCLERODERMA:
The patient was admitted with worsening dyspnea over the last
three months, with a TTE on a recent admission consistent with
elevated right sided pressures. The patient underwent a right
heart catheterization during this admission which did
demonstrate pulmonary hypertension. Her pulmonary pressures
improved with both inhaled oxygen and nitric oxide
administration. Notably, the patient carried with her a
diagnosis of Scleroderma, however it was unclear how she got
this diagnosis. The patient was told that the diagnosis was made
solely based on the physical exam, without biopsy or serologies.
Given the unclear history of her scleroderma, her serologies
were resent. Her anti-Scl 70 antibody was negative, however she
was discharged with pending RNA POLYMERASE III AB which should
be followed up as an outpatient. The pulmonology team saw that
patient in the hospital, and recommended a workup for underlying
hypoxemia which could result in hypoxic vasoconstriction in the
pulmonary vasculature and resultant pulmonary HTN. Continuous O2
saturation did not reveal nocturnal desaturations. PFTs were
obtained which demonstrated mild restrictive pulmonary
physiology. A high resolution CT scan showed no evidence of
interstitial lung disease. The patient may benefit from some
directed pulmonary HTN pharmacotherapy, though her right heart
cath response to vasodilatory and O2 was borderline. The patient
should continue to follow up with our pulmonary hypertension
specialist for a discussion about the most appropriate therapy.
The patient was satting well on room air on the day of
discharge.
# CELLULITIS, LEFT LEG
# LYMPHEDEMA
# CHRONIC VENOUS STASIS ULCERS:
The patient was found to have a leukocytosis on admission, and
had bilateral lower extremity warmth and erythema. While her
symptoms were bilateral, her erythema was significantly worse on
the left side, and there was concern for left leg cellulitis.
Given this, she was treated with PO Linezolid. Her erythema was
constant despite treatment, and did not significantly improve.
Moreover, the patient was found to have a UTI (discussed below)
which explained her initial leukocytosis. Linezolid was
discontinued after three days of therapy and her symptoms were
attributed to venous stasis.
# UTI, UNCOMPLICATED:
The patient had a positive urinalysis and a urine culture
growing pan sensitive E. Coli on admission. She was treated with
three days of ceftriaxone.
CHRONIC ISSUES
# HTN: The patient was continued on atenolol 12.5 mg daily,
losartan 25 mg daily.
# HYPOTHYROIDISM: Continued on levothyroxine 50 mcg daily.
# HYPERLIPIDEMIA. Continued on aspirin 81 mg daily and
simvastatin 40
mg qPM.
#CHRONIC PAIN: Continued on tramadol 50 mg q6h PRN and
pregabalin 25
mg BID.
# GERD: Continued on pantoprazole 40 mg daily.
TRANSITIONAL ISSUES:
====================
[] Follow up serologies for scleroderma: RNA Polymerase III Ab
pending
[] Discharge Hgb: 7.9 (baseline ___, please get follow up CBC
[] Discharge Cr 1.1: Please get BMP at first follow up
[] Concern for abusive relationship: Social work filed against
pt's friend ___ investigation into this case
#CODE: Full
#CONTACT: HCP ___ - ___
#DISPO: Medicine
>30 minutes were spent of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Pregabalin 25 mg PO BID
4. Simvastatin 40 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. Atenolol 12.5 mg PO DAILY
7. TraMADol 50 mg PO BID:PRN Pain - Moderate
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Atenolol 12.5 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. Pregabalin 25 mg PO BID
9. Simvastatin 40 mg PO QPM
10. TraMADol 50 mg PO BID:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Pulmonary hypertention
- Uncomplicated urinary tract infection
- Cellulitis
Secondary diagnosis:
- Hypertension
- Lymphedema
- Venous stasis ulcers
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. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were feeling short of breath
- Your legs were red and warm which was concerning for an
infection
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- You were found to have an infection in your urine
- This infection was treated with antibiotics
- You had a skin infection on your legs
- This was treated with antibiotics
- You had a procedure to measure the pressures in your heart
- The artery that brings blood to the lungs had high pressures
- We think this is why you were feeling short of breath
- You will be seen by a specialist on discharge
- There is limited evidence to support a diagnosis of
scleroderma, however, there are still some tests that are
pending. Please discuss following up with a rheumatologist with
your PCP.
WHAT SHOULD I DO NOW?
- Take all of your medications as prescribed
- Follow up with the lung specialist at the appointment below
It was a pleasure to care for you during your hospital stay.
Your ___ care team
Followup Instructions:
___
|
10340808-DS-33 | 10,340,808 | 27,649,709 | DS | 33 | 2136-09-27 00:00:00 | 2136-09-27 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cipro Cystitis / Tegretol / Bactrim / Aspirin /
Haldol / Ketorolac / Phenytoin / Morphine / Ibuprofen / Clinoril
/ Ssri's / Iodine-Iodine Containing / Iodinated Contrast- Oral
and IV Dye / gentamicin / doxycycline / loratadine / Celebrex /
Prozac / Levaquin / Wellbutrin / cephalexin / Mellaril / Motrin
/ Dilantin / Sulfa (Sulfonamide Antibiotics) / vancomycin /
cilostazol
Attending: ___
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of connective
tissue disease, CTD-associated PAH, HTN, HLD, T2DM, GERD,
hypothyroidism, and depression w/ prior suicide attempt,
recently
admitted with complicated UTI, who presents with abdominal pain,
diarrhea, and failure to thrive, consistent with complicated UTI
and pyelonephritis. She was admitted to ___ from ___ - ___
with
pansensitive Klebsiella pneumonia UTI after she was unable to
tolerate PO antibiotics. She was trialed on cefpodoxime, which
she was able to tolerate, and she was discharged on this
medication. She had pruritis after its administration, for which
she was also given ondansetron and diphenhydramine. She was also
provided with follow-up with urology given her recurrent UTIs.
She now returns, reporting that she did not take the antibiotics
at home as they made her itchy. The following day, she developed
diarrhea, with up to four episodes per day and diffuse lower
abdominal pain. She noted erythema and pain in her left lower
leg. She also reported that she did not have food at home and
reported not having eaten in five days. Her PCP recommended that
she present to the ED for further treatment and disposition
planning.
On arrival to the ED, her initial vital signs were T 98.6F BP
172/82 mmHg P 69 RR 20 O2 98% RA. Examination was notable for
being afebrile, hypertensive, chronically ill, frail appearing
woman in NAD, dry mucous membranes, RRR, ___ systolic murmur
appreciated throughout the precordium. CTAB, no wheezes, rales,
or rhonchi, soft, diffusely tender to palpation in lower abdomen
without rebound or guarding. Left sided CVA tenderness. RLE with
patch of erythema circumscribed on previous admission and still
within lines. LLE with patch of warmth, erythema, and tenderness
to palpation. Labs were notable for normal chemistries, WBC 4.6,
H/H 9.9/33.2, PLT 307. Lactate 1.9. CT of the abdomen/pelvis was
performed without contrast, which did not demonstrate acute
intra-abdominal process. No hydronephrosis. No perinephric
stranding, although evaluation for pyelonephritis limited in the
absence of IV contrast. She received IV vancomycin and cefepime,
1L NS, 25 mg IV diphenhydramine, and PO simvastatin 40 mg. She
was admitted to the medical service.
On arrival to the floor, she endorsed the narrative as above.
Since she has been home, she did not take the antibiotics as
prescribed as they made her itchy. She has also been
experiencing
flank and back pain, nausea, vomiting, and diarrhea. She said
that she has had 13 green bowel movements since ___. She
denies fevers, chills, chest pain, shortness of breath. She
endorses abdominal pain. She denies dysuria, hematuria,
hematochezia, or melena.
Past Medical History:
Limited Scleroderma/CREST
Hypertension
Hyperlipidemia
Diabetes type 2
GERD
Hypothyroidism
IBS
Depression with prior suicide attempt
Osteoporosis
MVA in ___ (s/p numerous orthopedic surgeries of the lower
extremities)
Recurrent osteomyelitis of LLE requiring explantation of
hardware
h/o CCY
Social History:
___
Family History:
Her father died at ___- his autopsy noted cerebral palsy.
Physical Exam:
ADMISSION:
VS: T 99.0F BP 184/84 mmHg P 90 RR 18 O2 97% RA
General: Chronically ill, frail appearing woman, NAD. Hard of
hearing.
HEENT: Anicteric sclerae, EOMs intact, MMM OP clear.
CV: RRR, III/VI systolic murmur heard throughout precordium.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, TTP in RLQ and LLQ; no rebound or guarding.
Back: Left sided CVA tenderness.
Extremities: RLE with circumscribed patchy erythema within lines
from prior admission. LLE with warmth, erythema, and tenderness
to palpation.
Neuro: A&Ox3.
DISCHARGE:
GENERAL: Elderly female, A/Ox3, NAD.
HEAD: NC/AT. Well-healed scar over right forehead where previous
___ biopsy was performed.
NECK: Supple.
CARDIAC: RRR, ___ holosystolic murmur heard best @ RUSB.
RESPIRATORY: Normal effort, CTABL.
ABDOMEN: Soft, tenderness across left flank w/ palpation, +BS.
EXTREMITIES: Warm. Dry, flaking skin at both ankles. Swelling
around both knees. On the LLE is a well-demarcated area of
petechiae and what appears to be scraped skin. Deformities ___
trauma.
PSYCHIATRIC: Upset and would like to go home.
NEURO: CN II-XII intact, with full visual fields. Strength is
grossly ___ in bilateral upper and lower extremities. Reflexes
not tested.
Pertinent Results:
ADMISSION:
==========
___ 07:25PM BLOOD WBC-4.6 RBC-4.11 Hgb-9.9* Hct-33.2*
MCV-81* MCH-24.1* MCHC-29.8* RDW-16.6* RDWSD-48.7* Plt ___
___ 07:25PM BLOOD Neuts-63.5 ___ Monos-6.3 Eos-0.9*
Baso-1.1* Im ___ AbsNeut-2.93 AbsLymp-1.24 AbsMono-0.29
AbsEos-0.04 AbsBaso-0.05
___ 07:25PM BLOOD Plt ___
___ 07:25PM BLOOD Glucose-100 UreaN-13 Creat-0.9 Na-143
K-4.5 Cl-104 HCO3-22 AnGap-17
___ 04:15AM BLOOD Calcium-9.3 Phos-2.7 Mg-1.4*
___ 04:15AM BLOOD ALT-7 AST-15 LD(LDH)-146 AlkPhos-63
TotBili-0.4
___ 08:24PM BLOOD Lactate-1.9
DISCHARGE:
==========
___ 08:23AM BLOOD WBC-6.2 RBC-3.35* Hgb-8.5* Hct-28.7*
MCV-86 MCH-25.4* MCHC-29.6* RDW-16.9* RDWSD-51.8* Plt ___
___ 05:21AM BLOOD Glucose-80 UreaN-20 Creat-1.1 Na-142
K-5.0 Cl-108 HCO3-25 AnGap-9*
___ 05:21AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.6
MICROBIOLOGY:
==============
___ 1:48 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 4:15 am BLOOD CULTURE
Blood Culture, Routine (Pending): NGTD
___ 8:25 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
Brief Hospital Course:
SUMMARY:
=========
Ms. ___ is a ___ w/ connective tissue disease,
CTD-associated PAH, HTN, HLD, T2DM, GERD, hypothyroidism, &
depression w/ prior suicide attempt, w/ 2 recent
hospitalizations for UTI, who presents w/ diarrhea and flank
pain in setting of not taking PO antibiotics.
ISSUES ADDRESSED:
=================
# ___:
Creatinine 1.4 from baseline 1.0 on ___. As she was normal on
admission, we felt that this represented pre-renal etiology in
the setting of poor PO intake. We have fluid challenged with 1 L
of LR to which the patient responded to well. Discharge 1.1.
# Flank pain:
# Urinary tract infection:
Patient now presents for ___ time in past 2 weeks w/ UTI. Her
culture ___ & ___ shows pan-sensitive Klebsiella pneumoniae
however she has been unable to tolerate any antibiotic regimen
as she continues to not take antibiotics upon discharge as she
reports itch. Repeat UCX was clear. As she was not able to
tolerate PO or PIVs we placed a mid-line and gave ceftriaxone 1g
x 3 days (___).
# Anemia:
Stable over several months. Iron studies most consistent with
iron-deficiency. LDH elevated but otherwise no evidence of
hemolysis. Iron supplementation w/ 324mg Q48H. Transfused HGB <
7 which she required once and responded to appropriately.
# Primary pulmonary HTN:
Stable on room air on admission. Was seen at Pulmonary HTN
___ & started on sildenafil which was stopped ___ side
effects. There was consideration of trialing ambrisentan which
was not started due to concerns of side effects. As such she is
currently on no therapy. She did not require O2.
# Connective tissue disease:
Carries a chart diagnosis of Sjogren's & scleroderma though no
Rheumatology visits here. Per previous notes, she was followed
reviously by a rheumatologist at ___ but notes and labs
have were not available on previous visits; her symptoms include
dry eyes, dry mouth, Raynaud's phenomenon, dysphagia, reflux,
and finger deformities. In ___ she was seen in-house for
respiratory symptoms and lab results showed positive ___ &
positive anti-centromere thought to be consistent with true CTD.
She was set up for Rheumatology follow-up which has not yet
occurred.
# HTN:
Continued home atenolol, losartan held ___ given ___ and we
will not continue given normotension throughout hospitalization.
# HLD:
Continued home statin.
# T2DM:
Gave ISS while inpatient.
Continued pregabalin for neuropathy.
# GERD:
Continued home pantoprazole.
# Hypothyroidism:
Continued home levothyroxine.
TRANSITIONAL ISSUES:
====================
# HTN:
[] Losartan held on discharge given stable blood pressures.
CODE: DNR/DNI
CONTACT: HCP Pat Medeires ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 12.5 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Pantoprazole 40 mg PO Q24H
6. Pregabalin 25 mg PO BID
7. Simvastatin 40 mg PO QPM
8. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
10. Cefpodoxime Proxetil 400 mg PO Q12H
11. DiphenhydrAMINE 25 mg PO BID:PRN itch
12. Ondansetron 4 mg PO BID:PRN nausea
Discharge Medications:
1. Atenolol 12.5 mg PO DAILY
2. DiphenhydrAMINE 25 mg PO BID:PRN itch
3. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Ondansetron 4 mg PO BID:PRN nausea
7. Pantoprazole 40 mg PO Q24H
8. Pregabalin 25 mg PO BID
9. Simvastatin 40 mg PO QPM
10. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
11. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until instructed by your
PCP.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
diarrhea
urinary tract infection
acute kidney injury
SECONDARY:
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 taking care of your ___.
WHY WERE YOU ADMITTED?
-You had diarrhea.
-You had another urinary tract infection.
WHAT HAPPENED WHILE YOU WERE HERE?
-We give the antibiotics.
-We tested your stool for an infection which he did not have.
-We tried to control your pain and nausea.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
-Continue to take all your medications as prescribed.
-Go to all of your appointments.
We wish you the best moving forward!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10340808-DS-34 | 10,340,808 | 25,278,257 | DS | 34 | 2136-10-02 00:00:00 | 2136-10-02 17:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cipro Cystitis / Tegretol / Bactrim / Aspirin /
Haldol / Ketorolac / Phenytoin / Morphine / Ibuprofen / Clinoril
/ Ssri's / Iodine-Iodine Containing / Iodinated Contrast- Oral
and IV Dye / gentamicin / doxycycline / loratadine / Celebrex /
Prozac / Levaquin / Wellbutrin / cephalexin / Mellaril / Motrin
/ Dilantin / Sulfa (Sulfonamide Antibiotics) / vancomycin /
cilostazol
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per Dr. ___:
___ h/o connective tissue disease w/ pulmonary artery
hypertension, HTN, HLD, T2DM, GERD, hypothyroidism, and
depression presents with nausea. She was admitted ___ for
abdominal pain, diarrhea, and failure to thrive treated for UTI.
She notes nausea and abdominal pain during this admission that
improved at discharge but did not fully resolve. She notes that
Zofran helped during the admission but did not take any since
discharge even though this was a new discharge medication. She
currently has epigastric chest pain that moves up to her chest
and then forehead. She endorses progressive SOB attributed to
pulmonary artery hypertension; even though her oxygen levels are
fine she feels like her body needs oxygen. She endorses chills
and sweats noting that she never gets a fever. She has chronic
urinary and fecal incontinence (unchanged) without any other
symptoms also noting that she never gets symptoms with UTIs.
In the ED tmax 98.5F, HR 87-127, BP 146/88-207/94, SpO2 99% on
RA, RR ___. She had reported a chief complaint of acute
shortness of breath to them likely due to pulmonary artery
hypertension but with concern for PE; D-dimer was elevated
unable
to obtain CTA chest (due to contrast allergy) and unlikely that
VQ scan would be of any benefit. She had a CT abdomen/pelvis
that did not have any acute pathology, and she was admitted for
observation of her respiratory status.
ROS: as above otherwise 10point ROS negative
Past Medical History:
Limited Scleroderma/CREST
Hypertension
Hyperlipidemia
Diabetes type 2
GERD
Hypothyroidism
IBS
Depression with prior suicide attempt
Osteoporosis
MVA in ___ (s/p numerous orthopedic surgeries of the lower
extremities)
Recurrent osteomyelitis of LLE requiring explantation of
hardware
h/o CCY
Social History:
___
Family History:
Her father died at ___- his autopsy noted cerebral palsy.
Physical Exam:
DISCHARGE EXAM:
98.8
PO 136 / 68 82 18 98 2LNC
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
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities
PSYCH: pleasant, appropriate affect. her mood is "okay" and no
longer angry from earlier in the day. Denies SI, no HI, no AH or
VH.
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Please note, at 11:47AM on ___, a couple hours prior to her
scheduled lung scan, the patient had requested to leave AMA but
I was able to convince her to stay:
Patient was requesting to leave against medical advice at that
time. I have recommended to her to stay in the hospital setting
to undergo a lung V/Q scan to rule out an acute pulmonary
embolism as a cause of her dyspnea that she came in the hospital
with.
The patient insists that she would like to leave immediately,
despite my recommendation to her that she should stay. She is
upset with her perceived treatment by the floor staff. She
believes they do not want to care for her, because a case
manager
had explained to her some documents pertaining to observation
versus inpatient level of care, and she is convinced that this
implies we want her to leave the hospital immediately.
My exam of her at the time of her AMA request was that she
denies any suicidal
ideation, no homicidal ideation or desire to harm herself or
anyone else, she denies any auditory or visual hallucinations,
and displays linear and goal directed thinking. There is no
psychomotor agitation or retardation on exam. Although her mood
is angry, she is not labile and her affect is appropriate for
her
current mood. The patient states she would never want to harm
herself and has no plans to do so.
I had also seen Ms. ___ earlier this morning and the only
change since that examination is her angry mood.
She was able to articulate this choice of leaving AMA
consistently, demonstrates understanding of the reason for
hospitalization and proposed treatment plan, the risks of leave
AMA (developing acute hypoxic respiratory failure, arrhythmias,
obstructive shock, or death), and provides a rational
explanation
for discharge (she does not like her interactions with the
staff,
she states she believes the floor staff are trying to push her
out the door and will not give her the best care). She
understands that the risks apply to her.
Fortunately - the patient ultimately decided about an hour
later, that she would be willing to stay to have the V/Q scan
done after I convinced her that the staff was not intending to
"push her out the door".
I asked her if I could call any family or close friends to give
them an update and allow them to check on her at home. She
declined my offer.
Pertinent Results:
___ 05:00AM BLOOD WBC-6.3 RBC-3.84* Hgb-9.7* Hct-32.3*
MCV-84 MCH-25.3* MCHC-30.0* RDW-17.6* RDWSD-54.1* Plt ___
___ 06:05PM BLOOD ___ PTT-28.3 ___
___ 05:00AM BLOOD Glucose-88 UreaN-13 Creat-0.9 Na-143
K-4.3 Cl-104 HCO3-24 AnGap-15
___ 05:00AM BLOOD ALT-11 AST-19 AlkPhos-61 TotBili-0.7
___ 05:00AM BLOOD Lipase-161*
___ 05:25PM BLOOD cTropnT-<0.01
___ 02:20PM BLOOD cTropnT-<0.01
___ 10:17PM BLOOD D-Dimer-1001*
___ 02:20PM BLOOD Albumin-4.4 Calcium-10.3 Phos-3.6 Mg-1.7
___ 05:24PM BLOOD Lactate-1.1 K-4.1
V/Q Lung scan on ___:
I spoke to the radiologist at ___ about the prelim lung scan
result. It shows no evidence of a PE.
Brief Hospital Course:
___ year old female with history of connective tissue disease and
pulmonary artery
hypertension on 2L NC, HTN, HLD, NIDDM2, GERD, hypothyroidism,
and depression who presented with nausea and abdominal pain, and
dyspnea.
#Dyspnea
#History of pulmonary artery HTN
#Chronic hypoxic respiratory failure
-This is characterized by the patient as progressive over
months,
especially with exertion. No acute new dyspnea.
