note_id
stringlengths 13
15
| subject_id
int64 10M
20M
| hadm_id
int64 20M
30M
| note_type
stringclasses 1
value | note_seq
int64 2
133
| charttime
stringlengths 19
19
| storetime
stringlengths 19
19
| text
stringlengths 1.56k
52.7k
|
|---|---|---|---|---|---|---|---|
10345163-DS-3 | 10,345,163 | 22,270,397 | DS | 3 | 2143-04-02 00:00:00 | 2143-04-05 09:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sent from ___ clinic for hypertension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is ___ with h/o HTN, stroke in ___ with some
residual R sided weakness, recently diagnosed diastolic and
systolic CHF who is being referred in from ___ clinic for
hypertensive emergency. The patient recently established care
with Dr. ___ who referred him to nephrology. As per
report, the patient's pressures typically have been running in
the 200s, with associated headaches and dyspnea on exertion. The
patient's blood pressure regimen has been uptitrated as an
outpatient, but he does not know what medications he he taking;
he does know that he is taking multiple pills.
While in clinic, the patient was noted to have a headache, as
well as pressures in the 250s systolic, prompting his referral
to the ED.
While in the ED, initial VS: 99.0 72 ___. The patient
had head CT that was negative for any acute intracranial
process. He was given a total of 70 mg IV Labetolol and 200 mg
PO Labetolol, with his lowest systolic pressure documented at
196. Labs notable for creat 4.7, trop 0.15, CK-MB 13, with
normal MB index.
On arrival to the floor, the patient reports feeling well. He
denied having any chest pain, no shortness of breath or trouble
breathing. Denied any headaches, no changes in his vision. Did
endorse having some neck pain, which he think he strained at
work. The patient denies ever having chest pain; he does report
that he has started to notice some shortness of breath with
exertion, but currently feels fine. The patient also notes that
he has been having ___ swelling; has had to cut his socks in
order for them to be more comfortable given the swelling.
Initial blood pressure check on the floor was ~240s systolic
(both arms checked, with manual and machine cuff). The patient
remained asymptomatic. Given the concern for more frequent blood
pressure monitoring, or even an arterial line for continuous
monitoring, the ICU was contacted. After discussion between the
MICU resident and overnight intensivist, it was thought that the
patient should remain on the floor because he continued to be
asymptomatic.
This morning patient reports mild headache. He was continued on
labetolol 200mg Q8H overnight and still has SBP of 200.
ROS:
+ muscle cramps at night
+ B/L ___ swelling at the end of the day
+ tired when walking ___ a block
Past Medical History:
- HTN
- stroke in ___ with ?residual R sided weakness
- systolic and diastolic CHF
Social History:
___
Family History:
denies history of CV issues or HTN
Physical Exam:
ADMISSION EXAM:
VS: 98.3 240/110 -> 238/120 78 20 97RA
GENERAL: well appearing, pleasant gentleman, NAD, laying
comfortably in bed
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, no
papilledema noted on opthalmoscope exam
NECK: supple, could not appreciated JVD given patient habitus
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR S1 S2
ABDOMEN: obese, soft, nontender, nondistended, +BS
EXTREMITIES: ___ pitting edema noted b/l up to knees, 2+ DP
pulses
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, though favors his right side when he walks,
which he reports is residual from his stroke in ___
.
DISCHARGE EXAM:
VS: 98.1, 168/92 (120/70-188/100), 52-89, 12, 99% RA
GENERAL: well appearing, pleasant gentleman, NAD, sitting
comfortably in bed
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, could not appreciate JVD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR S1 S2
ABDOMEN: obese, soft, nontender, nondistended, +BS
EXTREMITIES: trace edema, 2+ DP pulses
NEURO: awake, A&Ox3, CNs II-XII grossly intact, grossly NML
sensation, muscle strength ___ throughout
Pertinent Results:
LABS:
___ 03:40PM BLOOD WBC-10.0 RBC-4.69 Hgb-13.5* Hct-39.4*
MCV-84 MCH-28.8 MCHC-34.4 RDW-13.9 Plt ___
___ 03:40PM BLOOD Neuts-70.6* Lymphs-17.1* Monos-4.7
Eos-7.1* Baso-0.6
___ 08:10AM BLOOD WBC-10.1 RBC-4.62 Hgb-13.3* Hct-38.5*
MCV-83 MCH-28.7 MCHC-34.5 RDW-14.0 Plt ___
___ 03:40PM BLOOD Glucose-109* UreaN-44* Creat-4.7* Na-139
K-4.3 Cl-104 HCO3-23 AnGap-16
___ 08:25AM BLOOD Glucose-97 UreaN-46* Creat-4.9* Na-138
K-4.1 Cl-102 HCO3-23 AnGap-17
___ 03:30PM BLOOD UreaN-45* Creat-4.6* Na-137 K-3.7 Cl-100
HCO3-25 AnGap-16
___ 08:10AM BLOOD Glucose-125* UreaN-50* Creat-4.8* Na-135
K-4.5 Cl-99 HCO3-23 AnGap-18
___ 03:40PM BLOOD CK(CPK)-562*
___ 01:57AM BLOOD CK(CPK)-420*
___ 08:25AM BLOOD CK(CPK)-390*
___ 03:30PM BLOOD CK(CPK)-377*
___ 03:40PM BLOOD CK-MB-13* MB Indx-2.3
___ 03:40PM BLOOD cTropnT-0.15*
___ 01:57AM BLOOD CK-MB-9 cTropnT-0.19*
___ 08:25AM BLOOD CK-MB-9 cTropnT-0.20*
___ 03:30PM BLOOD CK-MB-9 cTropnT-0.18*
___ 08:25AM BLOOD Calcium-8.9 Phos-5.1* Mg-2.4
___ 03:30PM BLOOD Calcium-8.5 Phos-5.3* Mg-2.4
___ 07:55AM BLOOD Calcium-8.9 Phos-5.2* Mg-2.4 Cholest-186
___ 08:10AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.4
___ 07:55AM BLOOD Triglyc-189* HDL-41 CHOL/HD-4.5
LDLcalc-107
___ 08:25AM BLOOD PTH-352*
___ 08:25AM BLOOD 25VitD-12*
___ 08:25AM BLOOD C3-106 C4-34
___ 06:42PM URINE Color-Straw Appear-Clear Sp ___
___ 06:42PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:42PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 06:42PM URINE Mucous-RARE
___ 04:00PM URINE Hours-RANDOM Creat-112 Na-44 K-50 Cl-43
TotProt-900 Prot/Cr-8.0* Albumin-602.1 Alb/Cre-5375.9*
___ 04:00PM URINE Osmolal-399
.
EKG ___:
Artifact is present. Sinus rhythm. Left axis deviation. There is
a non-specific intraventricular conduction delay. Left
ventricular hypertrophy with associated ST-T wave changes,
although ischemia or myocardial infarction cannot be excluded.
There is a late transition which is probably normal. No previous
tracing available for comparison.
Rate PR QRS QT/QTc P QRS T
73 ___ 44 -58 123
.
CT HEAD W/OUT CONTRAST ___:
No intracranial hemorrhage or acute territorial infarction.
.
EKG ___:
Sinus rhythm. The P-R interval is prolonged. Left axis
deviation. There is a non-specific intraventricular conduction
delay. Left ventricular hypertrophy with associated ST-T wave
changes, although ischemia or myocardial infarction cannot be
excluded. Compared to the previous tracing of ___ the P-R
interval is slightly longer.
Rate PR QRS QT/QTc P QRS T
63 ___ 35 -50 137
.
CXR ___:
There is moderate-to-severe cardiomegaly. There are low lung
volumes. The aorta is tortuous. The lungs are clear. There is
no evidence of pulmonary edema, pneumothorax or pleural
effusion.
.
US RENAL ARTERY DOPPLER ___:
1. Echogenic kidneys indicating diffuse parenchymal renal
disease. Minimally increased resistive indices, otherwise
normal Doppler.
2. No hydronephrosis, stone mass in either kidney.
.
EKG ___:
Sinus bradycardia. Prolonged P-R interval. Left anterior
fascicular block. Left ventricular hypertrophy with secondary
repolarization change. Compared to the previous tracing of
___ no change.
Rate PR QRS QT/QTc P QRS T
51 ___ 147
Brief Hospital Course:
Mr. ___ is ___ with h/o HTN, stroke w/ minimal residual
right-sided weakness, recently diagnosed diastolic and systolic
CHF who was admitted from ___ clinic for hypertensive urgency
vs. emergency.
# Hypertensive Urgency: Patient reported headache on admission,
but CT head was negative in ED. Pt initially treated w/
labetolol 300mg Q8H; nifedipine 30mg daily was added, and he was
converted from labetolol to carvedilol for cardioprotective
effects. He was also started on Lasix 40mg daily. SBP was
140s-160s prior to discharge.
# Demand Ischemia: The patient was noted to have troponin of
0.15 CK-MB 13, and MB index 2.3, in the setting of having a
creat of 4.7. We do not have any baseline CEs in our system. The
patient denies ever having chest pain, and really only mentioned
dyspnea on exertion with walking. EKGs showed ST changes
difficult to interpret in setting of LVH. Based on his history,
his troponin could be demand ischemia or just elevated in the
setting of his CKD, though cannot be sure as we do not have a
baseline. Trop were essentially stable x3 with flat CK-MB.
# CKD: The patient was noted to have creat of 4.7 on
presentation, likely secondary to his chronic, untreated
hypertension. U/S shwoed diffuse parenchymal disease. Nephrology
recommended vitamin D, Lasix as above, treatment of HTN, and
outpt f/u to discuss further treatment options.
# Systolic and Diastolic CHF: The patient had recent ECHO that
shows both systolic and diastolic dysfunction. Systolic
dysfunction was thought to be c/w CAD/ischemic cardiomyopathy.
He was started on Lasix as above and will have outpt cardiology
f/u for further work up of possible CAD. He should likely have
outpatient stress test. Statin should be started as an
outpatient. Aspirin 81mg was started prior to discharge.
Transitional Issues:
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloniDINE 0.2 mg PO BID
2. Metoprolol Tartrate 100 mg PO BID
3. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
2. NIFEdipine CR 30 mg PO DAILY
RX *nifedipine 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth every other day Disp
#*30 Tablet Refills:*0
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Duration: 4 Weeks
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1
capsule(s) by mouth weekly Disp #*4 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertension
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted in the setting of high blood pressures. Your
medication regimen was altered and at the time of discharge your
blood pressure was well controlled without further episodes of
headache. It will be of the utmost importance to take your
medications as prescribed and follow-up with your PCP and
speciality appointments.
It was a pleasure caring for you here at ___.