-The ED had checked D dimer which was elevated to ~1000.
-We obtained a V/Q scan on day of discharge which was negative
for PE. CTA chest more difficult to
obtain due to contrast allergy.
-It's likely her chronic dyspnea is due to her pulmonary HTN.
-She is not currently on any treatment for pulmonary artery
hypertension due to allergies, side effects, cost of medication,
etc. Defer to outpatient pulmonology for further treatment.
-Continue home oxygen (2L NC) for the ___.
#Nausea, abdominal pain in the ED
-This seems to be an ongoing issue previously attributed to UTI.
-It is not of concern to the patient the day after admission.
-It has resolved since presentation to the ER.
-She had negative troponin x 2 serial check with telemetry no
events and EKG showing no acute ST-T ischemic changes.
-She had CT A/P in the ED which showed no acute findings in the
abdomen or pelvis
#HTN
-Losartan was held during previous admission for ___ and
normotension. However, initial BP in the ED 207/94, which could
have been in setting of pain and/or anxiety. This resolved on
its own.
-Continue atenolol; if BP remains
elevated in the office setting, she can restart low dose
losartan.
CHRONIC MEDICAL PROBLEMS
1. Hypothyroidism: continue levothyroxine.
2. GERD: continue pantoprazole
3. NIDDM II with peripheral neuropathy: PCP stopped metformin
monitoring HbA1C.
4. HLD: continue atorvastatin
5. Normocytic anemia: noncompliant with ferrous sulfate.
Previously required blood transfusion. THis was stable
6. Connective tissue disease: Carries a chart diagnosis of
Sjogren's & scleroderma though no Rheumatology visits here. Per
previous notes, she was followed previously by a rheumatologist
at
___ but notes and labs have were not available on
previous
visit. Her symptoms include dry eyes, dry mouth, Raynaud's
phenomenon, dysphagia, reflux, and finger deformities. In
___
she was seen in-house for respiratory symptoms and lab results
showed positive ___ & positive anti-centromere thought to be
consistent with true CTD. She was set up for Rheumatology
follow-up which has not yet occurred.
Greater than 30 minutes was spent on discharge planning and
coordination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 12.5 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Pregabalin 25 mg PO BID
5. Simvastatin 40 mg PO QPM
6. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
7. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
8. Bismuth Subsalicylate 15 mL PO TID:PRN indigestioin
Discharge Medications:
1. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
2. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
3. Atenolol 12.5 mg PO DAILY
4. Bismuth Subsalicylate 15 mL PO TID:PRN indigestioin
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Pregabalin 25 mg PO BID
8. Simvastatin 40 mg PO QPM
9. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Shortness of breath
History of pulmonary arterial hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Instructions: Dear Ms. ___,
It was a pleasure to be a part of your care team at ___
___.
====================================
Why did you come to the hospital?
====================================
-You had shortness of breath.
====================================
What happened at the hospital?
====================================
-We wanted you to undergo a lung scan test to look for any blood
clots that formed in your lung blood vessels that would have
caused your trouble breathing.
-Your lung scan test showed there was a low probability that
there is a blood clot in your lung blood vessels.
-It's possible your progressive increase in shortness of breath
over the last several months is from your pulmonary
hypertension. As you know, this can take a long time to get
better, if you are on the right treatments. You are not on any
active medication for this, it requires your lung doctor to
decide the right drugs.
==================================================
What needs to happen when you leave the hospital?
==================================================
-Please, call your PCP office to schedule a follow up to be seen
within a week. We will also notify your PCP of this hospital
stay.
-You'll need to make sure you see your lung doctor in follow up
within 1 month for your pulmonary hypertension.
-Please, pay attention to your symptoms.
If you experience any of the following or any of the danger
signs listed below, please return to any emergency department or
call ___ immediately.
___, shortness of breath, or trouble breathing
___, knife-like chest pain when you breathe in or
strain
___ or coughing up blood
___ rapid heartbeat
___ in any leg
___ in any leg
___ and redness in the involved leg
It was a pleasure taking care of you during your stay!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10340908-DS-14 | 10,340,908 | 23,014,359 | DS | 14 | 2161-05-02 00:00:00 | 2161-05-02 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bicondylar left tibial plateau fracture
Major Surgical or Invasive Procedure:
___: Closed reduction and external fixation of left tibial
plateau fracture
History of Present Illness:
___ p/w left knee pain and swelling s/p mechanical fall on
steps of courthouse at approximately 1pm. Pt states he lost his
balance and tripped, twisting his knee as he fell forward. He
struck his right shoulder upon falling. No head strike or LOC.
Pt
reports pain in knee and inability to ambulate since time of
injury. Denies any shoulder pain. No numbness or tingling of
extremities. At time of evaluation, patient denies fever/chills,
headache, dizziness, blurry vision, chest pain, shortness of
breath, nausea/vomiting, abdominal pain, dysuria, rash.
Past Medical History:
Hypertention
s/p TURP
Social History:
___
Family History:
noncontributory
Physical Exam:
Gen: elderly male, no acute distress
Neuro: alert and interactive, baseline mental status
CV: palpable distal pulses bilaterally
Pulm: No respiratory distress on room air
LLE: in ex fix, compartments firm but compressible, SILT
___, Fires ___, no pain with passive
ROM, palpable DP pulse
Pertinent Results:
___ 09:20AM BLOOD WBC-14.7* RBC-3.06* Hgb-9.1* Hct-28.4*
MCV-93 MCH-29.7 MCHC-32.0 RDW-13.0 RDWSD-44.2 Plt ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left bicondylar tibial plateau fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for closed reduction external
fixation of left bicondylar tibial plateau 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 home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
non-weight bearing in the left lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ planning of internal fixation.
A thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. Furosemide 20 mg PO 3X/WEEK (___)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC Q24H trauma
Start: Today - ___, First Dose: Next Routine Administration
Time
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
6. Pantoprazole 40 mg PO Q24H
7. Senna 17.2 mg PO HS
8. Vitamin D 400 UNIT PO DAILY
9. Allopurinol ___ mg PO DAILY
10. Furosemide 20 mg PO 3X/WEEK (___)
11. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left bicondylar tibial plateau fracture
Discharge Condition:
Gen: no acute distress
Neuro: alert and interactive, baseline mental status
Ambulatory status: with assist
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times
ACTIVITY AND WEIGHT BEARING:
- Non-weight-bearing left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- 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
Followup Instructions:
___
|
10341124-DS-24 | 10,341,124 | 29,353,024 | DS | 24 | 2163-04-04 00:00:00 | 2163-04-04 17:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
sulfa drugs / dapsone
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p kidney/pancreas transplant ___ has been doing well
at home with baseline Cr 1.0-1.2 and off insulin she is ___ weeks
out from exploratory laparotomy d/t closed loop obstruction. she
underwent LOA and was doing well she was d/c home on the ___. passing BM that is getting formed. She was not prescribed
ABx after surgery.
She was doing well at home gaining back her strength and
appetite. yesterday she started having diarrhea, with no
associated symptoms. no fever /chills, no N/v, no rectal
bleeding
no mucouse or melena.
she has no abdominal pain.
She presented to the ED HDS no fever.
Past Medical History:
Past Medical History:
1. ESRD on HD since ___ via LUE AV fistula
2. T1DM since age ___ with associated retinopathy, neuropathy,
and nephropathy.
3. Hypertension.
4. Hypothyroidism.
5. Lynch syndrome, last colonoscopy ___ with polypectomy x3
Past Surgical History:
1. Open appendectomy (as child)
2. Open bilateral inguinal hernia repairs (as child)
3. TAHBSO (___)
4. Breast biopsy x2, benign findings
5. Left eye cataract surgery
6. ___ cyst removal
7. Left knee arthroscopy
8. Right shoulder arthroscopy
Social History:
___
Family History:
Father - brain tumor
Mother - breast, cervical, & uterine cancers. Melanoma.
Sister - colon cancer
Brother - hepatitis C
3 children are all healthy
Physical Exam:
Vitals: 98.4 HR 78 BP 143 / 84 RR 19 PO2 97 RA
GEN: A&O, NAD after 2 doses of morphine
CV: RRR
PULM: breathing unlabored CTA b/l
ABD: Soft, mildly distended, NT, midline incision C/D I
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
KUB:
1. No free intra-peritoneal air.
2. Persistently dilated air-filled loops of small bowel in the
left abdomen when compared to the recent CT from ___
again suggestive of a small bowel obstruction which may be
partial, as air is noted distally within the colon and rectum.
___ 02:08PM BLOOD WBC-13.0* RBC-4.57 Hgb-13.6 Hct-44.5
MCV-97 MCH-29.8 MCHC-30.6* RDW-13.6 RDWSD-49.4* Plt ___
___ 02:08PM BLOOD Neuts-77.6* Lymphs-4.7* Monos-9.5 Eos-5.7
Baso-1.2* Im ___ AbsNeut-10.07* AbsLymp-0.61*
AbsMono-1.23* AbsEos-0.74* AbsBaso-0.15*
___ 02:08PM BLOOD Glucose-101* UreaN-11 Creat-0.8 Na-140
K-4.8 Cl-108 HCO3-17* AnGap-15
___ 02:08PM BLOOD ALT-13 AST-18 AlkPhos-101 Amylase-92
TotBili-0.3
___ 02:08PM BLOOD Albumin-4.0 Calcium-10.2 Phos-3.5 Mg-1.6
___ 06:15AM BLOOD WBC-9.4 RBC-4.80 Hgb-14.6 Hct-45.8*
MCV-95 MCH-30.4 MCHC-31.9* RDW-13.4 RDWSD-48.0* Plt ___
___ 06:15AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-145
K-4.9 Cl-108 HCO3-20* AnGap-17
___ 06:15AM BLOOD Amylase-94
___ 06:15AM BLOOD Calcium-10.2 Phos-3.7 Mg-1.7
___ 02:08PM BLOOD tacroFK-7.0
___ 06:15AM BLOOD tacroFK-8.6
Brief Hospital Course:
Ms. ___ is a ___ female with a history of kidney/pancreas
transplant on ___, and small bowel obstruction s/p ex lap
and LOA 2 weeks ago, who presented to the emergency room with 2
day history of diarrhea and abdominal xray concerning for
partial bowel obstruction, she was admitted to the transplant
surgery service for further management.
She remained hemodynamically stable and afebrile throughout her
hospitalization. Her diarrhea resolved, with no episodes during
this admission. She had a regular BM on ___. Stool studies and
CMV viral panel were sent. She had a normal WBC 9.4.
She continued her home immunosuppression, which included
CellCept and Tacrolimus She continued on atovaquone. Her
valgangicyclovir was discontinued due to no longer requiring
since she is ___ months post op from her original transplant.
Tacrolimus levels and doses are as follows. She was continued on
1.5 mg BID at the time of discharge
___ FK 1.5/1.5 ( 8.6)
___ FK 1.5/1.5 ( 7.0)
At the time of discharge, she was afebrile and hemodynamically
stable, she was tolerating a regular diet, her pain was well
controlled, she was voiding adequately and spontaneously, was
ambulating without assistance, and she was having regular bowel
movements. She was discharged home with follow up with Dr.
___ on ___.
Medications on Admission:
1. Docusate Sodium 100 mg PO BID
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H
4. Tacrolimus 1.5 mg PO Q12H Duration: 2 Doses
please have your labs drawn on ___ or ___. amLODIPine 2.5 mg PO DAILY
6. Amoxicillin ___ mg PO 1 HOUR PRIOR TO DENTAL WORK
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. At___ Suspension 1500 mg PO DAILY
10. Gabapentin 200 mg PO QHS
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Mycophenolate Sodium ___ 360 mg PO QID
13. Ranitidine 150 mg PO BID
14. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated
potassium
15. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Atovaquone Suspension 1500 mg PO DAILY
5. Gabapentin 200 mg PO QHS
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Mycophenolate Sodium ___ 360 mg PO QID
8. Ranitidine 150 mg PO BID
9. Tacrolimus 1.5 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
diarrhea
renal and pancreas transplant
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 diarrhea, abdominal pain,
which has since resolved. You are having normal bowel movements,
your lab work is normal, and you have remained afebrile. You are
now stable for discharge home. You have a follow up appointment
tomorrow with renal transplant. Please follow up with Dr.
___ on ___
Followup Instructions:
___
|
10341265-DS-17 | 10,341,265 | 25,701,590 | DS | 17 | 2114-05-12 00:00:00 | 2114-05-13 00:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
latex / Sulfa (Sulfonamide Antibiotics) / nitrofurantoin
Attending: ___.
Chief Complaint:
polytrauma s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ s/p unwitnessed fall at home. Pt found on the ground by her
son, found b/w bed and bathroom. Went to OSH, found to have
orbital fracture, maxillary sinus fracture, subdural hematoma
with GCS 15, pelvic fracture, hip fracture. Transferred for
higher level of care. On arrival patient complained of R hip
pain. Unable to provide significant history. Of note, pt in AF
w/ RVR at OSH from 100s-120s. Admitted to acute care surgery.
Past Medical History:
HTN, HLD, breast CA, atrial fibrillation, CHF, Crohn's disease,
on home hospice prior to this hospitalization
s/p mastectomy, hysterectomy
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 105 100/58 14 98%Ra
General: NAD
HEENT: ecchymoses over right eye, right eye conjunctiva with
blood
Neck: non tender
CV: irregularly irregular
Lungs: CTABL
Abdomen: soft, mild TTP to palpation in RLQ, reducible
umbilical hernia
GU: foley in place
Ext: 1+ pitting edema to shin
Neuro: A&0x2, no gross deficits
Skin: intact
DISCAHRGE PHYSICAL EXAM:
VS - afeb, 80s AF, 80-100/40-60, 16, 100%RA
Gen: alert, confused
HEENT: ecchymoses over right eye improving, conjuctival
hemorrhage stable
Neck: supple, no LAD
CV: irreg irreg
PULM: CTABL
ABD: soft, nontender, nondistended, sacral edema
GU: foley in place to gravity drainage, clear yellow urine
EXT: pitting edema bilat
Neuro: CN2-12 intact, gross motor and sensory intact
Skin: intact
Pertinent Results:
Injuries:
R pubic rami fx
R sacral ala fx
R temporal-parietal SDH
R orbital flr fx
Pl effus/pericard effus/pulm edema
R distal radius fracture
UA neg
Brief Hospital Course:
Ms. ___ is a ___ hx of CHF now s/p fall with R pubic rami fx,
R sacral ala fx, R temporal-parietal SDH, R orbital flr fx, R
distal radius fx and pleural effus/pericard effus/pulm edema.
When she was first admitted, it was not clear that she had been
under the care of a home hospice program. She was admitted to
the trauma surgical ICU at ___ after transfer from OSH. She
was given tramadol, morphine and Tylenol as needed for pain
control. She was started on Keppra for anti-seizure prophylaxis
per the request of our neurosurgical team's recommendations, but
this was d/c'd prior to discharge home. She continued on her
home Lopressor and Lasix for CHF and her SBP was closely
monitoring while she was in the acute period of monitoring after
acute SDH. From a pulmonary standpoint, she was never
intubated. She used the incentive spirometer and pulmonary
toilet was encouraged. She was given a low salt diet. A foley
catheter was placed and was left in place at the time of
discharge at the request of the patient for comfort while she
was less mobile. She was given SCDs for DVT/PE prophylaxis.
Orthopedics was consulted and recommended that she remain weight
bearing as tolerated bilaterally, and nonoperative management of
her injuries. Hand surgery placed a splint for her R wrist
fracture and she was discharged with instructions to follow up
with them. Plastic surgery repaired a 0.5cm superficial abrasion
of right supraorbital area and recommended nonoperative
management of her R ortibal floor fx. Prior to discharge, her
MOLST forms were verified and the ICU team met with the family.
She was discharged ___ to home with hospice services at the
request of the patient and family.
Medications on Admission:
Lasix 20', levothyroxine 25', Colace, lisinopril 2.5',
metoprolol 25' BID, Ativan, ASA 81', iron 325, MVT
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*4
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*2
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*2
4. Influenza Vaccine Quadrivalent 0.5 mL IM NOW ___. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
6. PNEUMOcoccal 23-valent polysaccharide vaccine 0.5 ml IM NOW
X1
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 cap by mouth twice a day Disp
#*60 Capsule Refills:*2
8. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain
RX *tramadol [Ultram] 50 mg ___ tablet(s) by mouth every four
(4) hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Distal radial fracture
-Right temporal parietal subdural hematoma
-Right orbital floor fracture
-Acute anterior right sacral ala fracture. Acute right pubic
rami fractures
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair, per orthopedics she can be weight bearing as
tolerated bilaterally.
Discharge Instructions:
ACTIVITY:
o You may proceed with activity as tolerated
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10341900-DS-15 | 10,341,900 | 27,744,561 | DS | 15 | 2181-07-26 00:00:00 | 2181-07-26 22:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bicycle collision
Major Surgical or Invasive Procedure:
Right neck exploration and wash out of right thigh wounds
History of Present Illness:
The patient is a ___ white male who is status post a
bicycle crash. He had lacerations to his neck on the right
side, as well as his right thigh. His workup included a CT
angio which showed no vascular injury but showed air bubbles up
in the area of the angle of his mandible on the right side. The
injury definitely penetrates platysma. He was no immediate
evidence of a vascular injury or penetration of the carotid
sheath; but a right vertebral artery dissection was ultimately
identified. He was brought to the operating room for neck
exploration. He also had a laceration on his right lateral
thigh which was planned for wash out. The indications and
possible complications of this were explained to him
preoperatively, and appropriate informed signed consent was
obtained.
Past Medical History:
PMH:
Denies
PSH:
Tonsillectomy age ___
Social History:
___
Family History:
NC
Physical Exam:
On admission:
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: C-collar in place. No TTP over CTL spine.
LUNGS: Clear to auscultation bilaterally
CV: Regular rate and rhythm,
ABD: soft, non-tender, non-distended,
PELVIS: stable:
EXT: Compartments are soft. Warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
SKIN: abrasion over bilateral knees. Abrasion over right
clavicle. Puncture wound over right later neck, zone II.
Puncture wounds x2 over lateral thight.
NEURO: GCS15. AAOX3. CNII-XII grossly intact. No gross
lateralizing neurological deficits
Motor exam: ___ Delt/Tric/Bic/BR/WF/WE/IO. ___
___
Sensory exam:SILT over C2-S4 region. No saddle anesthesia.
Intact
Rectal Tone.
On discharge:
98.4, 67, 121/789, 16, 98% RA
Gen: NAD, AAOx3
Neuro: CN II-XII intact
Wounds:
right neck wound C/D/I, no erythema/induration
Lower extremity dressings c/d/i
CV: RRR no m/r/g
Pulm: CTAB no w/r/r
Abd: Soft, NT/ND, no rebound/guarding
Ext: As above, no c/c/e
Pertinent Results:
___ 02:43PM BLOOD WBC-10.9 RBC-4.56* Hgb-14.3 Hct-43.8
MCV-96 MCH-31.4 MCHC-32.8 RDW-12.5 Plt ___
___ 02:43PM BLOOD Glucose-103* UreaN-16 Creat-1.0 Na-139
K-4.6 Cl-103 HCO3-27 AnGap-14
Brief Hospital Course:
Mr. ___ was admitted to the ACS service with HPI as stated
above. He went urgently the the operating room for the
above-stated procedure on ___. He tolerated the procedure
well; for full details please see the dictated operative report.
He went to the PACU and then to the floor in good condition.
His post-operative course was relatively uncomplicated.
Initiated with a tertiary survey, he was evaluated for further
injuries including x-ray of the right ankle per findings on the
secondary survey which ruled out fracture. He remained afebrile
and hemodynamically stable. He voided successfully and
tolerated a regular diet. On POD#1 the wicks were removed from
his right anterior thigh and his right neck. On POD#2 he was
seen by physical therapy who recommended discharge to home
without the need for home ___.
He will take aspirin, 81mg daily, for 30 days per neurosurgery
recommendations for the identified right vertebral artery
dissection. Also per nurosurgery recs, he will not follow up in
clinic with them.
He is discharged to home on ___ in good condition and with
appropriate instructions, warnings, prescriptions, and plans to
follow up.
Medications on Admission:
Denies
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Capsule Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
Do not drive a car or operate any other machinery while using
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right neck laceration, right vertebral artery dissection, C5-6
transverse process fractures, right leg wounds
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen following a bicycle collision during which you
sustained multiple injuries. You should be very careful to
avoid trauma. Stay off of your bicycle until otherwise advised
by your doctor and avoid all activities with a substantial risk
of trauma.
Take aspirin, 81 milligrams, every day for 1 month following
your discharge. You will be sent home with a prescription for
this medicine but you can purchase it over the counter.
You should immediately resume all of your home medicines unless
otherwise advised by your physician.
You may immediately resume your regular diet.
Please follow up as stated below.
Follow up with outpatient physical therapy as needed.
Followup Instructions:
___
|
10342338-DS-16 | 10,342,338 | 20,290,667 | DS | 16 | 2179-10-29 00:00:00 | 2179-10-30 11:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Allegra / oxybutynin / Robaxin
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with unknown neurological disease comprising left sided
weakness, dysarthria, and abnormal gait with progressive decline
over ___ years who p/w fall from bed.
Pt states she was attempting to get out of bed and ___ to her
weakness, slid out of bed onto the floor and hit the right side
of her face despite bracing her fall. She denies any other
injuries. No LOC, SOB, CP, palpitations, light
headedness/dizziness preceding the event. Pt's caregivers state
she has fallen from bed multiple times and that she is dependent
for ADLs. An extensive workup by neurology with MRI/A w/contrast
of Head/Spine, EMG, metabolic workup all have been unrevealing
as to the cause of her progressive weakness.
In the ED, initial vitals were: 97.7 98 118/73 18 100% RA
- Labs, including CBC, BMP, UA/Ucx, CXR were all within normal
limits.
- Imaging revealed: head CTs that showed no acute abnormality
Vitals prior to transfer were: 97.7 94 136/82 18 100% RA
Upon arrival to the floor, pt confirms history above. She
endorses muscle spasm on the right side of her neck.
Past Medical History:
- Osteoarthritis.
- Headache.
- Gestational diabetes
- unknown neurological disease comprising left sided weakness,
dysarthria, and abnormal gait with progressive decline
Social History:
___
Family History:
not relevant to the current hospitalization
Physical Exam:
ADMISSION EXAM
==============
Vitals: 97.9 120/80 83 17 100% RA
General: middle aged woman, hesitant speech, Alert, oriented, no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: no JVD, supple, no thyroid masses
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Scratches on legs bilaterally
Neuro: Hesitant and dysarthric speech, flat affect. CNII-XII
intact, left side of face w/ tremor with smile, 4+/5 strength
right upper extremity, ___ left upper extremity, ___ right
lower, ___ left lower. grossly normal sensation. Could not
elicit babinski.
DISCHARGE EXAM
==============
Vitals: 97.9 120/80 83 17 100% RA
General: middle aged woman, hesitant speech, Alert, oriented, no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: no JVD, supple, no thyroid masses
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Scratches on legs bilaterally
Neuro: Hesitant and dysarthric speech, flat affect. CNII-XII
intact, left side of face w/ tremor with smile, 4+/5 strength
right upper extremity, ___ left upper extremity, ___ right
lower, ___ left lower. grossly normal sensation. Could not
elicit babinski.
Pertinent Results:
ADMISSION LABS
==============
___ 02:40PM BLOOD WBC-4.6 RBC-4.47 Hgb-12.4 Hct-39.0 MCV-87
MCH-27.7 MCHC-31.8* RDW-14.6 RDWSD-46.2 Plt ___
___ 02:40PM BLOOD Neuts-59.5 ___ Monos-8.5 Eos-3.3
Baso-0.4 Im ___ AbsNeut-2.73 AbsLymp-1.29 AbsMono-0.39
AbsEos-0.15 AbsBaso-0.02
___ 02:40PM BLOOD ___ PTT-22.6* ___
___ 08:30PM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-141
K-4.8 Cl-102 HCO3-30 AnGap-14
___ 10:25PM BLOOD Lactate-1.2
IMAGING
=======
___ EKG Sinus rhythm. Borderline left atrial abnormality.
Non-specific T wave changes in the inferior leads. No previous
tracing available for comparison.
___ CXR
IMPRESSION:
No focal consolidations concerning for pneumonia identified.
___ CT HEAD W/O CONTRAST
IMPRESSION:
Subtle area of asymmetrically increased density within the right
basal
ganglia. Although this could be secondary to calcification,
given the
extensive motion artifact, this is incompletely evaluated on
this exam, and a tiny focus of hemorrhage cannot be excluded. A
repeat CT in ___ hr is recommended for further evaluation.
___ CT HEAD W/O CONTRAST
IMPRESSION:
No acute hemorrhage and no evidence for other acute intracranial
abnormalities.
Brief Hospital Course:
BRIEF SUMMARY
=============
___ with unknown neurological disease comprising left sided
weakness, dysarthria, and abnormal gait with progressive decline
p/w mechanical fall from bed.
ACTIVE ISSUES
=============
# S/p mechanical fall: The patient states that she had a
mechanical fall from her bed while at home. Likely ___ chronic
gait instability due to poorly defined neurological disease. No
evidence of underlying infection or electrolyte abnormality. She
received noncon head CT in the ED that was initially concerning
for possible bleed on initial read; however this was changed on
final read and subsequent CT head showed no acute changes. Given
she is high risk for recurrent falls, she was seen by ___ in the
ED who recommended rehab.
# Progressive neurologic disease of unclear etiology: Pt has
chronic, progressive neurologic illness comprising left sided
weakness, dysarthria, and abn gait, of uncertain etiology. Has
been worked up extensively, negative EMG, MRI/A, metabolic
workup. From neurology note, potential ddx includes atypical
parkinsonism (most likely), primary lateral sclerosis, or
spinocellabellar ataxia. As above, daughter said worsening over
past two weeks. Daughter denies that patient has any dysphagia.
The patient was seen by neurology while in-house who agreed with
rehab and recommended follow-up as outpatient as previously
scheduled on ___ for dopamine scan and video swallow study.
TRANSITIONAL ISSUES
=====================
# Please provide patient with resting splint for her left lower
extremity at night to prevent further contractures.
# Please have ___ work with patient on gait safety and range of
motion.
# Please ensure patient has transportation to make her three
appointments on ___.
# Please evaluate patient for aspiration with speech and swallow
study.
# CODE STATUS: Full (confirmed)
# CONTACT: daughter ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
# Mechanical fall
# Progressive neurologic illness of unclear etiology
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 hospitalization
at ___. You were admitted after having a mechanical fall at
home from being unsteady. You received two CT scans of your head
that were negative for bleeding. You were seen by physical
therapy, who recommend that you go to a ___ facility to work
with physical therapy and regain some strength. While you were
in the hospital, you were also seen by the neurology specialists
and they felt that there were no additional studies that needed
to be performed in the hospital. They felt that it was most
important for you to follow-up in clinic and receive the tests
that are scheduled for you on ___.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10342727-DS-16 | 10,342,727 | 21,126,589 | DS | 16 | 2164-08-17 00:00:00 | 2164-08-17 13:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Gentamicin / Amoxicillin /
codeine / OxyContin
Attending: ___.
Chief Complaint:
Acute left foot pain, pallor, paresthesia
Major Surgical or Invasive Procedure:
___: mechanical thrombectomy and lysis of left fem-pop
bypass graft
___: ___ graft stent
History of Present Illness:
Ms. ___ is a ___ year old female with history of peripheral
arterial disease status post left fem-pop bypass graft requiring
multiple interventions to preserve patency. She remains on
Apixiban 5mg BID, aspirin 81mg daily and clopidogrel 75mg daily
for this reason. She presents to ED with acute left foot pain,
paresthesia and weakness.
Past Medical History:
hyperlipidemia
hypertension
CAD s/p LAD stent
PVD s/p stents to left SFA x 4
Hearing impaired in left ear-wears a hearing aide
h/o ankle fracture
GERD
fasciitis s/p fasciotomy ___
tonsillectomy
appendectomy
s/p Total abdominal hysterectomy
___: Left common fem-AK pop bypass with PTFE complicated by
occlusion requiring thrombolysis, 4 compartment fasciotomies
___: lysis to left fem-pop graft, stent to native AT
Social History:
___
Family History:
Father and brother both died from MIs at age ___
Physical Exam:
Discharge exam
98.3 PO, 146/64, HR 79, RR19, 95% RA
General: Ms. ___ is a well developed female in no apparent
distress. She is ambulating ad lib with a cane and tolerating
activity well.
HEENT: Head is atraumatic, normocephalic, mucous membranes are
moist. Sclerae are anicteric. Neck is supple. There is no
JVD.
CARDIAC: Normal S1, S2. No clicks, murmurs or rubs. Brisk
capillary refill in all extremities.
LUNGS: Clear to auscultation
ABDOMEN: Obese, soft, no organomegaly appreciated. No
tenderness.
LOWER EXTREMITIES: Bilateral lower extremities are warm. Right
groin access site is benign. There is mild pretibial edema in
both lower extremities. Skin is intact. No blue toes. No
pedal edema.
PULSE EXAM: Femoral pulses palpable. Popliteal, ___ and DP
pulses palpable. Strength ___ in right lower extremity. Left
toes are ___.
Pertinent Results:
___ 10:20AM BLOOD Glucose-218* UreaN-16 Creat-1.0 Na-137
K-4.6 Cl-98 HCO3-26 AnGap-13
___ 04:40AM BLOOD WBC-7.3 RBC-3.02* Hgb-8.0* Hct-26.5*
MCV-88 MCH-26.5 MCHC-30.2* RDW-23.2* RDWSD-72.8* Plt ___
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of PAD status
post left fem-pop bypass graft requiring two prior graft
thrombectomies to preserve patency. She remains on Apixiban 5mg
BID, aspirin 81mg daily and clopidogrel 75mg daily for graft
patency. She presented to ED with cold left foot and sensory
motor deficit.
She underwent successful Angiojet thrombectomy, lysis, stenting
and angioplasty. Left foot perfusion improved. While in house,
apixiban held and pt was kept on Heparin gtt. Apixiban was
restarted on ___ evening.
Pt failed trial to void on POD 1 and was straight catheterized
once. Several hours later, she was able to void spontaneously
without difficulty.
On ___, her home medications were restarted. Her left leg edema
improved.
At time of discharge, she was tolerating ambulation well, her
vital signs were stable, her pulse exam was stable and her pain
was well controlled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Gabapentin 800 mg PO TID
3. Carvedilol 3.125 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Apixaban 5 mg PO BID
7. Atorvastatin 80 mg PO QPM
8. Furosemide 40 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. GlipiZIDE 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
DO NOT DRIVE while on Dilaudid
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
6 hours as needed Disp #*10 Tablet Refills:*0
3. Apixaban 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Carvedilol 3.125 mg PO BID
7. Clopidogrel 75 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Gabapentin 800 mg PO TID
10. GlipiZIDE 5 mg PO DAILY
11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
12. Lisinopril 10 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Critical limb ischemia secondary to occluded left lower
extremity bypass graft
Secondary:
DMII
urinary retention
Obesity
Anemia
Chronic systolic congestive heart failure
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:
Ms. ___,
It was a pleasure taking care of you. You are now being
discharged after undergoing clot removal from arteries in your
left leg. You are recovering well. Please follow the below
instructions for an uncomplicated recovery:
WHAT TO EXPECT:
You might feel tired. This might last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day.
You may walk and you may go up and down stairs
Increase your activities as you can tolerate - do not do too
much right away!
No driving until post-op visit and you are no longer taking pain
medications.
You should get up every day, get dressed and walk
You should gradually increase your activity
You may go outside and/or ride in a car
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit.
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over 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
over the area that is draining, as needed
You are expected to have some swelling of the leg you were
operated on. Keep your leg elevated and ACE bandaged to prevent
swelling and pain.
Elevate your leg above the level of your heart (use ___ pillows
or a recliner) every ___ hours throughout the day and at night.
Avoid prolonged periods of standing or sitting without your legs
elevated
You may have a decreased appetite. Your appetite should return
with time.
You might lose your taste for food and lose some weight.
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
MEDICATION:
No changes were deliberately made to your home medication
regimen.
Follow your discharge medication instructions below. These have
been carefully reviewed by your providers.
Use Tylenol (Acetaminophen) 1000mg every 8 hours. Be aware that
there are some over-the-counter and prescription medications
that contain acetaminophen. Be sure never to consume more than
3000mg of Tylenol/Acetaminophen in one day.
Your pain has been well controlled with Tylenol and Po Dilaudid
as needed. Dilaudid is a narcotic. Use narcotic pain
medication sparingly. You should require smaller amounts and
less frequent doses as time goes on. NEVER DRIVE OR OPERATE
MACHINERY WHILE ON NARCOTIC PAIN MEDICATION. If you are taking
narcotics, keep in mind that you may become constipated. You
can take over-the-counter stool softeners or laxatives to
prevent or treat this.
To prevent another blood clot, it is very important that you
stay on your blood thinner.
While on blood thinners, it is important that you report any
dizziness, light headedness, blood in the stool or urine to your
PCP.
Please call clinic at ___ with any questions or
concerns.
Followup Instructions:
___
|
10342727-DS-17 | 10,342,727 | 28,660,807 | DS | 17 | 2165-05-02 00:00:00 | 2165-05-02 13:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Gentamicin / Amoxicillin /
codeine / OxyContin
Attending: ___.
Chief Complaint:
LLE wound & pain x 1 week
Major Surgical or Invasive Procedure:
___ L fem-Tib artery bypass graft w/ propatan graft
___ Diagnostic LLE angio w/ occluded SFA and pop.
History of Present Illness:
Ms. ___ is a ___ F with PMH T2DM, CAD, HTN, and long
history of PVD with surgical history including left fem-AKpop
bypass with PTFE ___, c/b occlusion in ___,
___ all requiring open or endovascular thrombectomies,
who presents to the ED on ___ with a wound to the LLE. She
reports that
the wound started 1 week ago ___ as a fluid-filled blister.
She
does not remember any trauma.
Past Medical History:
hyperlipidemia
hypertension
CAD s/p LAD stent
PVD s/p stents to left SFA x 4
Hearing impaired in left ear-wears a hearing aide
h/o ankle fracture
GERD
fasciitis s/p fasciotomy ___
tonsillectomy
appendectomy
s/p Total abdominal hysterectomy
___: Left common fem-AK pop bypass with PTFE complicated by
occlusion requiring thrombolysis, 4 compartment fasciotomies
___: lysis to left fem-pop graft, stent to native AT
Social History:
___
Family History:
Father and brother both died from MIs at age ___
Physical Exam:
Neuro; awake alert oriented conversational
Lungs: CTA
ABd soft NT ND + BS
Ext LLE staple lines CDI / no drainage. DP dopplerable. Left
great toe with dry gangrene to medial aspect
Pertinent Results:
___ 04:29AM BLOOD WBC-7.9 RBC-3.19* Hgb-7.9* Hct-26.8*
MCV-84 MCH-24.8* MCHC-29.5* RDW-15.9* RDWSD-49.1* Plt ___
___ 05:00AM BLOOD ___ PTT-31.4 ___
___ 04:29AM BLOOD Glucose-137* UreaN-33* Creat-1.2* Na-138
K-5.1 Cl-98 HCO3-26 AnGap-14
Brief Hospital Course:
Ms. ___ is a ___ with PMH T2DM, CAD, HTN, DM and long history
of PVD with surgical history including left fem-AKpop bypass
with PTFE ___, c/b occlusion in ___
___ all requiring open or endovascular thrombectomies, who
presents to the ED on ___ with left leg pain and a wound to
the left great toe which has been present x1 week. She was
admitted and placed on heparin drip and antibiotics because of
worsening erythema of her foot.
She underwent a Diagnostic LLE angiogram on ___ which showed:
Complete occlusion of the superficial femoral and popliteal
artery in the left lower extremity.
Due to the long segment occlusion of the entirety of the
superficial femoral and popliteal artery as well as the
patient's nonhealing wound, decision was made to proceed with
common femoral to anterior tibial bypass via a lateral approach.
in view of her low EF and h/o CAD with stents She was seen and
cleared by cardiology for the pprocedure. The heparin drip was
discontinue on ___ and her eliquis started.
She ha sbeen followed by Pod and I&D of her left great toe was
done. Foot Xray was neg. Left leg became swollwen with pain,
___ neg for DVT. She requested to go to rehab and she has been
evaluated for that on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 3.125 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Gabapentin 800 mg PO TID
8. GlipiZIDE 5 mg PO DAILY
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Apixaban 5 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Glucose Gel 15 g PO PRN hypoglycemia protocol
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
7. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q4H:PRN Pain -
Moderate
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
9. lansoprazole 30 mg oral DAILY
10. Minocycline 100 mg PO BID Duration: 10 Days
11. Ondansetron 4 mg IV Q8H:PRN Nausea/Vomiting - First Line
12. Prochlorperazine 10 mg IV Q6H:PRN Nausea/Vomiting - Second
Line
13. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
14. GlipiZIDE 10 mg PO BID
continue with your previously scheduled dosing parameters
according to fsbs
15. Apixaban 5 mg PO BID
16. Atorvastatin 80 mg PO QPM
17. CARVedilol 3.125 mg PO BID
18. Clopidogrel 75 mg PO DAILY
19. Furosemide 40 mg PO DAILY
20. Gabapentin 800 mg PO TID
21. Lisinopril 10 mg PO DAILY
22. MetFORMIN (Glucophage) 1000 mg PO BID
23. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PVD,
DM
HTN, Hypercholesterolemia, CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms ___,
It was a pleasure taking care of you. You are now being
discharged after undergoing bypass surgery. This was performed
to improve your circulation. You are recovering well. Please
follow the below instructions for an uncomplicated recovery:
WHAT TO EXPECT:
You may feel tired. This might last for ___ weeks.
You are expected to have some swelling of the leg you were
operated on. Elevate your leg above the level of your heart
(use ___ pillows or a recliner) every ___ hours throughout the
day and at night.
Avoid prolonged periods of standing or sitting without your
legs elevated. You should wear an ACE wrap to this leg each
day. You can remove the ACE bandage for sleeping.
You are expected to have a decreased appetite. You might lose
some weight. Your appetite should return with time.
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.
You are expected to have some constipation, especially if
taking Narcotic pain medication. To avoid constipation, eat a
high fiber diet and drink plenty of water. You may use an
over-the-counter stool softener such as Colace or Docusate
Sodium 100mg twice daily and an over-the-counter laxative such
as Senna 2 tabs twice daily as needed for constipation. You
should be using these while taking narcotic pain medication.
MEDICATION:
Follow your discharge medication instructions below. These
have been carefully reviewed by your providers.
For pain, you may use Tylenol (Acetaminophen) 1000mg every 8
hours. Be aware that there are some over-the-counter and
prescription medications that contain acetaminophen. Be sure
never to consume more than 3000mg of Tylenol/Acetaminophen in
one day.
Use narcotic pain medication sparingly, if at all. You should
require smaller amounts and doses less often as time goes on.
NEVER DRIVE OR OPERATE MACHINERY WHILE ON NARCOTIC PAIN
MEDICATION.
If you are taking narcotics, keep in mind that you may easily
become constipated. You can take over-the-counter stool
softeners or laxatives to prevent or treat this.
ACTIVITIES:
You should get up out of bed every day and gradually increase
your activity each day, as you can tolerate. Do not do too much
right away!
Unless you were told not to bear any weight on operative foot,
you may walk and you may go up and down stairs.
No driving until post-op visit and until you are no longer
taking narcotic pain medications.
You may up and down stairs, go outside and ride in a car.
Increase your activities as you can tolerate!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit.
You may shower. Avoid direct spray on incision. Let the soapy
water run over incision, rinse and pat dry.
Your incision may be left uncovered, unless you have drainage
from the wound. If there is drainage, place a dry dressing over
the incision and notify the clinic at ___. You staples
will remain in place until about 3 weeks after your surgery.
Staples will be removed at post ___ clinic visit by your vascular
surgery team.
________________________________
Followup Instructions:
___
|
10342865-DS-14 | 10,342,865 | 22,734,488 | DS | 14 | 2161-10-21 00:00:00 | 2161-10-21 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac cath with ___ 1 to OM
History of Present Illness:
___ F with PMHx of HTN presented with severe substernal chest
pain radiating to L jaw and R arm, a/w SOB, approximately one to
one and a half hours prior to arrival in ED. Patient had never
had symptoms like this before. EMS was called, and found the
patient to have ST depressions in V1-V3. EMS gave 2 sprays SLN,
324 ASA with improvement in pain after SLN. No history of
diabetes, denies abdominal pain, fevers, lightheadedness,
diaphoresis, recent illness.
Past Medical History:
-HTN
-Bleeding ulcer (___)
-Hypothyroidism
-Pyelonephritis
Social History:
___
Family History:
Father: Died of stroke
Mother: Died of stomach cancer
Uncle: CAD
Physical ___:
ADMISSION EXAM
=====================
VS: T 98, HR 84, BP 105/67, RR 18, O2 Sat 97%.
GEN: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP low. Normal carotid upstroke without
bruits. No thyromegaly.
CV: RRR. normal S1,S2. No murmurs, rubs, clicks, or gallops.
LUNGS: No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM.
EXT: WWP, NO CCE. Full distal pulses bilaterally. No femoral
bruits.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. ___ strength throughout.
Sensation diminished on L side. Gait assessment deferred.
DISCHARGE EXAM
=====================
VS: T 98, HR 60, BP 109/55, RR 18, O2 Sat 98% on RA. Not
orthostatic.
GEN: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP low. Normal carotid upstroke without
bruits. No thyromegaly.
CV: RRR. normal S1,S2. No murmurs, rubs, clicks, or gallops.