Followup Instructions:
___
|
10345163-DS-4 | 10,345,163 | 21,061,672 | DS | 4 | 2143-08-03 00:00:00 | 2143-08-04 07:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M w/ PMH of hypertension, systolic and
diastolic heart failure who presents to the ED with vision
changes, hypertenison and renal failure. per patient he was
feeling unwell the day prior and went to his PCP, who noted that
he had hypertension. He was called today and told that he was in
renal failure and need to go to the emergency room so he came
in. He reports worsening leg cramps at rest and headaches that
are frontal and dull pressure sensation over the past week. In
addition he complains of some blurring vision without posterior
head pain. He reports 100% compliance with his medications. he
notes some peripheral edema, no orthopnea, no PND, no chest
pain, no palpitations. He has previosuly been worked up with a
renal artery ultrasound which was negative for stenosis and
previosu TTE in ___ which showed significant LVH. He denies
any family history of heart disease.
On arrival to the ED, his initial VS were98.2 63 199/101 18 99%
on RA. His labs were notable for a Cr of 10.7 and there was
concern given this was double his known baseline and he was
given 1L of IVF. He urinated 350cc in the ED. As his blood
pressure remained elevated he was given 10mg IV labetalol with
little effect. Head CT performed was prelim negative. His UA
showed proteinuria, but not UTI. He was peristently elevatd and
it was decided to start him on a labetalol drip, however this
had not been initiated yet at the time of transfer.
On arrival to the ICU he has no complaints. He reports his
previous headache has resolved and his leg cramps have also
resolved. He denies any chest pain or shortness of breath, and
reports being hungry.
Review of systems:
(+) Per HPI
(-) Denies fevers. Occasional chills. +headache (see hpi),
negaitve congesion, no cough, shortness of breath, wheezing,
PND, orthopnea, changes in appetitie, nausea, vomiting, changes
in bowel movements. no dysuria, no frequency, no change in
urianry volume. +leg cramps with recumbency not with exertion.
+peripheral edema.
Past Medical History:
- HTN
- stroke in ___ with ?residual R sided weakness
- systolic and diastolic CHF , last TTE in ___ showed mild
systolic dysfunction,
Social History:
___
Family History:
Denies history of CV issues or HTN
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.3, 216/105, 68, 12, 100RA
General- Alert and oriented x3, in NAD, sitting up in bed,
comfortable appearing, talking on the phone
HEENT- PEERLA,no facial asymmetry
Neck- JVP at 12,
CV- Distant heart sounds, RRR
Lungs- CTAB, moving good air to the bases, no adventitious
heart sounds
Abdomen- protuberant, soft, nontender, nondistended
Ext- trace peripheral edema to the mid shin bilaterally
Neuro- CN II-XII grossly intact.
DISCHARGE PHYSICAL EXAM:
Vitals- 104-139/50-60 60-70 98% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
===============
___ 11:11PM CK(CPK)-722*
___ 11:11PM CK-MB-10 MB INDX-1.4 cTropnT-0.17*
___ 07:09PM LACTATE-0.8
___ 03:40PM GLUCOSE-106* UREA N-95* CREAT-10.7*#
SODIUM-136 POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-18* ANION GAP-26*
___ 03:40PM estGFR-Using this
___ 03:40PM ALT(SGPT)-19 AST(SGOT)-18 CK(CPK)-1065* ALK
PHOS-126 TOT BILI-0.1
___ 03:40PM LIPASE-79*
___ 03:40PM cTropnT-0.19* ___
___ 03:40PM ALBUMIN-3.8 CALCIUM-7.8* PHOSPHATE-9.2*#
MAGNESIUM-2.8*
___ 03:40PM URINE HOURS-RANDOM CREAT-88 SODIUM-30
POTASSIUM-38 CHLORIDE-32 TOT PROT-452 PHOSPHATE-49.1
PROT/CREA-5.1*
___ 03:40PM WBC-8.9 RBC-3.90* HGB-11.0* HCT-30.9* MCV-79*
MCH-28.2 MCHC-35.6* RDW-13.7
___ 03:40PM NEUTS-67.0 LYMPHS-16.8* MONOS-4.9 EOS-10.5*
BASOS-0.8
___ 03:40PM PLT COUNT-326
___ 03:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:40PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
IMAGING:
========
___ HEAD CT:
IMPRESSION:
1. No acute intracranial hemorrhage or large vascular
territorial infarcts.
2. Multiple chronic lacunar infarcts, as before
___ CXR
IMPRESSION: AP chest compared to ___:
Severe cardiomegaly and mediastinal vascular engorgement are
stable, pulmonary
vascular caliber is top normal, pulmonary arteries are enlarged,
but there is
no pulmonary edema or pleural effusion. The lungs are low in
volume but
clear.
Vein mapping of left and right upper extremities ___- report
still pending
Brief Hospital Course:
___ with history of poorly controlled hypertension presenting
with hypertension and renal failure.
#Hypertensive urgency- patient with another admission for
hypertensive urgency. Per outpatient PCP, patient not compliant
on his medications with SBPs in the low 200s. He has LVH on his
TTE from ___ indicating likely chronically uncontrolled. He
was re-started on 300mg of labetalol TIF and nifedipine 30mg
daily. He did not require IV medications for blood pressure
control. He was transfered to regular floor further management.
On the floor he responded well to nifedipine 30 mg at night and
25 mg carvedilol BID with pressures 140-170s SBP. He will follow
up with cardiology and PCP.
#Renal failure- patient has known baseline CKD with Cr around
4.8. When last checked in our systsm was 4.8 and today was
10.7. Unclear what the precipitant of his worsening was or the
trajectory, hwoever patient reports that his PCP told him to go
to the hospital because of the renal failure. Previous workup
has included renal ultrasound that was negative. Renal was
consulted and recommended outpatient followup for fistula
placement. Vein mapping was complete in the hospital. Transplant
surgery also saw the patient and will follow the patient as an
outpatient.
#Elevated troponin-likley demand ischemia in the setting of
hypertensive urgency with LVH and with renal failure. Patient is
asymptomatic currently and EKG without any changes concerning
for ACS. Patient will need to follow up with outpatient
cardiology.
#Headache- patient with headache prior to admission. thsi has
resolved with tylenol. Given his elevated blood pressure CT head
was perfromed which was negative for acute intracranail bleed.
#Cramps- patient with cramping likely due to electrolyte
abnormalities from worsening renal fialure and his acidosis. his
UA which showed moderate blood but <1RBC is concerning for
possible myoglobinuria. No precipitating event or medication
change that could suggest rhabdo although not out of the picture
for causing acute renal failure given elevated CK. CK
downtrended with cramping not completely resolved prior to
discharge. Patient reports that muscle tightening has been
taking place especially on his right side after his stroke.
Transitional issues
- Patient has significant access issues to medical care: He does
not have his own car so has trouble reaching appointments unless
in ___ where he lives. He works at a ___ and is at
threat to lose his job with hospitalization and constant follow
up with physicians. he also is primarily ___ speaking so
language issues could be a hurdle for understanding the true
nature of his advanced disease due to blood pressure. In house
we used ___ interpretors to have thorough discussions
regarding the nature of his diseases, proper uses of
medications, especially blood pressure, and the importance of
follow up. Patient was connected with social work to explore
transporation options to reach his appointments
- Patient was not able to have an appointment made with
nephrology in house. The care connections team here will try to
make an appointment and if they cannot, the patient will be
asked to make an appointment on his own. However, given the
language barriers, the next provider can help to make an
appointment for him at BI nephrology: ___.
- Patient will require more education regarding hypertension and
effects on his organs moving forward. His insight remains poor
although language barriers play a certain role.
- He will need Chem 10 checked at his next appointment to assess
for how he is tolerating the torsemide started in house to help
with his volume and hypertension
- Medicines stopped in the hospitalzation: furosemide and
metoprolol
- medicines started: torsemide and carvedilol
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. NIFEdipine CR 30 mg PO DAILY
hold for sbp<100
3. Furosemide 40 mg PO DAILY
hold for sbp<100
4. Metoprolol Succinate XL 100 mg PO DAILY
hold for sbp<100 or hr<60
5. Fluoxetine 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluoxetine 20 mg PO DAILY
3. NIFEdipine CR 30 mg PO DAILY
RX *nifedipine 30 mg 1 tablet extended release 24hr(s) by mouth
once at dinner Disp #*30 Tablet Refills:*1
4. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice per day:
breakfast and dinner Disp #*30 Tablet Refills:*3
5. Torsemide 20 mg PO DAILY
RX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth once per day
Disp #*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertension
CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You came to the hospital for high blood pressure. Here we used
medicines to lower your blood pressure. Your blood pressure has
been high for a long time and as a result your kidneys are
failing. You will need to follow up closely with the kidney and
transplant doctors to monitor your kidney function and the
possibility of starting dialysis in the future.
Home medicines that you will no longer be taking:
Metoprolol
New medications that you will begin taking at home:
nicardipine 30 mg by mouth at night for high blood pressure
carvedilol 25 mg by mouth once in the morning AND once at night
for high blood pressure
Please follow up with the heart, kidney, and transplant doctors.
You will also need to have your blood drawn at your next
appointment to monitor for how you are doing with new medicine
torsemide.
Followup Instructions:
___
|
10345163-DS-5 | 10,345,163 | 21,655,959 | DS | 5 | 2143-11-01 00:00:00 | 2143-11-04 23:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Tunneled IJ placement ___
Right radiocephalic arteriovenous fistula ___
History of Present Illness:
___ yo male with hx of CKD, CHF (baseline creatinine 4.8 in
___, during ___ in ___, who was referred to the emergency
room by transplant surgery outpatient after his BP was found to
be in ___ systolic. The patient stated he did not take his
blood pressure medications the morning of admission because he
ran out. He complained of blurry vision,mexertional shortness of
breath and chest pain for the 2 weeks prior to admission.
In the ED, initial vs were: T 97.6 P 69 BP 247/98 R 16 O2 98%
RA. Labs were remarkable for BUN of 119, Creatinine of 13.2, H/H
8.___.4, representing a decrease vs baseline (pt declines
hemeocult), troponin 0.12 (consistent with baseline trops). EKG
showed no changes concerning for ACS. Patient was given
nifedipine CR 30mg, furosemide 40mg ___, and labetalol 100mg
___. BP dropped down to SBP to 170s. Vitals on Transfer: 71
192/94 18 100% RA.