LUNGS: No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM.
EXT: WWP, NO CCE. Full distal pulses bilaterally. No femoral
bruits. R groin access site with bandage, no hematoma or active
bleeding.
SKIN: M
NEURO: A&Ox3. CN ___ grossly intact. ___ strength throughout.
Sensation diminished on L side. Gait assessment deferred.
Pertinent Results:
AD___ LABS
===============
___ 07:15PM ___
___ 07:15PM ___ PTT-27.7 ___
___ 07:15PM PLT COUNT-233
___ 07:15PM WBC-7.4 RBC-4.03 HGB-12.0 HCT-38.3 MCV-95
MCH-29.8 MCHC-31.3* RDW-15.2 RDWSD-53.2*
___ 07:15PM GLUCOSE-139* LACTATE-1.4 NA+-144 K+-4.0
CL--110* TCO2-20*
___ 07:15PM UREA N-15 CREAT-1.0
___ 07:15PM LIPASE-32
___ 09:32PM CK-MB-74* cTropnT-2.74*
PERTINENT LABS
===============
___ 09:32PM CK-MB-74* cTropnT-2.74*
PENDING LABS
===============
Brief Hospital Course:
___ F with PMHx of HTN presented with chest pain radiating to
jaw, found to have posterior STEMI and received ___ 1 to OM.
ACTIVE ISSUES
==================
#STEMI: BIBEMS ___ hours after symptom onset, received ASA 324
mg and SLNG x 2 in the field. In the ED, EKG revealed
ST-elevations in V7-V9, ST depressions in V1-V3. Initial
troponin was 2.74 and CK-MB was 74. She was given 4000 U heparin
IV, 180 mg ticagrelor, 2 mg morphine, and nitro gtt. Cardiac
cath on ___ showed: ______ She received ___ 1 to OM, and was
admitted to CCU for post-MI care. She was started on ticagrelor
90 mg BID, ASA 81 daily, metoprolol tartrate 12.5 mg daily.
Statin was held as pt reported history of statin allergy.
CHRONIC ISSUES
==================
#Hypothyroidism: Pt was continued on 88 mcg levothyroxine daily.
#Hypertension: Pt's home diltiazem was held, with SBPs 120s to
130s.
#Neuropathy: Pt was continued on home gabapentin (300 mg qAM,
600 mg qHS)
#Hx bleeding ulcer: Pt was continued on home omeprazole 40 mg
daily
TRANSITIONAL ISSUES
========================
NEW DIAGNOSIS: ___ CLASS I HEART FAILURE, EF 40%
- Rosuvastatin started at this admission, please evaluate for
patient tolerance and uptitrate as appropriate
- Please ensure cardiology appointment as outpatient
- Patient should have f/u echo in ___ weeks
- Continue DAPT x ___ year
NEW MEDICATIONS: metoprolol, lisinopril, aspirin, rosuvastatin
DISCONTINUED MEDICATIONS: diltiazem
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO QAM
2. Gabapentin 600 mg PO QHS
3. Diltiazem Extended-Release 300 mg PO DAILY
4. Omeprazole 40 mg PO QHS
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Gabapentin 300 mg PO QAM
2. Gabapentin 600 mg PO QHS
3. Levothyroxine Sodium 88 mcg PO 6X/WEEK (___)
4. Omeprazole 40 mg PO QHS
5. Aspirin 81 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Rosuvastatin Calcium 10 mg PO QPM
9. TiCAGRELOR 90 mg PO BID
10. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-------------------
STEMI S/P DES
SECONDARY DIAGNOSIS
-------------------
DE ___ SYSTOLIC 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 the ___
___.
You were admitted because you had a heart attack. You underwent
cardiac catheterization which revealed 100% blockage in the left
circumflex coronary artery. You had 1 stent placed with good
flow.
It is very important to take all of your heart healthy
medications.
You are now on aspirin. You need to take aspirin everyday. If
you stop taking aspirin, you risk the stent clotting and death.
Do not stop taking aspirin unless you are told by your
cardiologist. No other doctor can tell you to stop taking this
medication.
You are now on Brillinta (also known as ticagrelor). This
medication helps keep your stent open. Do not stop taking
ticagrelor unless you are told by your cardiologist. No other
doctor can tell you to stop taking this medication.
Because of your heart attack, your heart does not pump as well
as it did, a condition called "heart failure." Please weight
yourself everyday. Problems breathing or swelling in your legs
can be signs of worsening heart failure and you may need to take
water pills to pee out the extra fluid. Your weight on discharge
was 201 lbs. If you gain more than 3 lbs or have any of the
above symptoms, please call your doctor for further
instructions.
We wish you all the best,
Your ___ Cardiology team
Followup Instructions:
___
|
10343676-DS-5 | 10,343,676 | 22,231,479 | DS | 5 | 2117-06-30 00:00:00 | 2117-06-30 18:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R tibial plateau fracture
Major Surgical or Invasive Procedure:
Tibial plateau ORIF
History of Present Illness:
___ male with no medical history transferred from OSH with
right tibial plateau fracture. This morning, patient was driver
of motorcycle, helmeted, at 20 mph, struck a car and fell
striking right knee and back. Found to have contusion over
scapula, right tibial plateau fracture. Patient reports pain w/
flexion of right knee, no pain at rest. No tingling, numbness in
leg. No prior surgeries to leg.
Past Medical History:
None
Social History:
___
Family History:
n/c
Physical Exam:
VSS
Right lower extremity:
- In hinge knee brace and wrap c/d/i
- Soft, non-tender thigh and leg
- Cap refill <2 seconds, no pain on passive stretch
- ___ fire
- SILT S/S/DP distributions
- 1+ ___ pulses, WWP
Pertinent Results:
See OMR for all lab and imaging 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 R tibial plateau fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for ex-fix placement and ___ for
ORIF, which the patient tolerated well. For full details of the
procedures please see the separately dictated operative reports.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home with 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
NWB in the RLE, and will be discharged on Lovenox 40 mg SC daily
for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 1 injection SC daily Disp #*28
Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*40 Tablet Refills:*0
5. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Right tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - may require assistance or aid
(walker or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing in right lower extremity, in hinged knee
brace
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add Oxycodone 5mg as needed for increased pain. Aim to
wean off this medication in 1 week or sooner. This is an
example on how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with Dr. ___ in the ___ Trauma
Clinic ___ days post-operation for evaluation. Please call
___ to schedule appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
Non weight bearing right lower extremity
Evaluate and treat
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Followup Instructions:
___
|
10343679-DS-20 | 10,343,679 | 23,111,594 | DS | 20 | 2144-10-16 00:00:00 | 2144-10-16 12:10:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amlodipine
Attending: ___.
Chief Complaint:
Generalized weakness, back pain
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
PCP: ___
.
HPI/EVENTS: Ms. ___ is a pleasant ___ h/o HTN, primary
hyperparathyroidism, chronic shoulder/upper back pain, cervical
stenosis, recent falls who was admitted with generalized
weakness. She reports feeling increasingly physically weak over
the past few months - specifically muscle weakness in upper arms
and lower extremity, requiring her to walk with a cane and
limited capacity for ambulating over distance. Had a fall in
___. She also notes persistent upper back/across the
shoulder pain - described as throbbing, constant, worse at
night, and increased in intensity over past ___ weeks.
This morning, she woke up and felt physically too weak to
get out of bed. Also described chills, diaphoresis. She called
her neighbor - who then called the pt's son. ___ was
called and she was brought to the ED for eval.
.
In the ED, initial vitals: 95.1 74 182/89 20 99% on RA
- Labs notable for: WBC 5.9, BUN/Cr ___, U/A RBC 6 WBC 172,
Nit +, ___ large
- Imaging notable for: CXR unremarkable
ROS: per HPI, denies fever, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
A 10 pt review of sxs was otherwise negative.
.
Past Medical History:
PMH
# HTN
# primary hyperPTH
# chronic pain: bil shoulders, upper back, lower ext
# mod-sev cervical spondylosis - multilevel mod-sev central
canal narrowing
# OA
# CTS s/p R-release (___)
# GERD
# gout
# Vit D deficiency
# unintentional wt loss
# Depression
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother w/hypertension
Physical Exam:
ADMISSION PHYSICAL EXAM:
GEN: NAD, appearing younger than stated age, pleasant but
appearing tired
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: normal BS, NT/ND, no HSM
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, 5- shoulder flexion bil, 4+ hand grasp, 5- elbow
flexion, other 5+ throughout, intact to light touch (except in
hands), 2+ Reflex elbow bil.
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent
.
DISCHARGE PHYSICAL EXAM
Vitals: 98.2
PO 144 / 73 63 18 100 RA
GEN: frail, elderly woman in NAD, pleasant, alert and conversant
EYES: PERRL, EOMI
ENT: moist mucous membranes, no exudates
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no wheezes
GI: normal BS, NT/ND
EXT: warm, well perfused extremities, chronic kyphosis of c
spine noted
SKIN: no rashes
NEURO: alert, oriented x 3, moving all extremities
PSYCH: full range of affect
Pertinent Results:
LABS: SEE BELOW
___ 12:25PM WBC-5.9 RBC-4.49 HGB-14.5 HCT-43.4 MCV-97
MCH-32.3* MCHC-33.4 RDW-12.8 RDWSD-45.5
___ 12:25PM PLT COUNT-298
___ 10:49AM LACTATE-3.0*
___ 10:30AM GLUCOSE-166* UREA N-21* CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-22 ANION GAP-20
___ 09:45AM URINE RBC-6* WBC-172* BACTERIA-FEW YEAST-NONE
EPI-1
___ 09:45AM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG
OTHER DATA:
# CXR (___): Heart size is unchanged, borderline enlarged. The
aorta is tortuous with atherosclerotic calcifications again
noted at the arch. The mediastinal and hilar contours are
unremarkable. The pulmonary vasculature is not engorged. Lung
volumes are low. No focal consolidation, pleural effusion or
pneumothorax is seen. Cholecystectomy clips are noted in the
right upper quadrant of the abdomen. Moderate degenerative
changes are present in the thoracic spine. IMPRESSION: No acute
cardiopulmonary abnormality.
# MRI Cervical Spine (___):
FINDINGS:
IMPRESSION:
1. Multilevel cervical spondylosis, as described, with most
notable findings
including up to severe spinal canal narrowing at the C3-C4
level, and up to
severe neural foraminal narrowing at the right C3-C4 and left
C5-C6 levels.
Degenerative findings to a lesser degree at other levels, as
described above.
2. There is suggestion of minimally increased STIR hyperintense
signal of the
C3-C4 cord, which may represent either myelomalacia or edema.
3. Bilateral thyroid nodules measuring up to 8 mm in the right
lobe. The
___ College of Radiology guidelines suggest that in the
absence of risk
factors for thyroid cancer, no further evaluation is
recommended.
4. Unchanged 2 mm anterolisthesis of C4 on C5, likely
degenerative.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White
Paper of the ACR Incidental Findings Committee". J ___
___ ___
12:143-150.
========================================================
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-4.4 RBC-4.56 Hgb-14.9 Hct-44.0 MCV-97
MCH-32.7* MCHC-33.9 RDW-12.4 RDWSD-43.9 Plt ___
___ 07:50AM BLOOD WBC-4.9 RBC-4.14 Hgb-13.4 Hct-40.3 MCV-97
MCH-32.4* MCHC-33.3 RDW-12.7 RDWSD-45.3 Plt ___
___ 08:30AM BLOOD Glucose-101* UreaN-19 Creat-1.0 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
___ 08:00AM BLOOD Glucose-109* UreaN-8 Creat-0.8 Na-137
K-3.9 Cl-102 HCO3-22 AnGap-17
___ 08:30AM BLOOD Calcium-11.4*
___ 08:00AM BLOOD Calcium-10.6* Phos-2.8 Mg-1.7
___ 03:27PM BLOOD PTH-68*
___ 10:21AM BLOOD Type-ART pH-7.48*
___ 10:21AM BLOOD freeCa-1.30
Brief Hospital Course:
Ms. ___ is an ___ woman with h/o HTN, primary
hyperparathyroidism, chronic shoulder/upper back pain, cervical
stenosis, recent falls who was admitted with generalized
weakness - unable to get out of bed; found to have a UTI.
Physical weakness likely multifactorial: cervical stenosis,
hypercalcemia (Ca ___, both worsened in setting of infection;
now overall improved with antibiotics. MRI C-spine was done due
to slow progressive decline which showed severe cervical spine
stenosis for which neurosurgery was consulted and recommended
outpatient followup.
Medically ready for discharge. ___ recommending rehab however
patient initially refused. Pt may be amenable now that her son
is involved. Awaiting rehab placement.
Rest of hospital course and plan as outlined below by issue:
#Generalized weakness
Admitted with weakness to the extent of not being able to get
out of bed - at baseline ambulatory but requires cane. UTI
contributing to her acute worsening of her weakness. Also
suspected component of cervical stenosis (accounting for pain
and ___ weakness) as well as possibly hypercalcemia too.
-Due to history of cervical spondylosis, an MRI of her neck was
ordered in the context of her generalized weakness which showed
severe narrowing (which was known) with very subtle signal
change. Discussed MRI findings with radiology, mild cord signal
change appears chronic associated with chronic cord flattening
(also seen on prior CT neck). Weakness has improved with
treatment of a UTI. However, per neurosurgery, given the slow
"progressive decline", she may be a candidate for non-emergent
decompression to prevent further decompensation. No acute
intervention indicated while inpatient but recommend outpatient
follow-up with ___ clinic.
#UTI: (urine leukocytes, nit +, frank pyuria).
-started on IV ceftriaxone ___ 1) (hx of pansensitive E
coli and zosyn R kleb but otherwise no sig resistance in the
past micro)
-urine culture grew mixed bacterial flora. In absence of micro
data and improvement on ceftriaxion thus far, will be treated
empirically with ceftriaxone for uncomplicated UTI with 3 days
of abx (completed day 3 of antibiotics as of ___
#Chronic pain - bil shoulder, neck: possibly from cervical
spondylosis
-continued lidocaine patch, duloxetine, Tylenol PRN.
-due to issues affording her medications, financial was enlisted
to help the patient apply for mass health, which was done, so
that she can receive assistance getting her medications,
particularly her duloxetine.
-PACT involved with her medications due to PCP-reported
financial issues obtaining them. Scripts will need to be
provided by her rehab facility.
#Hypercalcemia: Admit Ca ___ on admit but 10.2-10.6 after
hydration. PTH was checked which was actually lower than prior
at 68 (previous in ___, PTH was 102). likely worsened in
the setting of her infection and mild dehydration. Now back to
baseline after IVF. Albumin is actually quite normal at 5.0 and
ionized calcium was within the normal range at 1.30 (___).
#HTN: SBP consistently > 180s (chronically elevated as well)
-lisinopril dose was increased from 20 to 40mg
-verapamil dose was increased from 120mg q24h to 180mg q24h
-BPs have improved on the above new regimen
-BMP checked on ___ and stable Cr and serum potassium, recommend
another BMP check as below in transitional issues
#Gout: on allopurinol
#Glaucoma: Xalatan droplets
#Tob dependence: nicotine patch
#Transitional Issues:
-increased lisinopril from 20 to 40mg, should have recheck of
her BMP within 1 week after discharge (to be followed up by PCPs
office)
-increased verapamil from 120 to 180mg daily
-needs further titration of her BP meds as outpatient.
-neurosurgery follow up with Dr. ___ ___
Neurosurgery Spine), which is scheduled for ___.
#Contacts: ___ ___
-discussed care with her PCP via secure email to coordinate
follow up
-___: called ___ with an update, discussed plan including
MRI. Answered all questions.
-___: called ___ again but no answer left a voicemail to
update.
-___: son updated by team and discussed rehab
CONSULTS: ___, spine surgery
DISPO: medically ready but awaiting discharge plan: ___
recommended rehab however patient initially refused. Pt is now
amenable to rehab now that her son is involved. Discharge to
___.
spent > 30 minutes seeing the patient and organizing her
discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. DULoxetine 30 mg PO DAILY
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Lisinopril 20 mg PO DAILY
5. Verapamil SR 120 mg PO Q24H
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Vitamin D ___ UNIT PO DAILY
8. Nicotine Patch 14 mg TD DAILY
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QPM apply to upper back
2. Lisinopril 40 mg PO DAILY
3. Nicotine Patch 7 mg TD DAILY
4. Verapamil SR 180 mg PO Q24H
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Allopurinol ___ mg PO DAILY
7. DULoxetine 30 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-generalized weakness
-UTI
-Cervical Spinal Stenosis
-dehydration
-hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
D/C Instructions:
Dear Ms. ___,
You were hospitalized at ___.
Why were you in the hospital?
=======================
-generalized weakness
-UTI
-Cervical Spinal Stenosis
-dehydration
-high blood pressure
What did we do for you?
=======================
- you were given IV fluids
-we treated your UTI with antibiotics, which you completed while
you were in the hospital
-you had an MRI done of your neck which confirmed severe spinal
stenosis
-you were seen by physical therapy who you should be discharged
to acute rehabilitation
-you blood pressure medications were adjusted
What do you need to do?
=======================
- you are scheduled to see a spine surgeon to see if there is
anything that can be done about your neck and your progressive
weakness.
-we increased your lisinopril from 20 to 40mg, and you should
have a recheck of her labs within 1 week after discharge (to be
followed up by PCPs office)
-we also increased your verapamil from 120 to 180mg daily
Please follow up with your primary care doctor.
It was a pleasure taking care of you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10343782-DS-28 | 10,343,782 | 27,524,196 | DS | 28 | 2181-11-16 00:00:00 | 2181-11-17 20:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet
Attending: ___
Chief Complaint:
Nausea, Vomiting, A.Fib with RVR
Major Surgical or Invasive Procedure:
# L renal lithotripsy with nephrostomy tube removal
History of Present Illness:
___ F w history of recurrent UTIs, A.Fib and ___ who was
recently discharged the first week of ___ from ___ where she
was treated for septic shock from urinary source ___ obstructing
L renal calculus and proteus UTI who presented to the ED with
nausea and vomiting admitted to medicine for nausea control and
for atrial fibrillation with RVR.
Patient reports she first vomitted after sitting up during home
___ session this afternoon around 12:30pm. She reports feeling
dizzy x 4 days. The ___ services on ___ stated her
dizziness was likely due to dehydration. She denies fever but
subjectively felt warm, her vitals have been stable. Pt relates
no history of vertigo. Pt is not sure if she feels the room
spinning but says that her dizziness would increase if she sits
up or stands up. Pt states she has a mild headache that began
today. Pt denies LOC, change in hearing, tinnitus, increased
dizziness with head position changes, neck pain. On review of
systems she descibes chronic shortness of breath though at
baseline currently. Denies CP, abd pain, blood in vomit or stool
In the ED, initial vs were:97.4 64 192/69 18 97% ra. Labs were
remarkable for normal renal function and Hct above baseline.
Neuro was consulted who recommended head CT. Patient refused
head CT, but eventually agreed and it showed no acute changes.
Patient given Reglan and Ativan for nausea control. ED course
notable with A.Fib with RVR to 120, Metoprol 5mg IV x2 given
with good response. Vitals on Transfer: 107 ___ 98% RA
On the floor, vs were 97.8, 127/77, 65, 18, 99%RA
Past Medical History:
- Chronic UTIs
- Paroxysmal Atrial Fibrillation
- Ischemic Colitis
- Obesity
- ___'s Hypothyroidism
- Obstructive sleep apnea
- h/o thyroid cancer s/p partial thyroidectomy
- Ischemic Colitis
- Diastolic dysfunction with preserved EF
- Aortic stenosis - per chart but not seen on ___ TTE
- Vitamin D deficiency
- Barretts esophagus
- Hypertension
- Hypercholesterolemia
Social History:
___
Family History:
-Brother had ___ and DM
-Father had DM
-Mother had CHF
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals- 97.8, 65, 127/77, 18, 99%RA
General: Well-appearming obese woman in no acute distress.
HEENT: EOMI, anicteric, moist MM. Neck: Supple, no LAD
CV: irregularly irregular rate in ______, normal S1 + S2
murmur
Lungs: CTAB
Abdomen: Soft obese, mild lower abdominal tenderness, +BS, no
rebound tenderness, no organomegaly
GU: foley in place; also has L nephrostomy tube in place,
draining urine, dressing c/d/i
Ext: warm, well perfused, large scar on right inner thigh, skin
thickening over lower extremeties c/w chronic venous statsis,
minor erythema and bullae over shins bilaterally (chronic per
patient)
Neuro: CNII-XII intact, motor function grossly normal, A&O x3.
She has nystagmus with rightward gaze.
PHYSICAL EXAM ON DISCHARGE:
VS
I/O's: Past 8 hrs I 720 O 1020, Previous 24 hrs I 1490 O ___
GENERAL: NAD, alert, comfortable, pleasant, interactive
HEENT: NC/AT
LUNGS: Clear to auscultation bilaterally, no w/r/r
HEART: RRR, bradycardic, normal S1&S2, III/VI early systolic
murmur most prominent at RUSB, no r/g
ABDOMEN: soft, ND, tenderness to deep palpation in RLQ, no
masses or organomegaly
EXTREMITIES: WWP, non-blanching erythema on anterior legs
bilaterally
NEURO: no focal deficits
Pertinent Results:
LABS ON ADMISSION
___ 05:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 04:10PM estGFR-Using this
___ 04:10PM CK(CPK)-18*
___ 04:10PM WBC-4.8 RBC-3.95* HGB-11.7* HCT-34.7* MCV-88
MCH-29.5 MCHC-33.6 RDW-14.3
___ 04:10PM WBC-4.8 RBC-3.95* HGB-11.7* HCT-34.7* MCV-88
MCH-29.5 MCHC-33.6 RDW-14.3
___ 04:10PM NEUTS-78.0* LYMPHS-15.8* MONOS-3.9 EOS-1.4
BASOS-0.8
___ 04:10PM PLT COUNT-312#
___ 04:10PM ___ PTT-31.3 ___
LABS ON DISCHARGE
___ 07:15AM BLOOD WBC-5.1 RBC-3.75* Hgb-11.3* Hct-33.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-14.8 Plt ___
___ 07:15AM BLOOD Glucose-118* UreaN-19 Creat-0.8 Na-143
K-4.0 Cl-109* HCO3-26 AnGap-12
___ 07:15AM BLOOD Calcium-10.0 Phos-3.2 Mg-2.2
MICROBIOLOGY
___ 1:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:31 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 1:31 pm URINE Source: Kidney NEPHROSTOMY TUBE.
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
YEAST. >100,000 ORGANISMS/ML..
ANAEROBIC CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Test performed only on suprapubic and kidney aspirates
received in a
syringe.
IMAGING
CT HEAD AND CTA HEAD ___
FINDINGS:
Non contrast CT head:
Mild patchy bihemispheric periventricular and deep white matter
hypodensity is
nonspecific but may be function of chronic small vessel ischemic
change.
Gray-white matter differentiation is otherwise preserved.
Ventricular,
cisternal, and sulcal prominence may be a function of
age-related parenchymal
volume loss. No edema, mass effect, midline shift, or
herniation is
identified. No intra-axial or extra-axial hemorrhage or fluid
collection is
seen. There is a stable calcification in the right centrum
semiovale,
possibly related to a cavernoma. The calvarium appears
unremarkable. The
included paranasal sinuses and mastoid air cells are clear. A
___ cisterna
magna vs arachnoid cyst is noted.
CTA head:
Normal flow is noted in the petrous, cavernous, and supraclinoid
portions of
the internal carotid arteries. The right A! segment is
hypoplastic. The
anterior and middle cerebral, as well as the anterior
communicating arteries
are otherwise normal. The posterior cerebral, superior
cerebellar, and
basilar arteries are unremarkable. The intradural segments of
both arteries
are patent. No arterial stenosis, saccular aneurysm greater
than 3 mm, or AVM
is identified.
CTA neck:
There is normal opacification of the major neck vessels.
Incidentally noted is a left aortic arch with an aberrant right
subclavian artery taking a retroesophageal course. There
appears to be a common origin of the right common, left common,
and left subclavian arteries. The common, internal, and
external carotid arteries, as well as the vertebral artery,
demonstrate normal flow and enhancement. There is
retropharyngeal course of the right common carotid artery. The
right vertebral artery is hypoplastic, a normal variant; the
left vertebral artery is dominant. Both carotid bulbs are
unremarkable in appearance. The vertebral artery origins are
unremarkable. No stenosis, dissection, aneurysm, or
pseudoaneurysm is identified.
The left thyroid lobe is not identified; there appears to be a
cyst/nodule within the inferior right thyroid lobe was described
on ultrasound ___.
No significant lymphadenopathy is appreciated.
The aerodigestive tract is patent. The vocal cords appear
unremarkable
without grossly asymmetry. The vallecula and piriform sinuses
demonstrate no gross abnormalities.
The superficial soft tissue of the neck show no swelling or
abnormality.
There are no areas of necrosis or abnormal hypodensity within
the neck. There is no fatty streaking to suggest inflammation.
No soft tissue mass or fluid collection is seen.
No abnormal areas of contrast enhancement are identified.
Included bones demonstrate marked multilevel degenerative
changes with
posterior osteophyte formation and loss of disk space height.
The included visualized upper lung zones are clear.
IMPRESSION:
Age-related involutional and chronic microangiopathic changes
without acute hemorrhage or mass effect.
Grossly unremarkable CTA of the head and neck without evidence
of arterial stenosis, saccular aneurysm greater than 3 mm, AVM,
dissection, or pseudodissection.
___ ECHO
Study terminated before completion due to patient lack of
cooperation. The left atrium is mildly dilated. 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 70%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). The aortic valve is not well seen. There
is mild aortic valve stenosis. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is no
pericardial effusion.
Brief Hospital Course:
___ yo F w history of recurrent UTIs, paroxysmal A-Fib, and dCHF
who presents with dizziness, found to have BPPV, course c/b two
conversion pauses in setting of A-fib and sick sinus syndrome.
ACTIVE ISSUES
# Peripheral vertigo: Felt nauseous and vomited x1 on ___ while
sitting up in a chair after talking for about 10 minutes.
Orthostatics negative. Infectious workup was negative except
for urine culture as below, which was actually thought to
represent colonization, given no other clinical evidence for
true infection (however, was treated as below). Patient was seen
by neurology and CT head as well as CTA of the head and neck
were performed which were negative. Patient refused MRI due to
a problem with lying flat. The symptoms were not classic for
BPPV, and she would not tolerate a ___ or Epley. It
was felt she might have a labyrinthitis and she was started on
symptomatic treatment with meclizine which improved symptoms,
and she was able to perform all activities without dizziness
prior to discharge. Her afib was actually not thought to be
related to the dizziness given she was in sinus at a normal rate
for most of the admission and the conversion pauses were not
associated with these symptoms.
# Paroxysmal Afib: Patient has chronic A-fib. Occurred while in
ED, RVR up to 120's, received metoprolol tartrate 5mg IVx2 with
good response. At home, patient is rate-controlled with
metoprolol succinate 12.5 mg BID. Baseline HR is in the 50's.
Not on anticoagulation, CHADS2 of 3. Discussed with outpatient
cardiologist Dr. ___ on ___. Metoprolol was increased
initially and flecainide initiated; however, had significant
pause on conversion from afib to sinus rhythm. Medications were
adjusted to stop metoprolol and start amiodarone, with a amio
load of 200mg BID x1 month. Early in the admission, she had
converted and stayed in sinus with rates in the ___ for the
remainder of her time here. She will follow up with her
cardiologist for further management as an outpatient.
Amiodarone should be continued at 200mg BID until further
recommendations by her cardiologist.
# Sick sinus, tachy-brady syndrome: 2 conversion pauses of ___,
5s. First episode occurred at 10pm on ___ while she was sitting
up in a chair and in A-fib with rates 75-150. Cards evaluated
the pt, thought this was most likely due to SSS tachy-brady
syndrome and recommended pacemaker placement. Second episode
occurred at around 7:30am morning of ___ during morning
prerounds and was associated with a 5s pause. EKG performed, no
changes from previous. Troponins neg, unlikely to be ACS. K
repleted, Mg wnl, Ca wnl, albumin wnl. TTE showed no evidence of
valvular disease. Per Cards recs started amiodarone and will f/u
with cardiology outpatient.
# Recurrent UTIs w/recent admission for septic shock w/renal
calculus: Recently hospitalized beginning of ___, discharged
on Ceftriaxone and being followed by Urology with nephrostomy
tube in place. Finished 2 week course of CTX ___. UA on
admission was negative for nitrites, leuks. In setting of
consideration of possible pacemaker insertion for above
problems, urine was cultured on ___. UCx #1 (straight cath) pos
for E.coli, UCx #2 (Nephrostomy-tube) pos for flora and yeast.
These were thought to most likely be colonizers as there were no
WBCs on UA. She was covered with Vancomycin and Zosyn x3 days
for colonization, finished ___. Urology removed nephrostomy
tube on ___ and lithotripsy x3 performed, no intra-op
complications.
CHRONIC ISSUES
# Diastolic CHF: Chronic, Diastolic CHF with LVEF of 70% on TTE
yest (___), E/A ratio down to 0.77 from 0.9 in ___. Admitted
euvolmic and no evidence of decompensated CHF. Unable to lie
flat for more than a few minutes at baseline. Her furosemide
was held for 2 days ___ surrounding her urology procedure
given fluid losses/NPO status and minor hypovolemia. This
resolved and furosemide home dose was restarted ___.
# OSA: pt refused CPAP.
# Hypothyroidism: Chronic, stable, maintained on home dose
levothyroxine.
# Hyperlipidemia: continued home statin
# HTN: continued home lisinopril
TRANSITIONAL ISSUES
None.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Fexofenadine 60 mg PO BID
3. Flecainide Acetate 100 mg PO Q12H
4. Furosemide 20 mg PO DAILY
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Rosuvastatin Calcium 10 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 325 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 200 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Rosuvastatin Calcium 10 mg PO DAILY
9. Amiodarone 200 mg PO BID
10. Meclizine 25 mg PO Q6H
11. Prochlorperazine 10 mg IV Q6H:PRN nausea
12. Simethicone 40-80 mg PO TID:PRN gas
13. Fexofenadine 60 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis:
1) Atrial fibrillation with RVR
2) Vertigo
secondary diagnosis:
1) Nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you while you were admitted at
___. You were admitted due to dizziness and atrial
fibrillation with a fast heart beat. While you were here, you
had a CT and CTA of your head and neck to rule out a brain or
vascular process causing your dizziness. You were also seen by
neurology. While you were here you also had some pauses in your
heart rhythm and were seen by cardiology, who made
recommendations about heart medications and started amiodarone.
Your heart remained in a regular rhythm for most of the time you
were here. You also had your nephrostomy tube removed and
lithotripsy performed.
Your dizziness improved with meclizine and you should continue
this for symptomatic treatment.
Followup Instructions:
___
|
10343782-DS-30 | 10,343,782 | 26,606,878 | DS | 30 | 2185-12-21 00:00:00 | 2185-12-25 00:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet / Bactrim / Linzess
Attending: ___.
Chief Complaint:
Fever, leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of urosepsis and obstructing kidney stones, aortic
stenosis, afib on Xarelto, BPV, CHF with diastolic dysfunction,
Barretts esophagus with dysphagia, hypothyroid, chronic
lymphedema, HTN and ischemic colitis who is presenting with
lower back pain for the past month and chills that started last
night.
She has a history of getting very sick quickly and ending up in
septic shock with infections in the past. Her granddaughter's
wedding is tomorrow at 3 ___ and she is upset to possibly miss
this. She denies urinary symptoms, but does not usually have
these with her UTI. She endorses severe shaking chills that
started last night and then recurred today. She used Tylenol
last night and today and an elevated temperature of ___. She
also has increased incontinence over the last 2 weeks which is
another indication of UTI per patient.
She also endorses increasing redness and drainage from her left
lower extremity for the past few days.
She denies fall or trauma. She denies bowel incontinence. She
denies numbness, weakness or tingling of her lower extremities.
She denies nausea, vomiting, diarrhea, chest pain, shortness of
breath, change in her chronic abdominal pain. Her chronic back
pain is also unchanged from baseline.
In the ED, initial VS were: 100.9 56 185/59 16 98% RA
Exam notable for: Left anterior ___ with redness and weeping and
warmth compared to right ___ of equal size. Bilateral 4+ edema of
the ___. Midline spinal tenderness of L2-L4, no paraspinous
muscle tenderness. Mild Right CVAT. NTND abd. RRR. Mild crackles
bilaterally.
Labs showed:
- WBC: 10.4 (PMN 95%), Hgb 11.3 (baseline)
- INR 1.3
- Na 140, K 4.7 (hemolyzed), Cr 0.8 (baseline)
- Lactate 1.2
- U/A 1.023, ___, +Nit, 47 WBC, mod Bact, 1 Epi
Imaging showed:
- CXR: no acute process
- CTU (NC): no acute abnormality, hydronephrosis or perinephric
abnormality, or fracture. Nonobstructive nephrolithiasis and
diverticulosis without diverticulitis.
Patient received:
Acetaminophen 1000 mg
IV Ceftriaxone 1 gm
Amiodarone 200 mg
Rosuvastatin Calcium 5 mg
Lisinopril 20 mg
Allopurinol ___ mg
Tramadol 50 mg
Rivaroxaban 20 mg
Lidocaine 5% Patch
Transfer VS were: 98.1 64 131/67 16 99% RA
On arrival to the floor, patient reports that she has not had
any more chills. She c/o her chronic back pain and says her left
leg is more painful than her right. She did not notice the
erythema on the left leg. She denies acutely worsening edema,
dyspnea or exercise tolerance.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Atrial fibrillation
CAD
HFpEF
Aortic stenosis
HTN
HLD
Urosepsis
Recurrent UTIs
Urinary incontinence
Thyroid cancer s/p partial thyroidectomy
Hyperparathyroidism
Hypothyroidism ___ ___'s
Nephrolithiasis, obstructive
Stasis dermatitis / Lymphedema
Gout
GERD
___ esophagus
Ischemic colitis
BPPV
Chronic back pain
OA knees
Morbid obesity
OSA
Hearing loss
Social History:
___
Family History:
Father who had a renal calculus once, DM, mother with congestive
heart failure, and a brother with ESRD on HD, DM
Physical Exam:
=====================
ADMISSION
=====================
VS: 135/55 55 20 96% RA
Weight; 115.67 kg
GENERAL: WDWN woman in NAD
HEENT: EOMI, PERRL, anicteric sclera, hearing aid in place, MOM,
OP clear
NECK: supple, no LAD, JVD to below chin at 30 degrees
HEART: RRR, normal S1/S2, III/VI SEM RUSB
LUNGS: NLB on RA, CTAB
ABDOMEN: soft, nondistended, mildly tender in LLQ, no
rebound/guarding, +BS
EXTREMITIES: no cyanosis, severe lymphedema BLE to hips equally
with B/L distal stasis growths. LLE with erythema extending to
mid thigh, ill defined border with associated warmth and
tenderness with purulent cellulitis distal LLE
GU: trace left sided back pain at CVAT
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, face symmetric, moving all 4 extremities with
purpose
SKIN: warm and well perfused
=====================
DISCHARGE
=====================
VS: 97.9, 151/76, 53 18 97 Ra
GENERAL: AOx3, lying in bed, NAD
NEURO: AOx3, no focal deficits.
EYES: Anicteric sclera
ENT: MMM
NECK: Supple
CV: RRR, III/VI systolic murmur at RUSB
RESP: CTAB
GI: soft, NT/ND, Bowel sounds present
MSK: Lymphedema B/L extending to her hips. B/L distal stasis
growths, Her LLE demonstrates erythema extending to the mid-shin
with poorly demarcated borders. There is associated mild TTP and
warmth. No evidence of purulence.
EXT: warm and well perfused; no clubbing or cyanosis.
Pertinent Results:
====================
ADMISSION LABS
====================
___ 07:45PM BLOOD WBC-10.4*# RBC-3.74* Hgb-11.3 Hct-35.7
MCV-96 MCH-30.2 MCHC-31.7* RDW-14.0 RDWSD-49.0* Plt ___
___ 07:45PM BLOOD Neuts-95.1* Lymphs-2.1* Monos-2.3*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.91*# AbsLymp-0.22*
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01
___ 07:45PM BLOOD ___ PTT-34.2 ___
___ 07:45PM BLOOD Glucose-95 UreaN-22* Creat-0.8 Na-140
K-4.7 Cl-102 HCO3-24 AnGap-14
___ 07:45PM BLOOD Calcium-9.6 Phos-2.9 Mg-2.1
___ 07:55PM BLOOD Lactate-1.2
====================
PERTINENT RESULTS
====================
MICROBIOLOGY
====================
__________________________________________________________
___ 6:42 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 7:10 am SWAB Source: LLE drainage material.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S 2 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM------------- 0.5 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
__________________________________________________________
___ 8:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000
CFU/mL. PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
__________________________________________________________
___ 7:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
====================
IMAGING
====================
CXR (___): No acute intrathoracic process. Specifically, no
signs of pneumonia.
===
CTU Abdomen/Pelvis (___):
1. No acute abnormality in the abdomen or pelvis to explain
patient's reported back pain and fever. Specifically, no
evidence of hydronephrosis or perinephric abnormality. No
fracture.
2. Nonobstructive nephrolithiasis.
3. Sigmoid colonic diverticulosis without evidence of
diverticulitis.
4. No evidence of acute appendicitis.
5. A small focus of gas in the bladder is nonspecific but likely
related to
instrumentation. Please correlate clinically.
====================
DISCHARGE LABS
====================
___ 09:15AM BLOOD WBC-4.2 RBC-3.42* Hgb-10.4* Hct-32.6*
MCV-95 MCH-30.4 MCHC-31.9* RDW-14.1 RDWSD-49.4* Plt ___
___ 09:15AM BLOOD Glucose-105* UreaN-28* Creat-0.8 Na-145
K-4.4 Cl-107 HCO3-24 AnGap-14
___ 09:15AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.1
Brief Hospital Course:
Ms. ___ is an ___ y/o woman with history of recurrent
urinary tract infections complicated by urosepsis, obstructive
nephrolithiasis, urinary
incontinence, HFpEF, AS, thyroid cancer s/p partial resection,
___ esophagus, chronic back/knee pain, lymphedema who
presented with back pain and chills and was found to have
urinary tract infection and left lower extremity cellulitis.
===============
ACUTE ISSUES:
===============
# Urinary tract infection: Patient presented with chills and was
found to have pansensitive E. coli urinary tract infection.
Imaging was without obstructive nephrolithiasis and showed no
radiographic evidence of pyelonephritis. The patient was
initially given ceftriaxone, and given allergy to Bactrim and
drug-drug interactions with amiodarone, will complete 7-day
treatment course with
cephalexin (Last day: ___.
# Cellulitis: Patient was noted to have left lower extremity
erythema and serous drainage consistent with nonpurulent skin
and soft tissue infection. She was initially given vancomycin
and ceftriaxone and narrowed to cephalexin as above. She was
treated with tramadol for discomfort.
# Lymphedema: Patient has longstanding history of lymphedema
that increased her vulnerability to cellulitis as above. She
will follow up in the lymphedema ___ further management.
===============
CHRONIC ISSUES:
===============
# Chronic back pain
# OA knees: Lidocaine 5% Patch daily. Tramadol as above.
# Atrial fibrillation: Continued amiodarone and rivaroxaban.
# HFpEF: Continued lisinopril, torsemide.
# Aortic stenosis: Stable.
# HTN: Continued lisinopril.
# HLD: Continued rosuvastatin.
# Hypothyroidism ___ hashimoto's, thyroid cancer s/p resection:
Continued levothyroxine.
# Gout: Continued allopurinol.
# GERD c/b ___ esophagus: Continued omeprazole.
# OSA not on CPAP
======================
TRANSITIONAL ISSUES
======================
- Patient to continue cephalexin 500 mg Q6H to complete 7-day
course for E. coli urinary tract infection and cellulitis (Last
day: ___
- Patient provided with tramadol for increased discomfort due to
cellulitis
- Patient will follow up in the ___ clinic
- Communication: ___, friend, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Lidocaine 5% Ointment 1 Appl TP TID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Amiodarone 200 mg PO DAILY
7. Rivaroxaban 20 mg PO DAILY
8. Rosuvastatin Calcium 5 mg PO QPM
9. Torsemide 10 mg PO EVERY OTHER DAY
10. TraMADol 50 mg PO Q12H:PRN Pain - Moderate
11. Omeprazole 20 mg PO DAILY
12. Levothyroxine Sodium 200 mcg PO DAILY
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
14. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Cephalexin 500 mg PO Q6H
Last day: ___
RX *cephalexin 500 mg 1 capsule(s) by mouth Every 6 hours Disp
#*14 Capsule Refills:*0
3. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth Every 6 hours Disp #*20
Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Amiodarone 200 mg PO DAILY
6. Levothyroxine Sodium 200 mcg PO DAILY
7. Lidocaine 5% Ointment 1 Appl TP TID
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Lisinopril 20 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Rivaroxaban 20 mg PO DAILY
14. Rosuvastatin Calcium 5 mg PO QPM
15. Torsemide 10 mg PO EVERY OTHER DAY
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY:
- Cellulitis
- Urinary tract infection
SECONDARY:
- Lymphedema
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 ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were having chills and
back pain
WHAT HAPPENED IN THE HOSPITAL?
- We found that you had an skin infection called cellulitis
- We also found that you had a infection in your urine
- We gave you antibiotics by IV to treat this, and once you got
better we gave you antibiotic by mouth
WHAT SHOULD I DO WHEN I GO HOME?
- Your should continue to take your antibiotics as prescribed
- You should follow up in ___ clinic to help with the
swelling in your leg
We wish you the best!