Past Medical History:
- HTN
- stroke in ___ with ?residual R sided weakness
- systolic and diastolic CHF , last TTE in ___ showed mild
systolic dysfunction
Social History:
___
Family History:
Denies history of CV issues or HTN
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98 BP:186/87 P:112 R:22 O2:100% RA
General: Alert, awake, oriented, NAD
HEENT: MMM, PERRL, normal oropharynx
CV: RRR no m/r/g
Lungs: Mild bibasilar crackles, moving air well bilaterally
Abdomen: NTP, ND, NABS
GU: deferred
Ext: +2 pitting edema to knees, left worse than right
Neuro: no focal deficits
DISCHARGE EXAM:
VS: T: 97.6 BP: 124/63 HR: 65 RR: 15 SaO2: 96% RA
GEN: Alert, in NAD, laying in bed, appears stated age
HEENT: NC/AT, EOMI, sclera anicteric, right ear canal with
significant cerumen, right TM with adherent cerumen, no
tenderness at right pinna, no right periauricular tenderness, no
erythem at right external ear canal
PULM: CTAB, no wheezes, rhonchi, or rales appreciated
___: RRR, normal s1 and s2, no r/m/g appreciated
Abd: +BS, soft, nontender, not distended, no guarding/rebound
Ext: 2+ DP pulses, trace edema at ankles bilaterally, palpable
thrill at RUE at fistula site, no hematoma or erythema, stitches
in place, tunneled HD line at left upper chest w/out erythema or
streaking
NEURO: alert, oriented, strength ___ at BUE and BLE
Pertinent Results:
ADMISSION LABS:
___ 03:30PM BLOOD WBC-7.3 RBC-2.87* Hgb-8.1* Hct-23.4*
MCV-81* MCH-28.0 MCHC-34.4 RDW-14.5 Plt ___
___ 03:30PM BLOOD Neuts-70.4* Lymphs-13.5* Monos-5.4
Eos-9.5* Baso-1.1
___ 03:30PM BLOOD Glucose-96 UreaN-119* Creat-13.2*# Na-136
K-4.6 Cl-99 HCO3-17* AnGap-25*
___ 05:45AM BLOOD ALT-10 AST-8 LD(LDH)-225 AlkPhos-87
TotBili-0.2
___ 03:30PM BLOOD ___
___ 03:30PM BLOOD cTropnT-0.12*
___ 03:30PM BLOOD Calcium-8.0* Phos-10.0*# Mg-3.0*
___ 05:45AM BLOOD calTIBC-299 Ferritn-184 TRF-230
___ 05:30AM BLOOD PTH-455*
___ 12:49PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-BORDERLINE
___ 12:49PM BLOOD HCV Ab-NEGATIVE
DISCHARGE LABS:
___ 05:30AM BLOOD PTH-455*
___ 05:40AM BLOOD Cortsol-12.3
___ 07:05AM BLOOD WBC-7.7 RBC-2.90* Hgb-8.5* Hct-26.6*
MCV-92 MCH-29.2 MCHC-31.8 RDW-14.6 Plt ___
___ 07:05AM BLOOD Glucose-140* UreaN-63* Creat-10.6*#
Na-135 K-4.7 Cl-92* HCO3-24 AnGap-24*
___ 07:05AM BLOOD Calcium-9.1 Phos-6.5* Mg-2.7*
___ 05:55
ALDOSTERONE
Test Result Reference
Range/Units
ALDOSTERONE, LC/MS/MS 6 ng/dL
Adult Reference Ranges for Aldosterone,
LC/MS/MS:
Upright ___ am < or = 28 ng/dL
Upright ___ pm < or = 21 ng/dL
Supine ___ am ___ ng/dL
___ 05:55
RENIN
Test Result Reference
Range/Units
PLASMA RENIN ACTIVITY, 0.55 0.25-5.82
ng/mL/h
LC/MS/MS
___ ___
METANEPHRINES, FRACTIONATED, 24HR URINE
Test Result Reference
Range/Units
24 HR URINE VOLUME 600 mL
METANEPHRINE 15 L 90-315 mcg/24
h
NORMETANEPHRINE 64 L 122-676 mcg/24
h
METANEPHRINES, TOTAL 79 L 224-832 mcg/24
h
A four fold elevation of urinary normetanephrines
is extremely likely to be due to a tumor, while a
four fold elevation of urinary metanephrines is
highly suggestive, but not diagnostic of the tumor.
Measurement of plasma Metanephrines and Chromogranin
A is recommended for confirmation.
___ 15:04
CATECHOLAMINES
Test Result Reference
Range/Units
24 HR URINE VOLUME 600 mL
EPINEPHRINE, 24 HR URINE see note
Results are below the reportable range for this
analyte, which is 2.0 mcg/L.
Test Result Reference
Range/Units
NOREPINEPHRINE, 24 ___ 58 ___ mcg/24
h
CALCULATED TOTAL (E+NE) 58 ___ mcg/24
h
DOPAMINE, 24 HR URINE 17 L 52-480 mcg/24
h
CREATININE, 24 HOUR URINE 0.41 L 0.63-2.50 g/24
h
STUDIES/IMAGING:
CXR ___: No acute intrathoracic process identified
Right ___ US ___: No evidence of deep vein thrombosis in the
right leg. Right ___ cyst
R knee 3V ___: Chondrocalcinosis. Mild-to-moderate
degenerative changes of the right knee. No significant joint
effusion
MICRO:
___ 5:03 pm SWAB Site: EAR Source: R ear canal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ASPERGILLUS ___. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Brief Hospital Course:
___ yo male with hx of CKD, diastolic CHF, HTN, who presented
with hypertensive emergency and worsening renal function
# Hypertension: The patient had systolic blood pressures in the
240s on admission, while off his blood pressure medications. On
admission his blood pressure medications were restarted, with
continued poor control. He was evaluated for causes of
secondary hypertension. His renin, aldosterone, and cortisol
levels were within normal limits, and his urinary metanephrines
were low to normal. His urinary catecholamines were also low to
normal. Renal artery dopplers done in ___ were normal.
His anti-hypertensive medications were uptitrated and on
discharge his pressures were ranging between 130 and 180 and he
was on multiple medications (Nifedipine, Labetalol, Lisinopril).
He also received labetalol and hydralazine as needed for SBPs >
200. His did not have neurologic or cardiac symptoms associated
with his high blood pressures. He should follow up with his PCP
for further management.
# CKD: The patient presented with creatinine of 13. During a
previous hospitalization in ___ his creatinine was 10. His
kidney failure is likely due to his hypertension. Renal
consulted and recommended starting dialysis during this
admission. A tunneled IJ was placed on ___ for access and he
started dialysis. He got dialysis ___ as an inpatient with
plan to continue this schedule as outpatient. AV fistula was
placed at his RUE during his admission by transplant surgery.
He will need follow up with transplant surgery to determine when
his fistula has matured and is ready for use with dialysis.
# Headache: The patient had recurrent headaches during
admission. The headaches were likely initially due to high
blood pressures. As his pressures were more controlled, the
headaches were attributed to hemodialysis or tension headaches.
A recent head CT in ___ did not show any concerning mass
effects. He was treated symptomatically with tylenol and his
pain improved.
# Decreased hearing in R ear: The patient had evidence of
cerumen impaction in his right ear, treated with ear irrigation
and debrox and hydrogen peroxide drops with some resolution of
the impaction. However, the patient then developed increased
pain in the right ear and surrounding facial rash. ENT
consulted and recommended antibiotic ear drops for treatment of
otitis externa. Patient continued to have decreased hearing in
his R ear. ENT was re-consulted, noted adherent waxy substance
on his R ear. Was stared on colace ear drops, without
improvement. ENT noted they would need to see the patient as an
outpatient in their clinic to removal of his right ear wax.
# Otitis externa: was seen by ENT for R ear pain and decreased
hearing. Treated with antibiotic ear drops and colace ear
drops. Pain resolved, but patient still had decreased hearing.
ENT was reconsulted for continued decreased hearing. Patient
was noted to have significant cerumen impaction with adherence
to right tympanic membrane. ENT noted they would only be able
to remove cerumen from tympanic membrane in clinic with
specialized equipment. Appointment was made for Mr. ___ in
___ with ___ ENT team. His right ear was irrigated twice
while inpatient, some cerumen was removed with small improvement
in symptoms. Patient continued to complain of ear pressure and
decreased hearing on discharge. Symptoms should be re-evaluated
by PCP, would advise PCP to try to make earlier ENT appointment
for Mr. ___ if possible.
# Right medial leg pain: Resolved. The patient complained of
right medial knee pain during his hospital stay, and an
ultrasound revealed a ___ cyst. His pain was treated with
lidocaine patch, and prn oxycodone with improvement of his
symptoms. By discharge date, patient was no longer needing the
above interventions.
# Anemia: The patient had anemia on admission, with prior
baseline anemia. LIkely due to worsening kidney function. He
was placed on iron supplementation and was started on Epogen
(received during HD sessions). His hct remaied stable during
his stay. Patient was without signs of active bleeding.
TRANSITIONAL ISSUES:
# Hypertension: The patient had systolic blood pressures in the
240s on admission, while off his blood pressure medications. On
admission his blood pressure medications were restarted, with
continued poor control. He was evaluated for causes of secondary
hypertension. His renin and aldosterone levels were within
normal limits, and his urinary metanephrines were also low to
normal (catecholamines low to normal). The cause of his severe
hypertension is likely due to his worsening kidney function. His
medications were uptitrated and on discharge his pressures were
ranging between 130-220 on multiple medications (lisinopril 40
per day, labetalol 500mg TID, labetolol 300mg qHS, Nifedipine
90mg qHS). He should follow up with his PCP for further
management.
# CKD stage V: The patient presented with creatinine of 13.
During a previous hospitalization in ___ his creatinine was 10.
His kidney failure is likely due to his hypertension. Renal
consulted and recommended starting dialysis during this
admission. A tunneled IJ was placed on ___ for access and he
started dialysis. He will get dialysis ___ as an outpatient.
AV fistula was placed on ___, it will mature in ___ weeks. He
has outpatient follow-up with transplant surgery for his AV
fistula and has been set up with outpatient dialysis.
# Social issues: The patient had several social issues during
his admission that threatened access to medical care. The
patient does not have a car so has difficulty making
appointments, and he has difficulty taking time off work. Should
have continued follow-up with SW to ensure he is able to get his
medications/make it to dialysis. Would advise PCP to assist
patient with medication compliance.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg ___ DAILY
2. NIFEdipine CR 30 mg ___ DAILY
3. Furosemide 40 mg ___ DAILY
4. Labetalol 100 mg ___ BID
Discharge Medications:
1. Aspirin 81 mg ___ DAILY
RX *aspirin 81 mg 1 tablet,chewable(s) by mouth once a day Disp
#*30 Tablet Refills:*2
2. Furosemide 60 mg ___ AT 8AM AND 4PM ON NON-DIALYSIS DAYS
RX *furosemide 20 mg 3 tablet(s) by mouth twice a day Disp #*100
Tablet Refills:*2
3. Labetalol 500 mg ___ TID
RX *labetalol 200 mg 2.5 tablet(s) by mouth three times a day
Disp #*230 Tablet Refills:*2
4. NIFEdipine CR 90 mg ___ QHS
RX *nifedipine 90 mg 1 tablet extended release(s) by mouth at
bedtime Disp #*30 Tablet Refills:*2
5. Ferrous Sulfate 325 mg ___ DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*2
6. Labetalol 300 mg ___ QHS
RX *labetalol 300 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*2
7. Lisinopril 40 mg ___ DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
8. Nephrocaps 1 CAP ___ DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*2
9. sevelamer CARBONATE 2400 mg ___ TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 3 tablet(s) by mouth
three times a day Disp #*270 Tablet Refills:*2
10. Acetaminophen 650 mg ___ Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet extended release(s) by mouth
every six (6) hours Disp #*30 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertension
Kidney failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay. You were
admitted for high blood pressure and worsening kidney function.