-Your Care Team at ___
Followup Instructions:
___
|
10343848-DS-20 | 10,343,848 | 26,738,210 | DS | 20 | 2164-03-31 00:00:00 | 2164-04-02 14:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
amoxicillin / Augmentin
Attending: ___
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with dementia, afib not on AC,
pacemaker, prior CVA (on ASA) who presented to ___ with left face droop and left arm weakness, LKN ___ at
12:15PM. Telestroke was initiated. His exam at ___ revealed
subtle left facial droop, subtle left proximal arm weakness,
left
sensory extinction. NIHSS 8 for LOC, mild facial weakness, limb
ataxia, sensory, mild aphasia, mild dysarthria, extinction.
NIHSS
5 if accounting for baseline dementia - he is not oriented to
time/age and has some word finding trouble at baseline. CT
showed
no early changes, no bleed, CTA showed no LVO. Wife consented to
TPA with understanding that he is at higher risk of bleeding due
to dementia and age. TPA administered at 1356. He is being
transferred to ___ for post-TPA care.
Upon arrival, he has no complaints.
ROS:
On neurological review of systems, the patient denies headache,
loss of vision, blurred vision, diplopia, lightheadedness,
vertigo.
On ___ review of systems, the patient denies recent fever,
chills. Denies cough, shortness of breath, chest pain or
tightness, palpitations. Denies nausea, vomiting,
diarrhea,constipation or abdominal pain.
NIHSS performed within 6 hours of presentation at: ___ at
1545
NIHSS Total: 7
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 1
10. Dysarthria: 1
11. Extinction and Neglect: 1
Past Medical History:
Atrial Fibrillation, not on AC
advanced dementia dependent for all IADLs and some ADLs
alcohol abuse
CKD
CHF
prior CVA
HTN
Pacemaker
Ptosis
vasovagal episode
Social History:
___
Family History:
Non contributory to current stroke
Physical Exam:
On admission:
Vitals: T 98.6 HR 63 BP 140/69 RR 18 98% RA
___: Awake, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple. 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 x 0. Unable to relate history.
Inattentive, unable to name ___ backward. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were paraphasic errors. Trouble naming both high and low
frequency objects. Able to read without difficulty. Mild
dysarthria. Able to follow simple midline and appendicular
commands, but has trouble with complex commands. ___ recall.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. BTT present b/l.
V: Facial sensation intact to light touch.
VII: L NLFF.
VIII: hard of hearing b/l.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. + left pronation. +
action tremor bilaterally. He was able to lift and sustain both
arms and legs AG. Difficult for him to participate in formal
confrontation testing due to inability to follow directions. But
he was at least ___ on left deltoid, full strength in left
biceps, at least ___ in left triceps. Full strength in left
finger flexion. Right arm is at least ___ throughout. Left leg
is
___ at IP. Unable to formally assess remainder of left leg, but
easily moving it AG.
-Sensory: Decreased sensation to pinprick in left ___. +
extinction to DSS on left.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait: deferred
At Discharge:
Neurologic:
-Mental Status: Alert, oriented x 0. Disoriented and restless
at
times. Unable to relate history. Inattentive. Language is
fluent
with intact repetition and comprehension. Normal prosody. There
were paraphasic errors. Mild dysarthria. Able to follow simple
midline and appendicular commands, but has trouble with complex
commands. right gaze preference and regards more on the right
than left. Crosses to left.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. right eye esotropic
on primary gaze. rt ptosis. EOMI without nystagmus. No blink to
threat on the left
V: Facial sensation intact to light touch.
VII: L NLFF. Improved compared to before
VIII: hard of hearing b/l.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. + left pronation.
drifts
out . He was able to lift and sustain both arms and legs AG.
Difficult for him to participate in formal confrontation testing
due to inability to follow directions.
-Sensory: responds to touch in all extremities but unable to
fully access
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: deffered
-Gait: deferred
Pertinent Results:
___ 03:05PM BLOOD WBC-7.4 RBC-4.83 Hgb-14.4 Hct-44.9 MCV-93
MCH-29.8 MCHC-32.1 RDW-14.0 RDWSD-47.4* Plt ___
___ 03:05PM BLOOD Plt ___
___ 03:05PM BLOOD ___ PTT-35.0 ___
___ 03:05PM BLOOD Glucose-110* UreaN-17 Creat-1.4* Na-140
K-4.0 Cl-102 HCO3-23 AnGap-15
___ 03:20PM BLOOD ALT-13 AST-14 CK(CPK)-97 AlkPhos-134*
TotBili-1.3
___ 03:05PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.0
___ 03:20PM BLOOD %HbA1c-5.8 eAG-120
___ 03:20PM BLOOD Triglyc-76 HDL-49 CHOL/HD-2.6 LDLcalc-63
CT/CTA at ___ ___: CT showed no early changes, no bleed, CTA
showed no LVO.
Brief Hospital Course:
Mr. ___ is a ___ year old with dementia (oriented to self
but often doesn't know where he is or the dates; knows most
family), afib not on anticoagulation (given remote history of
falls when he was an alcoholic, but now resolved), HFrEF,
pacemaker, prior CVA (on ASA) who presented to ___
___ with fall as well as left face droop and left arm
weakness, LKN ___ at 12:15PM. Telestroke was initiated. NIHSS 8
for LOC, mild facial weakness, limb ataxia, sensory, mild
aphasia, mild dysarthria, extinction. NIHSS 5 if accounting for
baseline dementia - is not oriented to time/age and has some
word finding trouble at baseline. CT showed no early changes, no
bleed, CTA showed no large vessel occlusion. Wife consented to
TPA with understanding that he is at higher risk of bleeding due
to dementia and age. TPA administered at 1356 on ___. He was
transferredto ___ for post-TPA care.
On admission, his symptoms were most consistent with right MCA
syndrome likely embolic from known afib not on AC. He was
monitored closely with neuro checks. After discussing with
patient's wife in detail about the risk of stroke in the setting
of A. fib, risks and benefits of anticoagulation (given his age
and comorbidities) she agreed with starting anticoagulation. He
was started on apixaban 5 mg twice daily as etiology was
attributed to cardioembolic process. Further stroke work-up
revealed LDL 63, TSH 2.7 and HgbA1c - 6.0. Transthoracic
echocardiogram showed an EF of 25 to 35%, with no evidence of
thrombus. His symptoms gradually improved with some improvement
in dysarthria and had mild left hemiparesis on discharge. He was
evaluated by ___, OT and ST. Swallow evaluation revealed
increased risk of aspiration given latency but recommended
starting soft diet with bite-size solids and thin liquids with
one-to-one supervision and assistance.
#Hospital acquired delirium on background of dementia
His hospital stay is also complicated by hospital-acquired
delirium in the setting of baseline dementia. Received PRN
Seroquel 12.5mg at bedtime one night(he was on it at home
previously but was discontinued given prolonged QTC). This was
not continued as he did not need it prior to discharge.
#Hypotension
His blood pressure was also well controlled and low normal at
baseline. He had several episodes of asymptomatic sbp to 60
which was repeated and was 90. This occurred within a few hours
after his Lasix. CBC was stable and he was otherwise afebrile
and asymptomatic. Metoprolol was decreased to 6.25 mg oral twice
daily. He takes Lasix 40 mg alternating with 20 mg daily which
resulted in low blood pressures. Lasix 40 mg every other day was
discontinued. Continue Lasix 20 mg every other day and monitor
daily weights. If he gains more than 3 pounds in 1 day, consider
increasing Lasix to 20 mg daily and titrate up as appropriate.
Transitional issues:
[] Monitor blood pressure daily. Increase metoprolol dose (prior
home dose was 25 mg twice daily) or resume Lasix (also if
evidence of volume retention/weight gain)
[] Consider Seroquel 12.5 mg p.o. at bedtime as needed for
agitation
[] Check Cr in one week and at follow-up PCP appointment to
ensure Cr<1.5. If Cr persistently > 1.5, apixaban dose will need
to be reduced to 2.5 mg bid.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Memantine 10 mg PO BID
3. Tamsulosin 0.4 mg PO QHS
4. Furosemide 40 mg PO EVERY OTHER DAY
5. Furosemide 20 mg PO EVERY OTHER DAY
6. FLUoxetine 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Metoprolol Tartrate 6.25 mg PO BID
3. Atorvastatin 10 mg PO QPM
4. FLUoxetine 20 mg PO DAILY
5. Furosemide 20 mg PO EVERY OTHER DAY
Hold for SBP<110
6. Memantine 10 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic CVA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of difficulty with speech
and left arm weakness resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Atrial fibrillation
- Congestive heart failure
Your blood pressure was well controlled and low normal and hence
your metoprolol dose was decreased and Lasix 40 mg every other
day has been held.
We are changing your medications as follows:
- Started apixaban 5 mg PO Twice daily
- Decreased dose of metoprolol to 6.25 mg PO twice daily
- Discontinued furosemide 40 mg every other day given episodes
of hypotension after dosing
- Stopped aspirin 81 mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10343862-DS-25 | 10,343,862 | 23,614,301 | DS | 25 | 2169-10-03 00:00:00 | 2169-10-05 14:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with extensive CAD and PVD, DM2, HTN, and HL s/p recent
fem-pop who from presents from ___ for presumed
cellulitis of the wound site, c/b hyperkalemia, and hematocrit
drop. Apparently his ___ sent him to ___ when she saw his
cellulitis and INR elevation. He feels well and denies any pain
in the leg as well as any chest pain, shortness of breath, or
abdominal pain. At ___ his INR was noted to be 5 and he
stated he had recently been holding his warfarin for this. He
was given IV vancomycin as well as IV glucose, insulin, calcium
gluconate for hyperkalemia.
.
In the ED, initial VS: 98.7 65 90/45 16 90%. Exam was notable
for guaiac positive brown stool. Labs were notable for an INR of
7.2 (given 2mg PO vitamin K), creatinine of 1.6, and K+ of 5.9.
EKG did not show any hyperacute T waves. He was given
insulin/glucose anyway. CT abdomen was performed given modest
HCT drop and r/o'd RP bleed. Vascular surgery saw the patient
and noted excellent perfusion bilaterally on exam. They
recommended admission to medicine with antibiotic coverage with
Vanco/Cipro/Flagyl and colonoscopy.
.
Overnight, nephrotoxics were held. He currently has no
complaints and is feeling well.
Of note discharged at end of ___, from Vascular service
on ___ after an elective re-do of a right fem-pop bypass.
His INR was initially 7.0 and trended down to 2.3 with FFP.
Post-op course was unremarkable but he did have some oozing from
the access sites.
Past Medical History:
1. Peripheral vascular disease s/p failed R->L fem-fem, R
ax-bifem, L fem-pop, removal of prior bypass, and R ax-fem to R
BK pop on ___ and recent re-do of right fem-pop. On
long-term anti-coagulation (warfarin) to ensure graft patency
2. History of fungal graft infections with retained graft
material. On long-term fluconazole which should not be stopped
given high risk of fungemia without suppressive therapy
3. CAD s/p CABG x 5
4. chronic back pain
5. s/p MVA remote
6. COPD on home O2
7. DM2
8. HTN / HLD
9. TIA ___ years ago)
10. GERD
11. h/o LLE cellulitis.
Social History:
___
Family History:
Mother died of MI at ___. Father had lung CA, no known coronary
disease. Older sister with DM. Has a daughter and son who are
healthy. No known additional family history of stroke, MI.
Physical Exam:
VS - Temp 98.0F, BP 102/54, HR 66, RR 22, O2-sat 98% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
auscultated
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, obese, mildly tense with multiple fascial
defects with hernias, nontender, no masses or HSM
EXTREMITIES - WWP, 3+ edema in bilateral LEs to thighs, 1+
peripheral pulses
SKIN - significant erythema and warmth over medial portion of
right thigh surrounding prior surgical site with staples in
place, with baseline erythema to below the knees bilaterally
with scaling of skin consistent with chronic changes; no
tenderness to palpation, no discharge, and no evidence of any
collections
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
CT abdomen:
.
MPRESSION:
1. No retroperitoneal hematoma. Small hematoma at the right
lateral
subcutaneous tissues at the surgical site.
2. Fluid filled small and large bowel may be due to diarrhea or
mild ileus.
Correlate with clinical symptoms.
3. Abdominal aortic aneurysm, unchanged in size from ___.
4. Status post axillofemoral bypass. Stent patency cannot be
evaluated on
this study.
5. Diverticulosis without diverticulitis.
Brief Hospital Course:
1. Right thigh cellulitis: Discreet area of redness near the
surgical site with warmth, edema, and erythema, but without pain
was taken to be cellulitis. The patient got a single dose of
vancomycin and then was switched over to levaquin (given that he
had been on ciprofloxacin) before. He continued to improve
clinically. The indication for fluconazole was clarified with
ID, and has been updated in his past medical history. It was
not related to this surgery, but to the fact that it is
suppressive therapy for infected ___ NEVER be stopped.
The patient did well and was discharged to f/u with his PCP to
determine the final course of abx.
2. Peripheral vascular disease and coagulopathy: The patient
came in with an INR of 7, guaiac positive stools, and hct drop.
His coumadin was stopped, he was given 2mg of PO K in the ED.
On HD 3 he was fully reversed and subtherapeutic. Given Dr.
___ concern for loosing all of his grafts if he
gets subtherpeutic we bridged with enoxaparin. We restarted
coumadin at 1mg daily and corrected his fluconazole dosing.
3. Acute blood loss anemia: Guaiac positive stools, prior
colonoscopy ___ years ago with polyps that were not concerning,
per patient. Elevated INR is likely causing a slow ooze, initial
HCT showed a continuing drop, but repeat hct showed stability
for 48 hours. The patient was discharged with f/u in our GI
clinic for outpatient cool.
Medications on Admission:
1. fluticasone-salmeterol 500-50 mcg/dose 1 puff BID
2. tiotropium bromide 18 mcg daily
3. omeprazole 20 mg daily
4. simvastatin 20 mg daily
5. amlodipine 10 mg daily
6. fluconazole 400 mg BID
7. albuterol sulfate ___ Puffs Inhalation Q6H PRN
8. prasugrel 10 mg daily
9. enoxaparin 80 mg BID
10. ciprofloxacin 500 mg BID for 2 weeks (from ___
11. sulfamethoxazole-trimethoprim 800-160 mg 2 Tablet PO BID for
2 weeks (from ___
12. metronidazole 500 mg TID for 2 weeks (from ___
13. NPH insulin 16 units at breakfast and 11 units at bedtime.
14. warfarin 2mg one day and 1mg the next.
___. oxycodone ___ mg q4h PRN pain
16. acetaminophen 325 mg q6h PRN pain
17. nicotine 21 mg/24 hr Patch daily
18. docusate sodium 100 mg BID
19. metoprolol succinate 100 mg daily
20. furosemide 80 mg BID
21. amlodipine-olmesartan ___ mg daily
22. spironolactone 25 mg daily
24. fentanyl 75 mcg/hr Patch 72 hr
Discharge Medications:
1. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation BID (2 times a day).
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q4H (every 4 hours) as needed for
SOB/wheezing.
7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
13. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
14. levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
15. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
16. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
Disp:*20 syringes* Refills:*0*
17. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Skin and Soft Tissue Infection c/b acute kidney injury
Supertherapeutic INR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It has been a pleasure taking care of you in the hospital.
You came in with a minor skin infection known as cellulitis.
You were treated with PO antibiotics and improved rapidly. Your
lasix had put you into kidney faillure. You must understand
that lasix will not treat your leg swelling because it is caused
by vein disease in your legs. Instead, to treat this swelling
you should elevate your legs whenever you ___ walking, and
should wear compression stockings unless Dr. ___ you
otherwise.
.
I have spoken to Dr. ___ and your ___ will check your
INR ___ and communicate it to him.
.
Your red blood cell count went down slightly durring your
hospital stay. We believe this was caused by oozing from your
GI track because your INR was SO high. However you are overdue
for your screening colonoscopy, so we advise that you f/u with
our GI doctors as ___ below for this.
.
Please START lovenox 80mg twice per day until Dr. ___
you otherwise. (your INR was 1.4 today)
Please take levaquin until you see Dr. ___ on ___ and
she tells to stop or continue for your cellulitis.
Please ask her on this day whether you can stop your flagyll as
well.
Please resume taking coumadin 1mg daily
.
Please STOP:
Ciprofloxacin
Lasix
Spironolactone, as it is elevating your potassium
Please ADJUST the dose of your fluconazole to 400mg daily,
either 1 tab 2x/day or 2 tabs once per day is fine, but you MUST
take this medication to prevent a potentially fatal infection.
Followup Instructions:
___
|
10344189-DS-3 | 10,344,189 | 28,214,279 | DS | 3 | 2165-11-07 00:00:00 | 2165-11-16 10:47:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right heel ulcer
Major Surgical or Invasive Procedure:
___: Debridement of heel ulcer x2
___: Angiogram of right lower extremity, angioplasty right
posterior tibial artery
___: Debridement with VAC placement
___: Guillotine amputation right leg
___: Right BKA revision
History of Present Illness:
___ w HTN, HLD, afib on coumadin/sick sinus syndrome, ESRD on HD
referred to ED from ___ clinic ___ worsening pain, malodorous
discharge from chronic R heel pressure ulcer x ___. Pt w
complex recent medical history including MSSA bacteremia c/b
endocarditis, septic L shoulder and multiple prolonged hospital
and rehab admissions from ___. Reports that during
these periods of protracted immobility he developed B/L heel
pressure ulcers. Pt reports that while L ulcer has slowly
healed, the R ulcer has become increasingly painful prompting
two ten day courses of Bactrim DS (___), NIAS
B/L ___ ___ (TBI R: 0.55. TBI L: 0.40) and office visit w Dr.
___ ___.
Scheduled for RLE angiogram ___ though ___ interim has
developed worsening pain and malodorous discharge with referral
to ED by PCP.
On surgical evaluation, pt reports that pain at R heel ulcer has
gone from moderate to severe and debilitating over last several
days. Drainage from wound has remained consistently minimal
though character of drainage has changed to become thicker and
increasingly malodorous. Patient currently ambulatory w walker.
Denies claudication, L foot pain, fever, chills, chest pain,
shortness of breath, nausea, vomiting, focal weakness/numbness.
Last dose coumadin ___ ___ anticipation of upcoming scheduled
angiogram.
Past Medical History:
PMH: ESRD on HD via LUE AVF (MWF), CAD, A.fib, sick sinus
syndrome, HTN, HLD, Gout, Hx colon adenoma, Hx prostate CA s/p
brachytherapy (___), Hx MSSA bacteremia c/b endocarditis,
septic L shoulder (___)
PSH: Pyloromyotomy (___), Open appy, R knee reconstruction
(1950s), B/L THR (___), R IHR (___), LUE AVF (___)
s/p angioplasty x~7, OD ___, Debridement R lateral
calf/ankle ulcer (___), L shoulder I&D for septic
joint (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
VS: 98.1 54 103/49 19 99%
GEN: WD, frail M ___ NAD
HEENT: NCAT, anicteric
CV: RRR
PULM: no respiratory distress
ABD: soft, NT, ND, well healed prior abdominal incisions
EXT: WWP, 1+ B/L ___ edema, L foot w black focus on great toenail
and small ulcer dorsum third toe, small scabbed ulcer L heel w
no erythema/drainage; R foot w posterior heel ulcer
approximately 2x2cm w necrotic base and mild erythema, +foul
smell, no gross purulent discharge, severely tender to palpation
around R heel ulcer precluding probing of wound.
NEURO: A&Ox3, no focal neurologic deficits
Physical Exam on Discharge:
VS: 98.6 68 91/53 16 97%
GEN: NAD, cachectic/frail-appearing
HEENT: NCAT, anicteric
CV: RRR, no murmurs, rubs, gallops
PULM: no respiratory distress, CTAB
ABD: soft, NT, ND, well healed prior abdominal incisions, no
rebound/guarding
EXT: edema, L foot w resolved black focus on great toenail,
staple line at amputation site intact - clean/dry, stable
echymoses about staple line.; LLE palpated ___, DP, popliteal,
femoral. RLE femoral palpated. UE b/l brachial, radial, ulnar
palpated 2+.
NEURO: A&Ox3, no focal neurologic deficits
Pertinent Results:
--LABS--
___ 07:26PM BLOOD WBC-17.2* RBC-3.74* Hgb-12.2* Hct-41.4
MCV-111* MCH-32.7* MCHC-29.6* RDW-19.4* Plt ___
___ 07:26PM BLOOD Glucose-173* UreaN-34* Creat-4.0*# Na-140
K-4.5 Cl-94* HCO3-27 AnGap-24*
___ 05:55AM BLOOD Calcium-9.3 Phos-5.9* Mg-2.5
___ 07:31PM BLOOD Lactate-2.6*
___ 07:26PM BLOOD ___ PTT-41.4* ___
___ 04:45AM BLOOD WBC-20.0* RBC-2.74* Hgb-8.8* Hct-30.0*
MCV-109* MCH-32.0 MCHC-29.2* RDW-18.8* Plt ___
___ 04:45AM BLOOD Glucose-67* UreaN-18 Creat-3.3*# Na-140
K-4.4 Cl-98 HCO3-27 AnGap-19
___ 04:45AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.3
___ 04:45AM BLOOD ___ PTT-43.1* ___
___ 12:15AM BLOOD ALT-15 AST-30 AlkPhos-176* TotBili-0.3
ANGIOGRAPHIC FINDINGS (___):
1. Normal caliber abdominal aorta without any signs of
occlusion or aneurysmal dilation.
2. Patent iliac arterial system bilaterally.
3. The right common femoral and profunda femoris is patent.
The right SFA is patent.
4. The right popliteal artery is patent.
5. The right anterior tibial artery is patent.
6. The right peroneal artery is patent.
7. The right peroneal artery has a short-segment stenosis
just after its branching off of the TP trunk, which was
treated with a 2 mm balloon angioplasty.
--MICRO--
Bone debridement #1
TISSUE RIGHT FOOT BONE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT ___
this culture..
Work-up of organism(s) listed below discontinued
(excepted
screened organisms) due to the presence of mixed
bacterial flora
detected after further incubation.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___:
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened for
the presence
of B.fragilis, C.perfringenes, and C.septicum. None of
these species
was found.
Bone debridement #2
TISSUE Site: BONE RT HEEL BONE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
3+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT ___
this culture..
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
--IMAGING--
CXR (___): ___ comparison with the study of ___,
there appears to be some improvement ___ the pulmonary vascular
congestion. Mild atelectatic changes at the bases without
definite pneumonia.
RUQ US (___):
1. No evidence of cholecystitis.
2. Irregularly thickened stomach wall, possibly representing a
neoplastic
process. Further evaluation with a CT or endoscopy is
recommended.
3. Small left pleural effusion.
CT abd/pelv con (___)
1. Moderate left and small right non hemorrhagic pleural
effusion and adjacent atelectasis, partially imaged.
2. Diffuse bladder wall thickening is indeterminate, but may be
due to prior radiation, as fiducial seeds are seen ___ the
prostate gland.
Differential diagnosis includes bladder outlet obstruction and
infection. Malignancy cannot be excluded, but seems less likely
Hip Plain Film (___)
Break E therapy seeds are again visualized over the region of
the prostate the patient is status post bilateral hip
arthroplasty there degenerative changes of the lumbar spine.
Contrast is seen ___ the visualized portions of the colon. No
fractures identified
Brief Hospital Course:
Mr. ___ was admitted from rehab with an infected non-healing
ulcer of the right foot. The patient was treated with
antibiotics and was debrided twice by podiatry. He underwent
angioplasty of the right posterior tibial artery to improve the
blood flow to the ulcer. However, the ulcer remained clinically
infected and did not appear to be healing. Thus he underwent
guillotine amputation with subsequent below knee amputation. His
hospital course by system is summarized below.
Neuro: The patient was started on his home citalopram upon
admission. Pain control remained an issue. He was treated with
opiate narcotics. However, the dose was initially tapered due to
concern for sedation. Following the completion amputation, his
pain was treated oral oxycodone and IV dilaudid for breakthrough
pain.
CV: The patient was hemodynamically stable at the time of
admission. His home amlodipine was started upon admission. The
patient had known atrial fibrillation that remained rate
controlled. His Coumadin was restarted following his right
guillotine amputation on ___, held for the completion
amputation, and subsequently resumed.
Resp: There were no acute issues during this hospitalization.
Following the podiatric debridements, the white count remained
elevated and a chest x-ray was performed to rule out pneumonia
which was negative.
GI: The patient remained on a renal diet. Unfortunately he was
found to have relatively low PO intake that was insufficienct to
meet his caloric needs. PO nutrition was encouraged and
supplements were started. He was subsequently put on Megace for
appetite improvement. The patient was incidentally found to have
thickening of the stomach wall on RUQ US to rule out acute
cholecystitis. On official radiology reading, there was question
of a neoplastic process. However, there was not high clinical
suspicion for malignancy.
Renal: The patient underwent dialysis on his usual MWF schedule
under the care of our Nephrology service.
Endo: There were no acute issues.
Heme: The patient's coumadin had been held ___ anticipation for
the angiogram. Following the second debridement of the heel his
coumadin was restarted but was held when supratherapeutic. He
was given vitmain K prior to the guillotine amputation and then
placed on a heparin drip to bridge until the completion BKA,
after which Coumadin was resumed and dosed based on INR.
ID: The patient was initially placed on IV vancomycin (dosed at
dialysis) and zosyn. This was switched to vancomyocin and
ceftazidime both dosed at dialysis. Metronidazole was added for
anaerobic coverage when cultures revealed mixed flora. CXR
showed no evidence of pneumonia. RUQ US was done and ruled out
acute cholecystitis. On POD 7 from BKA revision, a small amount
of serosanguinous fluid was expressed and cultured from the
stump and there was no growth. Infectious Disease and Hematology
were consulted ___ regards to the patient's persistent
leukocytosis despite medical and surgical treatment and an
improved clinical picture. A peripheral blood smear and workup
suggested that the persistent leukocytosis was due to an acute
reactive infectious process. There was minimal suspicion for
malignancy. His WBC count continued to decrease slowly and at
the time of discharge was 20. His antibiotics were stopped on
day of discharge.
The patient was discharged to a rehabilitation ___
continued recovery with an anticipated less than 30 day stay. A
follow up appointment has been provided for Mr. ___ with Dr.
___. He will also follow up with his PCP for continued
monitoring of his white blood cell count and coumadin
management. If indicated, the incidental finding of gastric wall
thickening on RUQ US can be followed up with outpatient
endoscopy.
Medications on Admission:
Warfarin 6 MG as directed, amlodipine 10', zolpidem 5 QHS prn,
BACTRIM DS 1tablet QHS (___), SANTYL Topical
Ointment Apply to heel ulcers BID, cinacalcet 30', B
Complex-Vitamin C-Folic Acid ___ CAPS) 1capsule',
cholecalciferol 1,000', Allopurinol ___, Sevelamer Carbonate
2400 QAC, Pravastatin 20 QHS, Epogen 2,000 unit/mL Injection
(dose uncertain), citalopram 20', sodium bicarbonate 650'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Cinacalcet 30 mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Megestrol Acetate 40 mg PO QID
8. Nephrocaps 1 CAP PO DAILY
9. Pravastatin 20 mg PO HS
10. Senna 8.6 mg PO BID
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. Vitamin D 1000 UNIT PO DAILY
13. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
RX *zolpidem [Ambien] 5 mg 1 tablet(s) by mouth once at night
Disp #*30 Tablet Refills:*0
14. Amlodipine 10 mg PO DAILY
15. Omeprazole 20 mg PO DAILY
16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 hours Disp #*30
Tablet Refills:*0
17. Warfarin 1 mg PO DAILY Duration: 1 Dose
Re-dose based on daily INR as necessary.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Non healing ulcer of the right heel
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with an infected ulcer of the
right heel. This was debrided by the podiatry service and the
blood flow to the heel was improved with an angioplasty of one
of the arteries ___ your leg. Unfortunately the heel did not
appear to be heeling and the infection persisted and so the leg
was amputated below the knee. Surgery went well and you have
been recovering well. You worked with physical therapy who
recommended you be discharged to rehabilitation facility to
continue your recovery.
A follow up appointment has been made for you with Dr. ___
___ staple removal. A lower extremity ultrasound has also been
scheduled prior to this visit.
Upon discharge you will resume your home dialysis schedule.
Please follow up with your primary care physician after
discharge from the hospital for appropriate follow up care.
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
An appointment will be made for you to return for staple
removal.
Monitor wound for signs of infection - expanding redness,
swelling, purulent drainage
MEDICATION:
Continue all other medications you were taking before surgery,
unless otherwise directed
You will be discharged on coumadin which will require close
monitoring. This will be managed by the physicians at your
rehabilitation ___, and upon discharge will be managed by
your PCP, ___.
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
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 ___ wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which ___ turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site.
Followup Instructions:
___
|
10344413-DS-6 | 10,344,413 | 29,534,331 | DS | 6 | 2154-11-03 00:00:00 | 2154-11-03 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left proximal femoral shaft fracture
Major Surgical or Invasive Procedure:
Antegrade nailing of left femur
History of Present Illness:
___ M with h/o bilateral femur IMN for limb lengthening in
___ now transferred from OSH for L pathologic femur
fracture. He underwent bilateral femur lengthening using Precice
intramedullary lengthening rods on ___ at the ___
___ in ___, ___. His intramedullary rods were
removed 3 months ago at ___, and he was told he could resume
normal physical activity. Two days ago, he noticed a pain in
his proximal thigh radiating to his knee, and assumed it was
muscular pain. Today, he was stretching his thigh muscles to
relieve the pain and felt a pop in his left thigh, with
immediate pain and inability to ambulate. He presented to an
OSH ED, where he was found to have a left pathologic femur
fracture and was transferred to ___ for further management.
Currently, he is comfortable and denies numbness or tingling in
the left lower extremity.
Past Medical History:
PMH: None.
PSH: Bilateral femoral IMN with Precice intramedullary limb
lengthening rods ___, ___, ___), bilateral
femoral IMN removal ___, ___).
Social History:
Denies tobacco, alcohol, illicit drug use.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left proximal femoral shaft fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for antegrade nailing of the left
femoral shaft, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
neurovascularly intact distally in the LLE extremity, and will
be discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth DAILY Disp #*28 Tablet
Refills:*0
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 four (4) hours
Disp #*55 Tablet Refills:*0
5. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left proximal third femoral shaft fracture s/p antegrade nailing
Discharge Condition:
Mental status: AOX
Ambulatory status: Active with crutches
Overall: 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 to left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 325 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- You can take your dressing off on ___.
Followup Instructions:
___
|
10344639-DS-16 | 10,344,639 | 23,855,074 | DS | 16 | 2179-04-30 00:00:00 | 2179-05-01 15:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / meropenem
Attending: ___.
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
ultrasound guided drainage of abscess
History of Present Illness:
Ms. ___ is a ___ postmenopausal woman who presented as a
transfer from ___ for concern for Left ___ discovered on
CT scan. She reported that on ___, she started having
chills, malaise, body aches. She checked her temperature at the
time and found it to be 104.5. She had taken tylenol at the time
thinking she had a viral illness, which resolved the fever.
However, she started to have vaginal discharge and developed
bilateral lower abdominal pain and recurrence of a fever to 102.
She presented to ___ where she was afebrile
with stable vitals but had a leukocytosis of 16. She had a
pelvic exam, which was notable for yellowish discharge, +CMT.
She had a CT scan, which was concerning for a 3cm ___. Given
these findings, she was started on Gent/Clinda and transferred
to ___ ED. Upon presentation, patient endorsed nausea but no
emesis. She denied diarrhea. She continued to have lower
abdominal pain. She was afebrile with stable vitals.
Past Medical History:
OB Hx:
1 SVD at term, no complications
2 TAB's with D&C's
GYN Hx:
Postmenopausal since age ___, 1 episode of postmenopausal
bleeding
s/p neg em bx
Denies any recent instrumentation
Denies history of abnormal Paps
Remote hx of trichomonas and exposure to Gonorrhea which was
treated with negative subsequent STI screening.
Hx of salpingitis resulting in removal of IUD in the ___
On review of record, patient has documented hx of a left
hydrosalpinx, which was still seen on imaging in ___ measuring
3.8cm.
Exposures: Reports that she and husband use sex toys during
intercourse, which she inserts into her vagina and they also
have
anal sex
Med Hx:
- Elevated cholesterol
- ? stroke vs. TIA, no deficits
- Shingles
Surg Hx:
- Breast biopsy, which was negative
- D&C's
Social History:
___
Family History:
non-contributory
Physical Exam:
Upon Admission Physical Examination
Vitals: 98.4 92 110/66 16 97%
GEN: No acute distress
HEART: RRR no m/r/g
LUNGS: CTAB
ABDOMEN: +BS, soft, non-distended, moderate tenderness to
palpation in b/l lower abdomen L>R without rebound or guarding.
No CVAT.
PELVIC: Normal appearing external genitalia. On insertion of
speculum, cervix was visualized with yellowish non-purulent
discharge coming from the os. GC/CT cultures obtained. On
bimanual examination, there is notably CMT on deviation of the
cervix towards the patient's right. No uterine or right adnexal
tenderness is appreciated. There is moderate TTP in left adnexa.
EXT NT/NE.
Upon Discharge physical exam:
98.5 126/82 78 16 78/RA
Gen: NAD, A&O x 3
CV: RRR, no r/m/g
Pulm: CTAB
Abd: soft, NT, ND, mild discomfort in lower abdominal quadrants
though no r/g/d
Ext: moving all 4 extremities
Pertinent Results:
Pelvic US ___
HISTORY: Pelvic pain, fevers. CT with concern for tubo-ovarian
abscess.
COMPARISON: CT abdomen pelvis ___, pelvic
ultrasound ___.
TECHNIQUE: Grayscale Doppler ultrasound images of the pelvis
were taking,
first using a transabdominal approach, then a transvaginal
approach for better
delineation of the uterus and adnexa.
FINDINGS:
The uterus is retroverted and measures 5.6 x 3.2 x 8 x 4.4 cm.
The
endometrium is regular and measures 2 mm. The right ovary is
unremarkable. A
small amount of complex free fluid is seen adjacent to the right
ovary. There
is a left hydrosalpinx, which is now contains complex fluid and
thick walled.
The hydrosalpinx was seen in ___ ultrasound, but complexity is
new since the
prior study. This corresponding to the abnormality seen on the
recent CT. The
left ovary is not visualized.
IMPRESSION:
New complexity of the known left hydrosalpinx. Given the
clinical
presentation, this may represent a tubo-ovarian abscess.
Followup to imaging
resolution is recommended.
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service.
She was continued on IV gentamicin and clindamycin. A pelvic
ultrasound confirmed a diagnosis of likely tubo-ovarian abscess.
On ___, she underwent ultrasound guided drainage.
Post-procedure, she developed fever and chills. Her antibiotics
were switched to meropenem and vancomycin and repeat cultures
were sent. Her blood cultures showed did not have any growth
by hospital day 3, and her ___ cultures showed S. pneumoniae.
She developed a rash that and her meorpenem was d/c as she had a
history of penicillin allergies. She was then transitioned to
oral levo/flagyl.
Her WBC improved from 14 (pre-drainage) to 11. She defervesced
the evening after her drainage and remained afebrile for the
remainder of her hospital stay. Her abdominal tenderness
subsided, and the patient was able to resume her normal daily
activities including tolerating a regular diet, ambulating
independently, voiding spontaneously, with minimal pain
controlled with ibuprofen/acetaminophen.
On ___, the patient was in stable condition for discharge.
She was discharged home with levofloxacin, sensitive to the
abscess culture, and metronidazole for a 14 day regimen. She
will follow-up with the residency practice as scheduled.
Medications on Admission:
- Lovastatin 20mg daily
- Baby ASA daily
- Vitamin D and B12 supplements
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
3. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp
#*14 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
tubo-ovarian abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General instructions:
* Take your medications as prescribed.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* Nothing in the vagina (no tampons, no douching, no sex) until
follow-up appointment
* You may eat a regular diet
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
10344852-DS-17 | 10,344,852 | 24,736,668 | DS | 17 | 2154-06-01 00:00:00 | 2154-06-02 07:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI (per chart review as patient unable to respond):
___ y/o M with PMH of depression w/ suicide attempts, HTN, HCV,
ETOH abuse, and COPD found down by his father with the patient
seen on the floor with his numerous medication bottles open with
his reported meds being: seroquel, buproprion, benztropine, and
valproic acid. No e/o other ingestion of items notable like ETOH
or other illicits. No e/o trauma reported. Patient was reported
lethargic but no other gross evidence of respiratory compromise,
n/v or seizure activity. Was originally brought to ___ by
EMS and transferred to ___ as wanted to initiate carnithine
therapy unavailable there.
In the ___, initial vs were 97.1 86 119/78 20 99% 2L.
On the floor, patient was alert but mildly lethargic but
appropriately answering to simple questions. No complaints. Did
not respond to questions to SI/HI or what medications he took.
Review of systems:
Unable to obtain
Past Medical History:
ETOH abuse
ETOH withdrawal seizures
Depression
Suicide attempts
COPD
Hepatitis C
HTN
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9 64 97/49 96% on RA
General: Alert, oriented x2 (did not he was at ___ but knew he
was in a hospital), no acute distress, mildly lethargic but
arousable and answers questions appropriately and follows
commands, no e/o trauma noted
HEENT: Sclera anicteric, MMM, oropharynx clear, PEERL with no
e/o dilation or being pinpoint
Neck: Supple, no LAD
Lungs: CBAT, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
NEURO: CNII-XII intact, ___ bicep flexion/extension, hand
grasping, leg raises, foot flexion/extension
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
Vitals: Afebrile, VSS
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PEERL with no
e/o dilation or being pinpoint
Neck: Supple, no LAD
Lungs: CBAT, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
NEURO: CNII-XII intact, ___ bicep flexion/extension, hand
grasping, leg raises, foot flexion/extension
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION:
___ 04:30PM BLOOD WBC-3.1* RBC-4.81 Hgb-13.9* Hct-42.9
MCV-89 MCH-28.8 MCHC-32.3 RDW-15.6* Plt Ct-82*
___ 04:30PM BLOOD Neuts-54.7 ___ Monos-4.2 Eos-1.5
Baso-1.0
___ 04:30PM BLOOD Glucose-75 UreaN-5* Creat-0.6 Na-131*
K-4.1 Cl-98 HCO3-24 AnGap-13
___ 04:30PM BLOOD ALT-165* AST-107* CK(CPK)-142 AlkPhos-81
TotBili-0.4
___ 04:30PM BLOOD Lipase-14
___ 04:30PM BLOOD Albumin-3.4* Calcium-8.0* Phos-3.9 Mg-1.6
___ 04:30PM BLOOD Ammonia-36
___ 04:30PM BLOOD Valproa-234*
___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:46PM BLOOD ___ Temp-36.2 pO2-46* pCO2-49*
pH-7.34* calTCO2-28 Base XS-0 Intubat-NOT INTUBA Comment-GREEN
TOP
___ 05:59PM BLOOD Lactate-1.3
HOSPITALIZATION & DISCHARGE:
___ 02:51AM BLOOD WBC-2.9* RBC-4.51* Hgb-12.9* Hct-39.8*
MCV-88 MCH-28.7 MCHC-32.5 RDW-15.7* Plt Ct-85*
___ 08:35AM BLOOD WBC-4.1 RBC-4.84 Hgb-13.9* Hct-42.4
MCV-88 MCH-28.8 MCHC-32.8 RDW-15.6* Plt ___
___ 08:10AM BLOOD WBC-4.7 RBC-4.50* Hgb-13.0* Hct-39.4*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.5 Plt ___
___ 08:00AM BLOOD WBC-3.7* RBC-4.70 Hgb-13.6* Hct-41.0
MCV-87 MCH-29.0 MCHC-33.2 RDW-15.5 Plt ___
___ 02:51AM BLOOD Plt Ct-85*
___ 10:20AM BLOOD ___ PTT-40.0* ___
___ 07:25PM BLOOD Glucose-69* UreaN-5* Creat-0.6 Na-131*
K-3.9 Cl-99 HCO3-25 AnGap-11
___ 02:51AM BLOOD Glucose-72 UreaN-5* Creat-0.6 Na-133
K-4.0 Cl-102 HCO3-24 AnGap-11
___ 10:20AM BLOOD Glucose-81 UreaN-6 Creat-0.6 Na-131*
K-4.6 Cl-97 HCO3-25 AnGap-14
___ 08:35AM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-133 K-4.3
Cl-98 HCO3-25 AnGap-14
___ 08:10AM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-127*
K-3.8 Cl-92* HCO3-27 AnGap-12
___ 03:38PM BLOOD Na-129* K-3.9 Cl-95*
___ 08:00AM BLOOD Glucose-96 UreaN-7 Creat-0.6 Na-133 K-4.0
Cl-99 HCO3-27 AnGap-11
___ 07:25PM BLOOD ALT-152* AST-106* AlkPhos-72 TotBili-0.4
___ 02:51AM BLOOD ALT-161* AST-124* AlkPhos-74 TotBili-0.6
___ 08:35AM BLOOD ALT-181* AST-130* LD(LDH)-193 AlkPhos-85
TotBili-0.7
___ 07:25PM BLOOD Calcium-7.6* Phos-3.5 Mg-1.5*
___ 02:51AM BLOOD Albumin-3.1* Calcium-8.2* Phos-3.8 Mg-1.6
___ 10:20AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.2
___ 08:35AM BLOOD Albumin-3.8 Calcium-9.2 Phos-2.8 Mg-1.7
___ 08:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.6
___ 08:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7
___ 07:25PM BLOOD Ammonia-27
___ 01:25PM BLOOD Ammonia-39
___ 08:35AM BLOOD Ammonia-63*
___ 12:55PM BLOOD Ammonia-51
___ 08:10AM BLOOD Osmolal-262*
___ 08:00AM BLOOD Osmolal-273*
___ 08:10AM BLOOD TSH-3.4
___ 07:25PM BLOOD Valproa-161*
___ 02:51AM BLOOD Valproa-98
___ 10:20AM BLOOD Valproa-76
___ 08:35AM BLOOD Valproa-32*
EKG:
Sinus rhythm. Baseline artifact. Poor R wave progression across
the
precordium of unknown significance. No previous tracing
available for
comparison. Clinical correlation is suggested.