Your blood pressure medications were increased and your
pressures were better controlled. You were started on dialysis
during admission for kidney failure. You will need to get
dialysis three times per week after discharge. In addition, an
AV fistula was placed by the transplant surgery team. This will
mature in ___ weeks and will be able to be used for dialysis
after that point. You have a follow up appointment with the
transplant team on ___ (appointment details: ___
01:45p ___ (___), ___
___ (___)). In addition, your right ear
pain/pressure/decreased hearing were evaluated by the ENT team.
You were treated with ear drops and ear irrigation. You have
follow-up with ENT in ___. You should follow up with your
PCP for continued management of your high blood pressure and
kidney failure. If you develop fevers, chest pain, shortness of
breath, worsening ear pain, or drainage from your surgical
wound, please seek evaluation by a medical professional.
DO NOT attempt to remove ear wax from your ear with any object.
This could damage your ear drum. You may use over the counter
ear drops, but placing any object in your ear could cause
permanent damage.
Followup Instructions:
___
|
10345163-DS-9 | 10,345,163 | 28,363,105 | DS | 9 | 2144-07-01 00:00:00 | 2144-07-01 16:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower extremity redness and swelling
Major Surgical or Invasive Procedure:
___: Hemodialysis
History of Present Illness:
___ ___ M with h/o CKD on HD (___), recent
admission on ___ with NSTEMI s/p BMS, HTN, stroke in ___,
and CHF (last echo ___, EF 45-50%) who presents with RLE
pain, swelling, erythema. Was just discharged ___ when he was
here for ___ cellulitis tx w vancomycin qHD; he missed his HD
session ___. Since discharge, the pain and erythema in his
leg has been consistent, not worse not better. No fevers or
chills. Went to see his PCP today who rec'd returning to the ED
for further evaluation. The leg redness initially developed at
the end of the admission was was thought to represent
superficial thrombophlebitis vs lymphangitis.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger: 98.7 60 223/91 20 100% ra. Labs showed
no leukocytosis, no left shift. LENIs showed no dvt, 5.6cm
___ cyst. Was given vancomycin, labetalol for SBP 220 ->
195.
Review of Systems: as above.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- Hospitalization for lumbar back pain in ___ - likely DJD.
- ESRD on HD - thought to be due to poorly controlled HTN, on HD
since ___ originally had tunneled cath, but in ___ had
fistula made; no graft in place
- HTN
- stroke in ___ with ?residual R sided weakness
- systolic and diastolic CHF, last TTE in ___ showed mild
systolic dysfunction
- NSTEMI s/p bare medical stent on ___ given concerns about
medication compliance; at high risk for thrombosis b/c of
aneurysm seen during cath
- apple core lesion in sigmoid colon seen on lateral lumbar
spine film in ___ but not on CTABDpel, has not had colonscopy
since
Social History:
___
Family History:
Denies history of CV issues or HTN; no hx of ESRD or HD
Physical Exam:
ADMISSION EXAM:
Vitals - 98.3 200/98 61 18 98%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: LLE without c/c/e. RLE with 2+ pitting edema to the
knee, erythematous over the anterior shin without signs of
bullae or excoriation, ttp over the areas of erythema. Mildly
warm.
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact
SKIN: warm and well perfused
DISCHARGE EXAM:
Vitals: Tc97.9 Tm98.6 64 167/83(112/65-180/90) 18 100% on RA
General: Well appearing man sitting in chair in NAD; Comfortable
HEENT: MMM
Neck: Supple; No lymphadenopathy
Lungs: CTAB; No wheezes, crackles, or rhonchi
CV: S1S2 RRR, No murmurs or rubs
Ext: RUE with AV fistula with palpable thrilll; LLE without
c/c/e; RLE with 2+ edema to mid shin with mild erythema over
anterior>posterior shin. Decreased size from ___. No evidence
of injury; TTP over medial RLE erythema; Well perfused, 2+
pulses; Toenails with onychomycosis bilaterally
Neuro: Grossly intact
Pertinent Results:
ADMISSION LABS:
___ 03:45PM BLOOD WBC-7.8 RBC-3.14* Hgb-9.8* Hct-30.3*
MCV-96 MCH-31.1 MCHC-32.2 RDW-13.9 Plt ___
___ 03:45PM BLOOD Neuts-65.3 ___ Monos-4.9 Eos-9.4*
Baso-0.9
___ 03:45PM BLOOD ___ PTT-30.0 ___
___ 03:45PM BLOOD Glucose-86 UreaN-60* Creat-13.0*# Na-135
K-4.6 Cl-92* HCO3-25 AnGap-23*
___ 06:23PM BLOOD Lactate-1.9
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-9.9 RBC-3.22* Hgb-9.8* Hct-30.9*
MCV-96 MCH-30.3 MCHC-31.5 RDW-14.0 Plt ___
___ 06:30AM BLOOD Neuts-68.2 ___ Monos-4.8 Eos-7.9*
Baso-0.9
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD UreaN-69* Creat-13.5* Na-134 K-5.1 Cl-92*
HCO3-23 AnGap-24*
___ 06:30AM BLOOD Calcium-8.7 Phos-7.4*# Mg-3.0*
___ 12:36PM BLOOD Vanco-26.6*
IMAGING:
RLE Duplex (___) Preliminary Report: 1. No evidence of DVT.
2. ___ cyst in the right popliteal fossa measuring up to 5.6
cm. 3. Mild edema in the right calf.
Brief Hospital Course:
___ ___ male with h/o CKD on HD (___), recent
admission on ___ with NSTEMI s/p BMS, HTN, stroke in ___,
and CHF (last echo ___, EF 45-50%) and recent admission on
___ for RLE cellulitis on vancomycin qHD, presenting with
continued lower extremity erythema and pain.
ACTIVE ISSUES:
# RLE Cellulitis: Pt presented from ___ office with right lower
extremity redness and swelling. Recently admitted from
___ for RLE cellulitis, d/c on vancomycin qHD given
concern of poor follow-up with plan for 3 doses. On ___, missed
HD and vancomycin session due to long wait. Patient afebrile
during admission without sepsis, and denied worsening of RLE
erythema or swelling. Went for HD on ___ and given vancomycin x
1. Pt's RLE erythema improved and vitals remained stable, so he
was discharged home on oral regimen of doxycycline 100 mg po BID
x 5 days (to be completed ___.
#HTN: Poorly controlled on admission with SBP in 200s. Pt
reports he takes meds consistently at home. Received home
medications and prn hydralazine IV and improved to 150s. Likely
secondary to missed HD on ___. Remained asymptomatic throughout
admission and went for dialysis on ___. On discharge, pt had
elevated, though improved bp in the 160s.
#ESRD: On HD (___). Missed HD on ___. On
presentation had no clinical signs of volume overload or uremia.
K peaked at 5.1. Pt went for HD on ___.
CHRONIC ISSUES:
#CAD w NSTEMI s/p BMS ___: Stable throughout admission,
without chest pain or shortness of breath. Continued on home
meds including asa, lisinopril, plavix, labetolol, and statin.
TRANSITIONAL ISSUES:
# Cellulitis: Needs follow-up to determine resolution of
cellulitis and completion of doxycycline (abx to finish ___
# Hypertension: Presented with uncontrolled bp in the 200s,
improved with home meds and prn hydralazine. Discharged on home
meds, and should have bp checked.
# ESRD: Continue HD on ___ schedule.
# Onychomycosis: B/l toes - follow-up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY High LDL
3. Clopidogrel 75 mg PO DAILY
4. Cyclobenzaprine 10 mg PO TID:PRN muscle relaxer
5. Labetalol 600 mg PO Q8H
6. Lisinopril 40 mg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. NIFEdipine CR 90 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN back pain
10. sevelamer CARBONATE 2400 mg PO TID W/MEALS
11. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
12. Furosemide 120 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY High LDL
3. Clopidogrel 75 mg PO DAILY
4. Cyclobenzaprine 10 mg PO TID:PRN muscle relaxer
5. Furosemide 120 mg PO DAILY
6. Labetalol 600 mg PO Q8H
7. Lisinopril 40 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. NIFEdipine CR 90 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN back pain
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
13. Doxycycline Hyclate 100 mg PO Q12H Duration: 5 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Right lower extremity Cellulitis,
Hypertension
Secondary Diagnosis: End state renal disease, coronary artery
disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for an
infection of your right lower leg and for dialysis. On
presentation you also had a very elevated blood pressure, which
improved with your home medications. You were dialyzed during
your hospitalization and given one dose of your IV antibiotics.
You were then discharged with oral antibiotics and scheduled for
follow-up with your primary care physician.
Please take your antibiotics and blood pressure medications
every day as prescribed, and follow-up with your PCP at your
appointment listed below.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10345247-DS-14 | 10,345,247 | 22,376,430 | DS | 14 | 2123-03-20 00:00:00 | 2123-03-20 13:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Aspirin
Attending: ___.
Chief Complaint:
Fevers, rigors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo ___ man with metastatic
castrate resistant prostate cancer, who presents with
fevers/rigors 1 day after starting docetaxel.
He was first diagnosed with prostate cancer in ___ and was
metastatic to the bones and presumed lungs at presentation. He
underwent several treatments (bicalutamide, leuprolide,
abiraterone, enzalutamide) now s/p TURP and found to have
progression on Enzalutamide in ___ of this year. His last CT
torso was done in ___ and showed invasive prostate cancer
metastatic to the bladder with pelvic bone metastases. He was
started on palliative docetaxel ___ with plan for 21 day
cycle. He also received Neulasta. He continues on Leuprolide and
Denosumab Q3 months, last dosed on ___.
He received his first dose of docetaxel on ___. The
following evening he suddenly developed chills and rigors. He
was
found to be febrile to 101.5. He took NSAID and fever improved.
Patient and his wife called ___ at ___ who recommended
they present to the ED.