CXR:
FINDINGS:
There is elevation of the right hemidiaphragm and opacity at the
right base which most likely represents atelectasis however
infection cannot be excluded. The cardiomediastinal silhouette
and hilar contours are normal. The pleural surfaces are normal
without effusion or pneumothorax.
___ 09:54AM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:30PM URINE Color-Straw Appear-Clear Sp ___
___ 09:54AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.0 Leuks-MOD
___ 04:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 09:54AM URINE RBC-1 WBC-25* Bacteri-NONE Yeast-NONE
Epi-0
___ 09:54AM URINE RBC-1 WBC-25* Bacteri-NONE Yeast-NONE
Epi-0
___ 04:22AM URINE Hours-RANDOM UreaN-294 Creat-45 Na-53
K-10 Cl-33 TotProt-6 Phos-42.2 Mg-8.7 Prot/Cr-0.1
___ 04:22AM URINE Hours-RANDOM UreaN-294 Creat-45 Na-53
K-10 Cl-33 TotProt-6 Phos-42.2 Mg-8.7 Prot/Cr-0.1
___ 04:30PM URINE Hours-RANDOM UreaN-181 Creat-35 Na-98
K-26 Cl-96 TotProt-<6 Phos-30.5 Mg-4.0
___ 04:22AM URINE Osmolal-269
___ 04:30PM URINE Osmolal-353
___ 04:30PM URINE Osmolal-353
Brief Hospital Course:
MICU and Medical Floor Course:
___ y/o M with PMH of depression w/ suicide attempts, HTN, HCV,
ETOH abuse, and COPD found down by his father with evidence of
OD on valproic acid.
# Overdose: Valproic Acid (VPA) Intoxication. No evidence of
other co-ingestion noted on Utox or serum tox, but limitations
on testing noted. No clear evidence of other toxicity based on
report or physical exam. Presentation valproic acid level 234,
uptrending from prior value at ___ of 108. No evidence of
HD instability or significant lab abnormalities except LFTs are
elevated from prior despite history of HCV. Toxicology
consulted. Patient loaded with 6000mg carnitine then maintenance
dose of 1100 mg carnitine q4h until mental status improvement
noted with lab improvement of VPA and ammonia levels. He was
monitored closely without any acute events and with improvement
in mental status. His carnitine was discontinued on ___.
# Acute Liver Injury: Unclear chronicity but hepatotoxicity is a
known effect of VPA poisoning. Would recommend trending in the
outpatient setting.
# Suicide Attempt
Patient has a history of prior suicide attempts. He reported
attempt with taking valproic meds above. He was evaluated by
psychiatry and was placed on suicide precautions with a 1:1
Sitter. His psych meds were held given unclear if OD on other
meds and unable to assess via tox levels. Psychiatry advised
patient cannot leave AMA. Will require inpatient psych once
medically clear.
#Delirium:
After transfer to the medical floor, patient's mental status was
waxing and waning. He was occasionally A+Ox3 and occasionally
lethargic. Infectious workup was negative (CXR showed opacity at
right base but had no symptoms of cough and ambulatory oxygen
saturation was normal, opacity most likely due to atelectasis).
He had an episode of agitation on the evening of ___ during
which he reportedly was having auditory and visual
hallucinations and did try to get in bed with his roommate.
Thereafter, however, he did not have any episodes of agitation.
He was A+Ox3 on the morning of ___.
#Hyponatremia: On the morning of ___, patient's Na decreased
to 127 from 133 which was likely due to decreased PO intake
(patient did not have his fixodent and it was not comfortable to
eat without it). His Na returned to normal on ___ and he was
provided with fixodent.
# History of Alcohol abuse and withdrawal. Reported last drink 6
weeks ago. Patient had no evidence of withdrawal. Neg ETOH on
admission. He was placed on CIWA scale (given it was unsure
whether or not patient had been consuming alcohol as he is not
the most reliable historian) with lorazepam given hepatic
dysfunction. HE also received multivitamin, folate and thiamine.
He was transitioned to a diazepam CIWA scale but had not scored
on CIWA in >24 hours on ___.
TRANSITIONAL ISSUES:
-Continue to attempt to touch base with outpatient psychiatrist
and try to determine what psychiatric medications patient was
taking pre-admission
-Please determine what psychiatric medications patient should be
on and ensure patient has appropriate psychiatry follow-up on
discharge from inpatient psychiatry facility
-Please follow-up final urine culture and blood cultures from
___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Multivitamins 1 TAB PO DAILY
2. TraZODone Dose is Unknown PO Frequency is Unknown
3. BuPROPion Dose is Unknown PO Frequency is Unknown
4. QUEtiapine Fumarate Dose is Unknown PO Frequency is Unknown
5. Divalproex (EXTended Release) Dose is Unknown PO Frequency
is Unknown
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Thiamine 100 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: valproate overdose and suicide attempt
Secondary: depression
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were
admitted on ___ after an overdose of valproic acid. You were
initially admitted and monitored closely in the intensive care
unit. You were followed by toxicology and received carnitine
for the valproic acid overdose. You were placed on suicide
precautions and followed closely by psychiatry. You will
continue to receive inpatient psychiatry treatment after
discharge.
Please return to the emergency room if you experience fevers,
chills, chest pain, abdominal pain, thoughts about hurting
yourself, or any other new or concerning symptoms.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10345163-DS-11 | 10,345,163 | 24,795,047 | DS | 11 | 2146-06-10 00:00:00 | 2146-06-10 16:18:00 |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
___:
1. Coronary artery bypass graft x3, left internal mammary
artery to left anterior descending artery, and saphenous
vein grafts to posterior descending artery and obtuse
marginal artery.
2. Endoscopic harvesting of the long saphenous vein
History of Present Illness:
___ male ESRD on dialysis, ___ (45-50%), coronary
artery disease NSTEMI in ___ status post ramus stent with
a 2.75 x 15 mm Integrity bare metal stent, known occluded left
circumflex artery and 70% PLV branch, who presented with ___
substernal chest pressure and tightness, acute onset while at
rest at home. ___ had gone to dialysis on ___, and upon
arrival at home had the pain at rest, accompanied by
diaphoresis. Pain is sharp/pressure like and spreads to left
neck. ___ denies fevers, chills, nausea, vomiting,
palpitations, dizziness, syncope, pedal edema, DOE.
Cardiac cath performed revealed multivessel coronary artery
disease. Cardiac surgery was consulted for revascularization.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +hypertension, +dyslipidemia,
+diabetes +CKD
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: CAD with NSTEMI ___
s/p ramus branch BMS
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
ESRD secondary to hypertension on HD MWF;
-initiated HD with tunneled line, then had radiocephalic AVF
created on ___
HTN
CVA (___) with residual R-leg weakness
CHF: TTE in ___ with EF 45-50%, severe LVH
LVH
Dilated ascending aorta of (3.8 cm).
Valvular heart disease (1+ AR).
Social History:
___
Family History:
Denies history of CV issues or HTN; ___ hx of ESRD or HD.
Physical Exam:
ADMISSION Physical EXAM
==================
VS: 98.2 18 98-138/69-70 ___ 99% RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, ___ pallor or cyanosis of the oral mucosa. ___ xanthelasma.
NECK: Supple with JVP of <10 cm at 90 degrees.
CARDIAC: RRR, normal S1, S2. ___ murmurs/rubs/gallops. ___
thrills, lifts.
LUNGS: ___ chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, ___ accessory muscle use. ___ crackles, wheezes or
rhonchi.
ABDOMEN: Obese, Soft, NTND. ___ HSM or tenderness.
EXTREMITIES: ___ c/c/e.
SKIN: ___ stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Radial, DP pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS
==================
___ 03:17AM WBC-13.3*# RBC-3.46* HGB-10.5* HCT-31.9*
MCV-92 MCH-30.3 MCHC-32.9 RDW-13.6 RDWSD-45.4
___ 03:17AM NEUTS-85.7* LYMPHS-7.8* MONOS-4.8* EOS-0.7*
BASOS-0.5 IM ___ AbsNeut-11.38*# AbsLymp-1.04* AbsMono-0.64
AbsEos-0.09 AbsBaso-0.07
___ 03:17AM PLT COUNT-276
___ 03:17AM ___ PTT-27.2 ___
___ 03:17AM CALCIUM-9.3 PHOSPHATE-5.6* MAGNESIUM-2.5
___ 03:17AM CK-MB-52*
___ 03:17AM cTropnT-1.69*
___ 03:17AM GLUCOSE-100 UREA N-34* CREAT-8.0*# SODIUM-135
POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-27 ANION GAP-19
PERTINENT LABS
===================
___ 03:17AM BLOOD CK-MB-52*
___ 03:17AM BLOOD cTropnT-1.69*
___ 10:25AM BLOOD CK-MB-77* cTropnT-3.99*
IMAGES/STUDIES
====================
CARDIAC CATH ___:
Dominance: Right
* Left Main Coronary Artery
The LMCA is without significant disease.
* Left Anterior Descending
The LAD is calcified with 40-50% proximal disease.
The ___ Diagonal is with diffuse disease to 40%.
The ___ Diagonal is very small caliber.
The ___ Diagonal is moderate caliber with mild disease
* Circumflex
The Circumflex is chronically occluded in the mid vessel after a
small severely diseased OM branch.
There is filling of the distal OM beyond the occlusion via
left-to-left collaterals.
* Ramus
The Ramus is with a patent proximal stent, and mild-moderate
diffuse disease beyond.
* Right Coronary Artery
The RCA is tortuous and heavily calcified, with 40% stenosis
proximally, 60% eccentric hazy distally, and
then complete occlusion in the RPL beyond the bifurcation. The
distal RPL fills sloly via right-to-right and
left-to-right collaterals.
The RPDA has 70-80% proximal and mid stenoses.
Intra-procedural Complications: None
Impressions: PTCA of the RCA
CXR ___:
IMPRESSION:
1. Low lung volumes with bronchovascular congestion. ___ focal
pneumonia.
2. Persistent moderate cardiomegaly.
___ EKG:
Clinical indication for EKG: R07.9 - Chest pain, unspecified
Sinus rhythm. Compared to tracing #1 there is ___ significant
diagnostic
change. TRACING #2
Read by: ___
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
65 ___ 50 -65 72
TTE ___:
The left atrium is elongated. ___ atrial septal defect is seen by
2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is mild regional left ventricular systolic
dysfunction with basal to mid inferior/infero-lateral
hypokinesis. There is ___ ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is ___ pericardial
effusion. LVEF: 50-55%
Compared with the prior study (images reviewed) of ___,
basal to mid posterior hypokinesis apperars new.
Right Upper Extremity AV Fistulogram ___:
1. Low flow in the fistula, with narrowing of the arterial
anastomosis.
2. Angioplasty of the arterial anastomosis to 4 mm, with
significant residual stenosis post plasty.
3. Angioplasty of the arterial anastomosis to 5 mm, with
significant residual stenosis post plasty.
4. Angioplasty of the arterial anastomosis to 6 mm, with
resolution the
stenosis post plasty.
5. Sluggish flow with areas of stenosis in the venous outflow,
treated with angioplasty to 5 mm, followed by 6 mm, with good
flow post plasty.
6. ___ central venous stenosis.
IMPRESSION: Satisfactory restoration of flow following
angioplasty of the arterial anastomosis to 6 mm, and the venous
outflow to 6 mm. The fistula is ready for use.
Non-Con CT Chest ___:
Mild aortic valve calcifications. Approximately 1 cm above the
valvular
level, the ascending aorta has a diameter of 35 x 36 mm. At the
same
anatomical level, the descending aorta has a diameter of 29 x 32
mm. The
diameter of the main pulmonary artery is within normal ranges.
Mild
calcifications of the ascending aorta. Moderate calcifications
of the
descending aorta. Severe coronary calcifications. The size of
the heart is at the upper range of normal. ___ pericardial
effusion. Mild elongation of the descending aorta. ___
dilatation of the vessel.
Moderate degenerative vertebral disease. ___ vertebral
compression fractures. ___ osteolytic lesions at the level of
the ribs, the sternum or the vertebral bodies. Moderate
respiratory motion are defects. ___ larger pulmonary nodules or
masses are seen. Mild thickening and irregularities of the
bronchial walls, reflecting chronic bronchitis. Solitary
subpleural cyst at the level of the right lower lobe (5, 162).
___ pleural thickening, ___ pleural effusions.
IMPRESSION:
___ of the ascending aorta are reported above. ___
evidence of
suspicious pulmonary changes. ___ pleural abnormalities. ___
evidence of
infection.
___
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ Portable TTE
(Complete) Done ___ at 9:31:54 AM FINAL
Referring Physician ___
___ Associ
___ Status: Inpatient DOB: ___
Age (years): ___ M Hgt (in): 67
BP (mm Hg): 137/71 Wgt (lb): 205
HR (bpm): 60 BSA (m2): 2.05 m2
Indication: acute MI, eval EF and RWMAS
Diagnosis: I34.0, I36.8, I35.9, I21.4
___ Information
Date/Time: ___ at 09:31 ___ MD: ___,
MD
___ Type: Portable TTE (Complete) Sonographer: ___
___, ___
Doppler: Full Doppler and color Doppler ___ Location: ___
Contrast: None Tech Quality: Adequate
Tape #: Machine: Q-2 Vivid
Echocardiographic Measurements
Results
Measurements
Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.5 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.5 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1
cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Left Ventricle - Stroke Volume: 154 ml/beat
Left Ventricle - Cardiac Output: 9.24 L/min
Left Ventricle - Cardiac Index: 4.51 >= 2.0 L/min/M2
Right Ventricle - Diastolic Diameter: 3.3 cm <= 4.0 cm
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: *3.8 cm <= 3.4 cm
Aorta - Arch: *3.1 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 25
Aortic Valve - LVOT diam: 2.8 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 1.2 m/sec
Mitral Valve - E/A ratio: 0.83
Mitral Valve - E Wave deceleration time: *368 ms 140-250 ms
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. ___ ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Mildly dilated LV
cavity. Mild regional LV systolic dysfunction. Apically
displaced papillary muscle (normal variant). ___ resting LVOT
gradient. ___ VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta. Mildly dilated aortic
arch.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). ___ AS.
Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___
MS.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: ___ PS.
PERICARDIUM: ___ pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Basal InferoseptalBasal AnteroseptalBasal Anterior
Basal InferiorBasal InferolateralBasal Anterolateral Mid
InferoseptalMid AnteroseptalMid Anterior
Mid InferiorMid InferolateralMid Anterolateral Septal
ApexAnterior Apex
Inferior ApexLateral Apex Apex
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is elongated. ___ atrial septal defect is seen
by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is mild regional left ventricular systolic
dysfunction with basal to mid inferior/infero-lateral
hypokinesis. There is ___ ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is ___ pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
basal to mid posterior hypokinesis apperars new.
ICAEL Accredited Electronically signed by ___, MD,
Interpreting physician ___ ___ 10:11
© ___ ___. All rights reserved.
___ 06:21AM BLOOD WBC-16.3* RBC-3.02* Hgb-8.8* Hct-27.1*
MCV-90 MCH-29.1 MCHC-32.5 RDW-14.8 RDWSD-48.9* Plt ___
___ 06:21AM BLOOD Glucose-97 UreaN-67* Creat-9.7*# Na-125*
K-4.8 Cl-83* HCO3-25 AnGap-22*
Brief Hospital Course:
___ male ESRD on dialysis, ___ (45-50%), coronary
artery disease, NSTEMI in ___ status post ramus stent with
a 2.75 x 15 mm Integrity bare metal stent, known occluded left
circumflex artery and 70% PLV branch, who presented with acute
onset of ___ substernal chest pressure and tightness while at
rest at home, elevated troponin 1.69 and MB 52, and nonspecific
new EKG changes (biphasic T waves on II, III, aVF).
Taken to cath where POBA performed but ___ stents or atherectomy.
# NSTEMI: ___ presented with ___ substernal, very typical
for ACS, and troponin 1.69, MB 52. While the ___ pain was
improved with nitro gtt, it was not completely relieved. ___
was treated with ASA 243mg, Plavix load 100mg, Metop 12.5mg,
Heparin gtt, Nitro gtt, Atorvastatin 80mg daily. ___ went to
cath ___ ___ (as mentioned above) and had POBA to RCA with
resolution of symptoms. Given concern for diffuse disease, the
___ was placed on 12 hours of abciximab and monitored
closely in the CCU. TTE showed LVEF of 50-55% with moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity was mildly dilated. There is mild regional left
ventricular systolic dysfunction with basal to mid
inferior/infero-lateral hypokinesis. The ___ remained
hemodynamically stable and was subsequently transerred back to
the floor in stable condition on ___. Given diffuse disease,
___ was evaluated by cardiac surgery and deemed to be a good
candidate for CABG. ___ was placed on Plavix washout and was
taken to the OR on ___.
# Chronic diastolic heart failure: EF 45-50% in ___, found on
follow up TTE to have LVEF 50-55% and findings as discussed
above. On exam the ___ did not appear to be frankly volume
overloaded, without crackles, JVD, pedal edema. The ___ was
maintained on Lisinopril 40mg and Lasix 60mg PO BID.
# CKD: ___ w/ ESRD from HTN, on MWF dialysis for about ___
years. The ___ was noted to have right upper extremity
fistula without palpable thrill or audible bruit. He underwent
___ fistulogram with satisfactory restoration of flow following
angioplasty of the arterial anastomosis to 6 mm, and the venous
outflow to 6 mm. The ___ was restarted on dialsysis,
initially on ___ schedule in preparation for CABG, and
ultimately switched back to ___. The ___ was continued on
Sevelamer and Nephrocaps.
#####SURGICAL COURSE######
___ underwent preop work up per usual and on ___ was
taken to the operating room where he underwent the following:1.
Coronary artery bypass graft x3, left internal mammary artery to
left anterior descending artery, and saphenous
vein grafts to posterior descending artery and obtuse marginal
artery.2. Endoscopic harvesting of the long saphenous vein with
Dr. ___. Please see operative note for further surgical
details. He tolerated the procedure well and was transferred to
the CVICU for further invasive monitoring. He awoke
neurologically intact and weaned to extubate. He weaned off of
pressor support. Beta-blocker/Statin and ASA were initiated. HD
was resumed. The pt complained of abdominal pain and RUQ US was
done. The US revealed:Bilateral atrophic kidneys, compatible
with history of ESRD with a complex left mid pole lesion that
appears changed since CT in ___ and could
represent hemorrhage into a cyst, though potentially worrisome
for a mass.
Further evaluation with MRI is recommended. Pt was advised to
have follow up with PCP for MRI as outpt. His abdominal pain
slowly resolved. Postoperatively he was confused and all
narcotics were discontinued. He continued to slowly progress
and was transferred to the step down unit for further
monitoring. Physical Therapy was consulted for evaluation of
strength and mobility. HD was resumed on his ___
schedule and was done prior to DC. He continued to slowly
progress and was ready for discharge to ___ on
___. By the time of his discharge on pod#10 he was ambulating
with assistance, wounds healing, and pain controlled. All follow
up appointments were advised.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Ketoconazole 2% 1 Appl TP BID
3. Carvedilol 25 mg PO BID
4. NIFEdipine CR 30 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Furosemide 60 mg PO BID
7. sevelamer CARBONATE 2400 mg PO TID W/MEALS
8. Aspirin 81 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Acetaminophen ___ mg PO TID:PRN pain
Discharge Medications:
1. Acetaminophen ___ mg PO TID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Nephrocaps 1 CAP PO DAILY
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Clopidogrel 75 mg PO DAILY
7. Ketoconazole 2% 1 Appl TP BID
8. Carvedilol 6.25 mg PO BID
9. Lisinopril 2.5 mg PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
11. Docusate Sodium 100 mg PO BID
12. Ipratropium Bromide MDI 2 PUFF IH QID:PRN wheezing
13. Senna 17.2 mg PO QHS
14. TraMADol 100 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q6h prn Disp #*15 Tablet
Refills:*0
15. Furosemide 60 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
CAD
SECONDARY DIAGNOSIS
=====================
-hypertension
-dyslipidemia
-diabetes
-CAD with NSTEMI ___ s/p ramus branch BMS
-ESRD secondary to hypertension on HD MWF
-CVA (___) with residual R-leg weakness
-diastolic CHF
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram and Tylenol
Incisions:
Sternal - healing well, ___ erythema or drainage
Leg Left - healing well, ___ erythema or drainage. Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, ___ baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please ___ lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
___ driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
___ lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
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