In the ED: T 97.7 F | 112 | 130/79 | 97% RA. He was given 1L LR
and cefepime x1.
On arrival to the floor, patient denies further episodes of
fever
or chills. He denies chest pain or dyspnea. He has a chronic
cough that is unchanged in character. He has no new rashes or
skin lesions. He has not had diarrhea but may have some
constipation. He has no dysuria. He did not have any
nausea/vomiting after chemotherapy.
Past Medical History:
- Hemorrhoids s/p surgery about ___ years ago
- Type II Diabetes
- Cataracts s/p surgery
- Hepatitis C exposure according to his labs, although he is not
aware of this diagnosis
- metastatic castration resistant prostate cancer
Social History:
___
Family History:
He has a brother in his ___ with similar urinary
symptoms, although it is unclear whether he has sought medical
attention or has a diagnosis of prostate cancer, a sister who
had
breast cancer in her ___, now alive status post mastectomy in
___. Denies any other family history of malignancy
Physical Exam:
==========================
ADMISSION PHYSICAL EXAM
==========================
VITALS: ___ 0704 Temp: 97.5 PO BP: 160/81 HR: 98 RR: 20 O2
sat: 98% O2 delivery: Ra
General: pleasant man in no acute distress; primarily
___ but able to speak some ___
HEENT: pupils equal and reactive, mucous membranes moist
Cardiovascular: regular rate and rhythm, no murmurs
Chest/Pulmonary: vesicular breath sounds, no crackles or
wheezing
Abdomen: soft, non-tender, non-distended
Pelvis/GU: no suprapubic tenderness
Extr/MSK: no edema, extremities are warm and well perfused
Skin: many tattoos, no rashes/lesions
Access: peripheral IV, no port/PICC
========================
DISCHARGE PHYSICAL EXAM
========================
VITALS: 99.4 PO 146 / 64 90 18 94 Ra
sat: 98% O2 delivery: Ra
General: pleasant man in no acute distress, laying flat in bed
HEENT: pupils equal and reactive, mucous membranes moist
Cardiovascular: regular rate and rhythm, no murmurs
Chest/Pulmonary: vesicular breath sounds, no crackles or
wheezing
Abdomen: soft, non-tender, non-distended
Pelvis/GU: no suprapubic tenderness
Extr/MSK: no edema, extremities are warm and well perfused
Skin: many tattoos, no rashes/lesions
Access: peripheral IV, no port/PICC
Pertinent Results:
=========================
ADMISSION LAB RESULTS
=========================
___ 03:15AM BLOOD WBC-18.1* RBC-4.82 Hgb-14.1 Hct-40.6
MCV-84 MCH-29.3 MCHC-34.7 RDW-13.7 RDWSD-41.9 Plt ___
___ 03:15AM BLOOD Neuts-92.4* Lymphs-4.4* Monos-1.3*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-16.76* AbsLymp-0.79*
AbsMono-0.24 AbsEos-0.02* AbsBaso-0.05
___ 03:15AM BLOOD Glucose-181* UreaN-28* Creat-1.2 Na-136
K-4.5 Cl-100 HCO3-22 AnGap-14
___ 03:15AM BLOOD ALT-24 AST-22 AlkPhos-62 TotBili-0.8
___ 03:15AM BLOOD Albumin-4.3 Calcium-9.9 Phos-3.7 Mg-1.6
___ 03:25AM BLOOD ___ pO2-53* pCO2-42 pH-7.45
calTCO2-30 Base XS-4
___ 03:25AM BLOOD Lactate-1.1
========================
DISCHARGE LAB RESULTS
========================
___ 05:58AM BLOOD WBC-11.1* RBC-4.48* Hgb-13.1* Hct-37.8*
MCV-84 MCH-29.2 MCHC-34.7 RDW-13.7 RDWSD-42.1 Plt ___
___ 05:58AM BLOOD Glucose-126* UreaN-16 Creat-0.8 Na-138
K-4.4 Cl-101 HCO3-21* AnGap-16
___ 05:58AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.1
========================
IMAGING AND REPORTS
========================
CHEST X-RAY ___
FINDINGS:
Streaky bibasilar densities likely reflect atelectasis. Focal
density in the left lower lobe best seen on lateral projection
is concerning for sequela of aspiration or pneumonia. There is
no pleural effusion or pneumothorax. Calcifications are noted in
the arch of the aorta. Otherwise, cardiomediastinal silhouette
is within normal limits.
IMPRESSION:
Focal density in the right lower lobe is concerning for sequela
of aspiration or pneumonia in the appropriate clinical setting.
Brief Hospital Course:
___ is a ___ yo ___ man with metastatic
castrate resistant prostate cancer, who presents with
fevers/rigors 1 day after starting docetaxel. He was found to
have a lobar opacity and was started on antibiotics for CAP.
ACUTE PROBLEMS:
===============
# CAP
Patient became febrile at home 1 day after starting
chemotherapy. He presented to the ED, where CXR showed a left
lobar opacity concerning for pneumonia. He was not neutropenic
given that he had received neulasta with his chemotherapy. He
was ruled out for flu and started on treatment for CAP with
ceftriaxone and azithromycin. Continued on azithromycin for
completion of Z-pack on discharge.
# Acute kidney injury
Creatinine was 1.2 on presentation from a baseline of 0.9. It
normalized after 1 liter of IV fluid repletion, suggesting
pre-renal injury.
CHRONIC PROBLEMS:
=================
# Metastatic Prostate Cancer, Castrate Resistant
Metastatic to bladder, pelvic and RP LN, bone. Most recently
progressed through enzalutamide ___. C1D1 docetaxel ___.
Last testosterone checked prior to chemo this week was < 3, and
PSA was 52 (from 30 in ___.
# T2DM
Patient states he has not been taking metformin at home.
# HTN
Patient states he has not been taking metoprolol at home.
======================
TRANSITIONAL ISSUES
======================
[ ] Continue antibiotics for a 5 day course, last day ___
___
HCP: ___ | wife | ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
3. Metoprolol Succinate XL 50 mg PO DAILY
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Denosumab (Xgeva) 120 mg SC EVERY 4 WEEKS
6. Triamcinolone Acetonide 0.025% Cream 1 Appl TP TID:PRN rash
7. Leuprolide Acetate 22.5 mg IM EVERY 3 MONTHS
8. Nystatin Cream 1 Appl TP TID:PRN rash
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
Last day ___
RX *azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth once a
day Disp #*3 Tablet Refills:*0
2. Denosumab (Xgeva) 120 mg SC EVERY 4 WEEKS
3. Leuprolide Acetate 22.5 mg IM EVERY 3 MONTHS
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Nystatin Cream 1 Appl TP TID:PRN rash
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
9. Triamcinolone Acetonide 0.025% Cream 1 Appl TP TID:PRN rash
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Community acquired pneumonia
SECONDARY:
-Metastatic prostate 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 ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted due to fever after starting chemotherapy.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- A chest x-ray showed pneumonia in your lung, so you were
started on antibiotics.
- A flu swab was checked and was negative.
- You improved and were ready to leave the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10345247-DS-15 | 10,345,247 | 24,242,720 | DS | 15 | 2123-04-29 00:00:00 | 2123-04-29 18:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Aspirin
Attending: ___.
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
eua, drainage of abscess, placement ___ drain ___
History of Present Illness:
___ is a ___ year old male with
metastatic, castrate resistant prostate cancer (mets to bones,
lungs) on Docetaxel (C2 D1 on ___, presenting with hematuria.
He reports that he was at his baseline state of health until
___, when he noticed trouble urinating, and when he did urinate
it was bloody. He also had lower abdominal pain. He went to ___ and had a Foley catheter placed and he had bladder
irrigation done. Admission was recommended but patient preferred
to return home with foley ___ place, with plan to follow up at
___.
Overnight ___ into ___ he was feeling well, emptying the
foley of urine, which did appear bloody, a few times overnight.
However, the morning of admission ___ he had two episodes of
all
blood being ___ the foley, and it overflowed onto the ground. He
reports that there was stool as well; his wife is adamant that
there was no stool ("I cleaned it, twice").
___ the ED, initial vitals were: 97.2 | 103 | 121/62 | 18 | 100%
RA
Labs were notable for:
16.6 > 11.3/34.6 < 154
PMNs 86.9
___ 14.4, PTT 31.1, INR 1.3
Chem-10 within normal limits.
UA with >182 RBC, WBC 3, few bacteria, 0 epis.
Upon arrival he was hand irrigated for multiple large blood
clots
and CBI was initiated.
A CT of the abdomen and pelvis with contrast showed the
following
on wet read:
1. Interval progression of malignant invasion of the bladder
which is the likely source of hematuria.
2. Scattered intra-abdominal and pelvic implants, some new and
others increased ___ conspicuity as above, concerning for
metastatic disease progression.
3. Stable retroperitoneal and pelvic lymphadenopathy, and
osseous
metastatic disease.
4. Findings suggestive of proctocolitis with prominent
hemorrhoids.
5. Redemonstration of right perianal fistula. Rim enhancing
fluid
collection measuring up to 5.0 cm posterior to the rectum is
seen
within the region of previously described intersphincteric
abscess, but was not clearly seen on the
previous study. This collection is also associated with a left
perianal fistula. MRI of the pelvis is recommended to better
assess fistulous disease.
6. Intraluminal bladder air is presumably related to Foley
catheterization.
Colorectal surgery was consulted and recommended MRI of the
pelvis to better delineate anatomy, and with plan for drainage
of
large abscess.
The patient was given Ceftriaxone 1gm IV and metronidazole 500mg
IV.
- Vitals prior to transfer: 97.5 | 110 | 139/83 | 19 100% ra
Upon arrival to the floor, the patient and his wife confirm the
above history. He requests that she help him translate.
Initially, he wants to leave AMA prior to his admission because
he and his wife have been together for ___ years and he cannot
sleep apart from her (he is ___ a shared room). They were very
polite about this barrier. Ultimately they were agreeable to a
recliner chair next to his bed.
Notably, he was recently treated for balinitis with fluconazole
150 mg PO, clotrimazole 1% topical BID x1, and cephalexin 500 mg
PO QID x7 days (subsequently tmp-smx for MRSA+), with
improvement
such that he was able to retract his foreskin without pain. He
is
still on topical clotrimazole. It has improved overall.
He has had a poor appetite for some time (only ate half a
sandwich today) and also strains to stool every ___ days. No
pain
with defecation, brbpr or melena.
Past Medical History:
- Hemorrhoids s/p surgery about ___ years ago
- Type II Diabetes
- Cataracts s/p surgery
- Hepatitis C exposure according to his labs, although he is not
aware of this diagnosis
- metastatic castration resistant prostate cancer
Social History:
___
Family History:
He has a brother ___ his ___ with similar urinary
symptoms, although it is unclear whether he has sought medical
attention or has a diagnosis of prostate cancer, a sister who
had
breast cancer ___ her ___, now alive status post mastectomy ___
___. Denies any other family history of malignancy
Physical Exam:
ADMISSION EXAM:
VS: ___ 2122 Temp: 97.5 PO BP: 139/83 HR: 110 RR: 19 O2
sat:
100% O2 delivery: ra
GENERAL: Appears older than stated age and chronically ill but
nontoxic, comfortable, no acute distress.
HEENT: MMM, mild subconjunctival pallor, no scleral icterus,
moist mucous membranes.
NECK: No concerning lymphadenopathy.
CV: RRR
PULM: Clear to auscultation with good air movement throughout
and
no adventitious sounds.
ABD: Soft, nontender, nondistended.
GU: Foley draining yellow urine. Uncircumcised penis with
notable
blood and clotting at the meatus, as well as what appears to be
some denuded/raw skin. Pain with retraction of foreskin. No
specific ulcers, chancres, vesicles.
EXT: Warm, well-perfused, no edema
SKIN: Multiple tattoos, many of which appear to be home-made.
NEURO: Face grossly symmetric, moving all limbs with purpose
against gravity.
ACCESS: PIV
DISCHARGE EXAM:
VS: ___ 1138 Temp: 98.3 PO BP: 107/56 HR: 92 RR: 18 O2 sat:
99% O2 delivery: Ra
GENERAL: Comfortable appearing
HEENT: MMM, mild subconjunctival pallor, no scleral icterus,
moist mucous membranes.
NECK: No concerning lymphadenopathy.
CV: RRR
PULM: Clear to auscultation with good air movement throughout
and
no adventitious sounds.
ABD: Soft, nontender, nondistended.
GU: Foley draining yellow urine. Uncircumcised penis with
notable
blood and clotting at the meatus, as well as what appears to be
some denuded/raw skin. Pain with retraction of foreskin. No
specific ulcers, chancres, vesicles.
EXT: Warm, well-perfused, no edema
SKIN: Multiple tattoos, many of which appear to be home-made.
NEURO: Face grossly symmetric, ambulating normally
ACCESS: PIV
Pertinent Results:
ADMISSION LABS:
___ 12:35PM BLOOD WBC-16.6* RBC-3.97* Hgb-11.3* Hct-34.6*
MCV-87 MCH-28.5 MCHC-32.7 RDW-14.6 RDWSD-46.5* Plt ___
___ 12:35PM BLOOD Neuts-86.9* Lymphs-6.8* Monos-4.1*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-14.45* AbsLymp-1.13*
AbsMono-0.68 AbsEos-0.00* AbsBaso-0.05
___ 12:35PM BLOOD ___ PTT-31.1 ___
___ 12:35PM BLOOD Glucose-131* UreaN-18 Creat-0.8 Na-138
K-4.2 Cl-101 HCO3-22 AnGap-15
___ 12:35PM BLOOD ALT-10 AST-14 AlkPhos-96 TotBili-0.6
___ 12:35PM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.4 Mg-1.8
DISCHARGE LABS:
___ 05:58AM BLOOD WBC-8.5 RBC-3.49* Hgb-10.1* Hct-30.7*
MCV-88 MCH-28.9 MCHC-32.9 RDW-14.6 RDWSD-46.5* Plt ___
___ 05:58AM BLOOD UreaN-15 Creat-0.7
OTHER IMPORTANT RESULTS:
Urine cytology ___ pending
MICRO:
Time Taken Not Noted ___ Date/Time: ___ 2:59 pm
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 12:53 pm SWAB LEFT SIDED FISTULA TRACK.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI ___
PAIRS.
___ CLUSTERS.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI ___
PAIRS.
___ CHAINS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary): RESULTS PENDING.
ANAEROBIC CULTURE (Preliminary):
___ 6:45 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set ___ the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
Reported to and read back by ___ AT
2150 ON
___ AND ___ AT 2146 ON ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS.
Other set of culture from ___ NGTD
Repeat blood cultures ___ NGTD
IMAGING:
CT ABDOMEN/PELVIS WITH CONTRAST:
1. Interval progression of malignant invasion of the bladder
which is the
likely source of hematuria.
2. Scattered intra-abdominal and pelvic implants, some new and
others
increased ___ conspicuity as above, concerning for metastatic
disease
progression.
3. Stable retroperitoneal and pelvic lymphadenopathy, and
osseous metastatic disease.
4. Findings suggestive of proctocolitis with prominent
hemorrhoids.
5. Redemonstration of right perianal fistula. Rim enhancing
fluid collection measuring up to 5.0 cm posterior to the rectum
is seen within the region of previously described
intersphincteric abscess, but was not clearly seen on the
previous study. This collection is also associated with a left
perianal fistula. MRI of the pelvis is recommended to better
assess fistulous disease.
6. Intraluminal bladder air is presumably related to Foley
catheterization.
MR PELVIS W & W/O CONTRAST:
1. Trans sphincteric perianal fistula(s) at approximately the 6
o'clock position at the superior margin of the anal sphincter
with right and left branches exiting the right and left gluteal
folds. There is either one fistula with proximal branching or
two separate fistulas arising within one millimeter of each
other. The left fistula courses at least partially within the
left puborectalis musculature. An abscess along the dominant
left fistula tract measures up to 2.2 x 4.8 cm.
2. Extensive metastatic disease includes infiltrative bladder
lesions, osseous lesions, and lymphadenopathy.
Brief Hospital Course:
Mr. ___ is a ___ y/o M with metastatic prostate cancer
presenting with recurrent hematuria/obstruction and a perianal
fistula w/ abscess.
#PERIANAL FISTULAE (B/L):
#POSTERIOR RECTAL ABCESS:
On admission noted to have perianal abscess measuring 5.0 cm,
"within the region of previously described intersphincteric
abscess," and is associated with left perianal fistula. He also
had leukocytosis with neutrophilic predominance. There is also
evidence of proctocolitis on imaging. Her reports constipation
(frequent straining, only passes stool every 2 to 3 days). MRI
pelvis confirmed perianal fistula either with branching or
possibly two separate fistulae that are millimeters apart.
Colorectal surgery performed EUA, drainage of abscess and
placement ___ drain on ___. That evening post-op,
patient's admission blood cultures returned positive for GPCs ___
both aerobic and anaerobic bottle, therefore he was started on
empiric IV vancomycin. Resulted as coag negative staph on ___,
and after discussion with ID, decision that this was likely
contaminant, and discontinued vanco. Per surgery for abscess,
treated with 3 further days of Augmentin. Abscess culture
pending, gram stain w/ GPCs ___ clusters, GPCs ___ chains, and
GNRs. Patient will follow up with CRS after discharge for
consideration of removal ___ drain.
#HEMATURIA:
Likely from known local invasion of his prostatic malignancy
into the bladder. Had recurrence w/ clot. Foley placed at
___ on ___ for hematuria, got 3w irrigation. He was
advised to be admitted, however patient chose to leave ED
instead with Foley with close follow-up ___ ___ clinic. Upon
presentation to our ED, Foley draining mostly clear urine with
slight pink tinge. After discussion with patient's urologist, we
removed Foley and he voided well. Urology had requested CTU,
however patient had just had CT w/ contrast of abdomen and per
radiology not much more information could be gathered from CTU
protocol. Urine cytology sent, pending result at time of
discharge.
#Balanitis: Had recent treatment for MRSA balanitis. This had
improved. Appears to have recurred upon admission. No phimosis.
Bloody appearance of foreskin may be from hematuria. Patient
refused mupirocin. Of note, his urologist had been suggesting
that if this recurs, plan would be for circumcision. Scheduled
for outpatient urology follow up on discharge.
#ANEMIA: Normal H&H ___ ___, hemoglobin 11.3 today. Could
be from hematuria, though 3 units of blood loss is quite
significant. Will obtain iron studies and reticulocyte count.
Low concern for sepsis at this time based on bili. Patient
appears to be somewhat iron deficient, plus likely concomitant
anemia of inflammation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Denosumab (Xgeva) 120 mg SC EVERY 4 WEEKS
2. Leuprolide Acetate 22.5 mg IM EVERY 3 MONTHS
3. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
4. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
5. Clotrimazole Cream 1 Appl TP BID apply to penis
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 3 Days
2. Clotrimazole Cream 1 Appl TP BID apply to penis
3. Denosumab (Xgeva) 120 mg SC EVERY 4 WEEKS
4. Leuprolide Acetate 22.5 mg IM EVERY 3 MONTHS
5. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
Discharge Disposition:
Home
Discharge Diagnosis:
Perianal fistula
Abscess
Hematuria
Metastatic prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital for a perianal fistula with an
infection inside (abscess). You had a surgery to clean out the
infection, and a small plastic drain was placed so that the rest
of the infection can slowly drain out.
You also were recently found to have bleeding ___ your urine, for
which a catheter had been placed. During this hospital stay, the
catheter was removed. You will need to follow-up with your
urologist very closely after discharge for further evaluation.
It was a pleasure taking care of you!
Sincerely, your ___ Team
Followup Instructions:
___
|
10345778-DS-18 | 10,345,778 | 29,296,823 | DS | 18 | 2187-04-14 00:00:00 | 2187-04-15 11:09:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Bactrim DS
Attending: ___.
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with ___ mechanical AVR on Coumadin
one month s/p
TURP with ___ who presented to the ED with clot retention
overnight. The patient reports intermittent hematuria since his
procedure that has been gradually improving. He denies fever,
chills, N/V, or dysuria. He held his Coumadin without bridge for
5 days perioperatively and then restarted. He reports that he
had
been holding Coumadin over the last week due to hematuria but
restarted 2 days prior to presentation. On the day prior to
admission, he noted
increasing difficulty urinating with worsening blood and clot
passage. He got to the point where he was unable to urinate so
presented to the ED. INR 1 and HCT stable since last month. A 3
way Foley was placed and CBI started. Given his INR was
subtherapeutic a heparin gtt was started in the ED.
Past Medical History:
-IgA nephropathy
-Aortic insufficiency with bicuspid aortic valve s/p aortic
valve replacement (___ mechanical valve ___
-ascending aortic aneurysm (dilated ascending aorta (5cm)
-BPH s/p laser photovaporization of prostate, PVP ___
-HTN
-CAD s/p PTCA LAD ___
-hyperlipidemia
-hernia repair
Social History:
___
Family History:
Mother: CAD, deceased from ___; no CA
Father: CAD; no CA
Physical Exam:
gen: no acute distress
resp: conversing easily
abd: soft nontender
gu: foley was clear then removed and patient passed void trial
Brief Hospital Course:
Mr. ___ was admitted to the urology service from the ED and
kept on CBI with hand irrigation as needed to remove clot. His
hematocrit was stable through his admission. By the day of
discharge, his urine had cleared and he passed a void trial. He
was discharged home with instructions to call in or return to
the ED if he was unable to urinate or had further hematuria.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 10 mg PO 2X/WEEK (___)
2. Warfarin 7.5 mg PO 5X/WEEK (___)
3. dutasteride 0.5 mg oral QPM
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Rosuvastatin Calcium 20 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Chlorthalidone 25 mg PO DAILY
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Senna 17.2 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. dutasteride 0.5 mg oral QPM
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Rosuvastatin Calcium 20 mg PO QPM
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Warfarin 10 mg PO 2X/WEEK (___)
12. Warfarin 7.5 mg PO 5X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding and clot retention after TURP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-drink plenty of water
-minimize constipation
-no heavy lifting
These steps can help you recover after your procedure.
DO drink plenty of water to flush out the bladder.
DO avoid straining during a bowel movement. Eat
fiber-containing foods and avoid foods that can cause
constipation. Ask your doctor if you should take a laxative if
you do become constipated.
Don't take blood-thinning medications until your doctor says
it's OK.
Don't do any strenuous activity, such as heavy lifting, for
four to six weeks or until your doctor says it's OK.
Don't have sex. You'll likely be able to resume sexual
activity in about four to six weeks.
Don't drive until your doctor says it's OK. ___, you can
drive once your catheter is removed and you're no longer taking
prescription pain medications.
You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve. You may
have clear or yellow urine that periodically turns pink/red
throughout the healing process. Generally, the discoloration of
the urine is OK unless it transitions from ___,
___ Aid to a very dark, thick or like tomato juice
color
Resume your pre-admission/home medications EXCEPT as noted.
You should ALWAYS call to inform, review and discuss any
medication changes and your post-operative course with your
primary care team.
Unless otherwise advised, blood thinning medications like
ASPIRIN should be held until the urine has been clear/yellow for
at least three days. Your medication reconciliation will note
if you may resume aspirin or prescription blood thinners (like
Coumadin (warfarin), Xarelto, Lovenox, etc.)
If needed, you will be prescribed an antibiotic to continue
after discharge or save until your Foley catheter is removed
(called a trial of void or void trial).
You may be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and it is available
over-the-counter
AVOID STRAINING for bowel movements as this may stir up
bleeding. Avoid constipating foods for ___ weeks, and drink
plenty of fluids to keep hydrated
No vigorous physical activity or sports for 4 weeks or until
otherwise advised
Do not lift anything heavier than a phone book (10 pounds) or
participate in high intensity physical activity (which includes
intercourse) for a minimum of four weeks or until you are
cleared by your Urologist in follow-up
Acetaminophen (Tylenol) should be your first-line pain
medication. A narcotic pain medication may also be prescribed
for breakthrough or moderate pain.
The maximum daily Tylenol/Acetaminophen dose is 3 grams from
ALL sources.
Do not drive or drink alcohol while taking narcotics and do
not operate dangerous machinery.
Followup Instructions:
___
|
10346483-DS-10 | 10,346,483 | 22,185,772 | DS | 10 | 2164-04-10 00:00:00 | 2164-04-10 12:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
c1-2 fracture, T2 wedge fx, L rib fx ___ possibly chronic
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o male transferred from ___ for further
evaluation of C1 fracture. He was climbing a flight of stairs at
his daughter's house earlier tonight and his hand slipped off of
the doorknob and he lost his balance. He reports falling down 16
steps and striking his head. He denies loss of consciousness or
syncope prior to the fall. The patient was taken to ___
via ambulance and underwent a CT of the cervical spine which
showed the C1 fracture; he was later transferred to ___ for
further evaluation.
He denies neck or back pain. He denies headache, dizziness,
confusion, blurred vision, or diplopia. He denies saddle
anesthesia, urinary or rectal incontinence, or numbness, pain,
weakness or tingling of the upper and lower extremities
bilaterally.
Past Medical History:
HTN, basal cell ca, bilat cateract surgery, Chronic renal
failure, DM type 2, erectile dysfunction, ___ syndrome
with
chronic LFT elevation, HLD, HTN, Leg edema, hearing loss, gout,
left ear auricle squamous cell excision
Social History:
___
Family History:
NC.
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3mm bilaterally. EOMs intact throughout.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right ___ 0 0
Left ___ 0 0
No ankle clonus.
Negative ___ sign bilaterally.
Pertinent Results:
___ 05:40PM GLUCOSE-259* UREA N-31* CREAT-1.3* SODIUM-136
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-22 ANION GAP-13
___ 05:40PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-1.7
___ 05:40PM WBC-7.6 RBC-3.79* HGB-11.5* HCT-34.6* MCV-91
MCH-30.3 MCHC-33.2 RDW-14.0 RDWSD-47.0*
___ 05:40PM PLT COUNT-145*
___ 05:40PM ___ PTT-26.8 ___
___ 09:57PM GLUCOSE-150* LACTATE-1.2 NA+-137 K+-4.8
CL--102 TCO2-25
___ 09:47PM UREA N-33* CREAT-1.4*
___ 09:47PM estGFR-Using this
___ 09:47PM LIPASE-68*
___ 09:47PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:47PM WBC-10.1* RBC-3.95* HGB-12.0* HCT-36.6*
MCV-93 MCH-30.4 MCHC-32.8 RDW-13.6 RDWSD-46.5*
___ 09:47PM PLT COUNT-149*
___ 09:47PM ___ PTT-28.0 ___
___ 09:47PM ___: CXR:
No acute cardiopulmonary process.
___: MRI cervical spine:
Acute type 2 odontoid fracture through the base of the dense.
The tectorial membrane and apical odontoid ligaments appear
intact.
Bilateral C1 posterior arch fractures with mild associated
retrolisthesis of C1 on C2 which is better seen on CT cervical
spine done ___.
Wedge-type compression fracture of the superior endplate of the
T2 vertebral body with less than 25% vertebral body height loss.
No epidural hematoma or cord edema or contusion.
Degenerative changes of the cervical spine most marked at the C
___, C5-6 and C6-7 levels resulting in at least moderate severe
spinal canal narrowing at the C4-5 and C5-6 levels.
Multilevel severe neural foraminal narrowing as described above.
Brief Hospital Course:
___ M s/p fall, ___ steps, found to have c1-2 fracture, T2 wedge
fx, L rib fx ___ possibly chronic. Neurosurgery was consulted
and recommended a hard collar be placed at all times and follow
up in 1 month. Tertiary exam found no new injuries. ___ were
consulted. On HD2, Mr. ___ was ready for discharge. He was
placed back on all his home meds and was tolerating a regular
diet. He was discharged from the hospital in stable condition
with his c-collar in place and asked to follow up in ___ clinic
and spine clinic.
Medications on Admission:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. GlipiZIDE 15 mg PO QAM
4. Januvia (SITagliptin) 50 mg oral DAILY
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. GlipiZIDE 15 mg PO QAM
4. Januvia (SITagliptin) 50 mg oral DAILY
5. Lisinopril 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
c1-2 fracture, T2 wedge fx, L rib fx ___ possibly chronic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent, but c-collar in place
Discharge Instructions:
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Please wear the collar at all times
If you note increased pain neck, decreased strength in arms and
hands, numbness hands or decreased should strength please call
the ___ clinic at ___ or Dr. ___ office at
___
Followup Instructions:
___
|
10346996-DS-14 | 10,346,996 | 28,926,268 | DS | 14 | 2162-12-01 00:00:00 | 2162-12-02 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Cipro / Flagyl /
Iodinated Contrast Media - IV Dye / Novocain / ibuprofen / MRI
contrast
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with a history of hyperlipidemia, chronic
anemia, RCC status post left partial nephrectomy not on
chemo presents with abdominal pain. Patient was recently
admitted to this hospital for abdominal pain consistent with
pancreatitis secondary to cholelithiasis. She is status post
cholecystitis cystectomy on ___ and was discharged on
___ at which point she was feeling well up until
yesterday. At this time she was started having increasing
abdominal pain nonbloody nonbilious vomiting multiple
episodes of loose stools decreased p.o. intake fevers and
lethargy. When attempting to go to the bathroom today with
her daughter's help she collapsed in her arms no LOC no head
strike. They called an ambulance and brought her in for an
eval.
Past Medical History:
___ s/p partial nephrectomy
s/p bilateral oophorectomy
Hypertension
Hypercholesterolemia
anemia
osteoarthritis
osteopenia
glaucoma
Social History:
___
Family History:
h/o heart disease, cirrhosis, cancer
Physical Exam:
Physical Examination: ___
General: Alert and Well Developed;
mod distress HEENT: Normal ENT inspection.
Eyes: Lids Normal; . Oropharynx / Throat:
Normal Pharynx. Neck: No Lymphadenopathy, No Meningismus and
Supple Respiratory: No Resp Distress and Normal Breath
Sounds Cardio-Vascular: No murmur, No rub and RRR Abdomen:
No Organomegaly; distended, incision c,d,i, +rebound/no
peritonitis, +tymapnitic Back: No CVA tenderness, No Midline
Tenderness and Non-tender Extremity: No edema Neurological:
Alert, Oriented X3 and No Gross Weakness Skin: No rash, No
Petechiae, Warm and Dry Psychological: Mood/Affect Normal
and Normal Memory/Judgment
Physical examination upon discharge: ___:
vital signs: t=98 bp 137/72, HR=71, O2 SAT=96 % room air
GENERAL: NAD
CV: ns1, s2, no murmurs
LUNGS: diminished BS bases bil, no wheezes
ABDOMEN: hypoactive BS, mild distention, soft, non-tender, port
sites healed
EXT: no calf tenderness bil, no pedal edema bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 05:17AM BLOOD WBC-9.9 RBC-2.76* Hgb-7.5* Hct-24.4*
MCV-88 MCH-27.2 MCHC-30.7* RDW-15.8* RDWSD-49.3* Plt ___
___ 04:48AM BLOOD WBC-10.9* RBC-2.94* Hgb-8.0* Hct-26.3*
MCV-90 MCH-27.2 MCHC-30.4* RDW-15.6* RDWSD-49.9* Plt ___
___ 05:05AM BLOOD WBC-35.3* RBC-2.99* Hgb-8.4* Hct-26.5*
MCV-89 MCH-28.1 MCHC-31.7* RDW-15.2 RDWSD-48.4* Plt ___
___ 12:50AM BLOOD WBC-24.5* RBC-3.48* Hgb-9.7* Hct-30.0*
MCV-86 MCH-27.9 MCHC-32.3 RDW-14.7 RDWSD-45.5 Plt ___
___ 04:34AM BLOOD Plt ___
___ 04:34AM BLOOD Glucose-91 UreaN-7 Creat-1.1 Na-140 K-4.3
Cl-103 HCO3-23 AnGap-14
___ 05:17AM BLOOD Glucose-97 UreaN-8 Creat-1.1 Na-143 K-4.3
Cl-103 HCO3-22 AnGap-18
___ 12:50AM BLOOD Glucose-159* UreaN-11 Creat-1.1 Na-133*
K-6.5* Cl-92* HCO3-22 AnGap-19*
___ 04:34AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
___ 01:00AM BLOOD Lactate-1.3 K-5.4*
___: CXR:
1. Low lung volumes with bibasilar atelectasis.
2. Small left pleural effusion.
3. No evidence of free intra-peritoneal air.
___: CT abd/pelvis:
1. Acute pancreatitis with interval slight improvement of
___
stranding since ___. No ___ fluid
collection.
2. Dilated and fluid-filled small bowel loops with transition
point visualized in the right lower quadrant suggests small
bowel obstruction. No ascites or bowel wall thickening to
suggest ischemia at this time.
3. Extensive sigmoid colonic diverticulosis with new focal
thickening of the sigmoid colon and faint ___ fat
stranding suggests early acute uncomplicated diverticulitis.
4. Additionally there is slight mural thickening and
thumb-printing of the
transverse colon which is nonspecific and can be seen in C diff
colitis.
5. No free air or free fluid in the abdomen.
6. Trace bilateral pleural effusions with minimal compressive
atelectasis of the dependent lung bases.
___: CT abd/pelvis:
1. Interval resolution of bowel obstruction.
2. No significant change in acute pancreatitis. No fluid
collection.
3. Bilateral lower lobe peripheral airspace disease is slightly
worse compared to yesterday and may represent atelectasis or
pneumonia in the appropriate clinical scenario.
4. Additional stable findings, including a stable right renal
mass, as
above.
___: KUB:
Following removal of the nasogastric tube, there has been
interval increase in small and large bowel dilatation suggestive
of recurrence postoperative ileus, similar to ___
___ 6:57 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
Reported to and read back by ___ ON
___ AT
23:27.
Brief Hospital Course:
___ year old female, s/p laparoscopic cholecystectomy on ___,
returned to the hospital on ___ with abdominal pain, nausea,
vomiting, and abdominal distention. Upon admission, the patient
was made NPO, given intravenous fluids, and underwent imaging
which showed dilated and fluid-filled small bowel loops
suggestive of small bowel obstruction. The patient had a
___ tube placed for bowel rest and was placed on serial
abdominal examinations. On HD #2, she was noted to have an
elevated white blood cell count to 35, but she remained
afebrile. The patient had a stool specimen sent for c.diff
which returned as positive and she was started on a 2 week
course of oral vancomycin. Over the next ___ hours, the white
blood cell count drifted down. The patient's ___ tube
was removed and the patient was started on a regular diet. She
continued to have mild abdominal distention and underwent an
x-ray of the abdomen which showed bowel dilatation suggestive of
an ileus. The patient continued on a diet as tolerated. Bowel
function returned and the patient's diet was advanced.
The patient was discharged home on HD #10. Her vital signs were
stable and she was afebrile. She was tolerating a regular diet
and voiding without difficulty. She was ambulatory and did not
require analgesia. A follow-up appointment was made in the
Acute care clinic. Discharge instructions were reviewed and
questions answered. A prescription was provided for the patient
to complete a 14 day course of vancomycin.
Medications on Admission:
Medications - Prescription
BRIMONIDINE - brimonidine 0.15 % eye drops. 1 drop ___ twice a
day
- (Prescribed by Other Provider)
DORZOLAMIDE - dorzolamide 2 % eye drops. 1 drop ___ twice a day -
(Prescribed by Other Provider)
ENALAPRIL MALEATE - enalapril maleate 20 mg tablet. Take one
Tablet(s) by mouth once a day
EPINEPHRINE [EPIPEN] - EpiPen 0.3 mg/0.3 mL injection,
auto-injector. - (Prescribed by Other Provider: ___
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. TAKE 1
TABLET BY MOUTH EVERY DAY
HYDROCORTISONE - hydrocortisone 2.5 % topical cream with
perineal
applicator. Apply twice a day as needed for hemorrhoids
HYDROCORTISONE [ANUSOL-HC] - Anusol-HC 2.5 % rectal cream with
applicator. Apply rectally twice a day as needed for hemorrhoids
VERAPAMIL - verapamil ER (SR) 240 mg tablet,extended release. 1
tablet(s) by mouth once a day
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 - calcium carbonate 500 mg (1,250
mg)-vitamin D3 400 unit tablet. Take one Tablet(s) by mouth
twice
a day - (OTC)
DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s)
by
mouth twice a day - (Prescribed by Other Provider: ___ during
___ hospitalization)
MULTIVITAMIN - multivitamin capsule. Take one capsule(s) by
mouth
daily - (OTC)
OMEPRAZOLE - omeprazole 20 mg tablet,delayed release. 2
tablet(s)
by mouth once a day - (Not Taking as Prescribed)
--------------- --------------- --------------- ---------------
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 7 Days
7 days left, last dose ___
RX *vancomycin [Firvanq] 50 mg/mL 125 mg by mouth every six (6)
hours Disp ___ Milliliter Refills:*0
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
4. Enalapril Maleate 20 mg PO DAILY
5. Labetalol 200 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Verapamil SR 240 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
clostridium. difficile colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You underwent removal of your gallbladder and you were
discharged home. You returned to the hospital with abdominal
pain, nausea, and vomiting. You underwent imaging and there was
concern for a small bowel obstruction. You were placed on bowel
rest and a ___ tube was placed for bowel decompression.
During this time, you also had an elevated white blood cell
count. A stool specimen was sent which returned as an
infection, clostridium difficile. You were started on a course
of vancomycin for C. Diff colitis and your white blood cell
count decreased. The ___ tube was removed and you
resumed a regular diet. Your vital signs have been stable and
you are preparing for discharge with the following instructions:
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.
*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. Complete course of vancomycin
as directed
Followup Instructions:
___
|
10347040-DS-3 | 10,347,040 | 22,525,403 | DS | 3 | 2145-09-15 00:00:00 | 2145-09-16 07:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M w/ history of IVDU now on methadone for 3 weeks
presenting for jaundice and abdominal pain. He has had RUQ and
right flank pain for the past 2 weeks that has been improving.
Pain was not related to food intake and consistently present.
Pain has resolved since yesterday.
Patient became reportedly jaundiced about 3 weeks ago, prior to
the onset of abdominal pain with significant improvement now.
Patient was evaluated at ___ for abdominal pain 10 days ago
but left AMA. He had an abdominal ultrasound 1 week ago at OSH
and told to report to the ED yesterday when his results were
reviewed.
Pertinent ED course (including exam, labs, imaging, consults,
treatment):
Hepatology was consulted in ED:
OSH labs consistent with HCV with immunity to HBV/HAV. HIV neg.
Would also consider possible DILI
- MRCP to evaluate ducts
- Blood cultures x3
- Quantitative immunoglobulins, ceruplasmin, HCV viral load and
genotype, HSV, VZV, EBV serologies, mono spot, ___,
Anti-mitochondrial ab, ant-smooth muscle ab, and RPR
- Evaluate for new medications for DILI
ED vitals:
99.5 HR 98, BP 135/78 RR 18 O2 100% RA
ED meds:
Gabapentin 800mg x3
Methadone 50mg
Clonazepam 2mg
Nicotine patch 21mg
Amphetamine-dextroamphetamine 20mg
Upon arrival to the floor, the patient denies abdominal pain,
n/v, diarrhea/constipation, fever or chills, or weight loss.
He has been using IV heroin for about a month prior to reporting
to detox center last month and starting detox. He's been on
methadone for 3 weeks since then. Denies sharing needles. Notes
that he hasn't had nausea/vomiting since detox. No recent travel
outside the country. No recent illnesses.
He had been using anabolic steroids including T400 and E2
steroids for 6 months post incarceration from ___ until
___. He's also been intermittently using Milk thistle and
aromacin and OTC vitamins such as Omega 3 &6.
On review of OSH atrius records, patient had Positive Hep C ab,
Neg HBcAb, HBsAg and positive HBsab and Hep A antibody. HIV
negative. Labs from ___ shows AST 1104 and ALT 1687 with Tbili
17.7
REVIEW OF SYSTEMS:
10 point review of system negative except per HPI.
Past Medical History:
IVDU on methadone
Seizures ___ to trauma
Surgical history:
appendectomy
hernia repair
facial reconstructive surgery post trauma
Social History:
___
Family History:
Grandfather and uncle with prostate cancer. No liver diseases
Physical Exam:
Admission Exam:
VITALS:97.6 PO 130 / 83 82 18 98 Ra
GENERAL: lying in bed comfortably AOx3
HEENT: icteric conjunctiva, PERRLA, EOMI
CV: RRR, no r/m/g
RESP: CTAB
GI: +BS, soft, NTND, no hepatosplenomegaly, negative ___
test
MSK: warm, well perfused, no ___ edema
SKIN: Jaundiced, multiple tattoos, no rash
NEURO: AOx3, moving all extremities equally, no asterixis
Discharge Exam:
Less than 24 hours after admission exam. No significant changes.
Pertinent Results:
Admission Labs:
___ 01:07PM GLUCOSE-107* UREA N-10 CREAT-0.9 SODIUM-139
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-28 ANION GAP-12
___ 01:07PM ALT(SGPT)-316* AST(SGOT)-202* ALK PHOS-121
TOT BILI-5.1*
___ 01:07PM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-3.8
MAGNESIUM-2.0
___ 11:19AM WBC-8.7 RBC-5.18 HGB-14.8 HCT-42.6 MCV-82
MCH-28.6 MCHC-34.7 RDW-19.8* RDWSD-54.1*
___ 11:19AM NEUTS-56.0 ___ MONOS-8.5 EOS-2.5
BASOS-0.5 NUC RBCS-0.2* IM ___ AbsNeut-4.85 AbsLymp-2.77
AbsMono-0.74 AbsEos-0.22 AbsBaso-0.04
___ 11:19AM PLT COUNT-165
___ 01:19AM AMA-NEGATIVE Smooth-NEGATIVE
___ 01:19AM ___
___ 01:19AM IgG-1485 IgA-338 IgM-140
___ 01:19AM HCV VL-4.9*
___ 08:42PM URINE HOURS-RANDOM
___ 08:42PM URINE UHOLD-HOLD
___ 08:42PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM* UROBILNGN-8* PH-6.5
LEUK-NEG
___ 08:42PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:42PM URINE MUCOUS-RARE*
___ 06:54PM LACTATE-1.5
___ 06:48PM GLUCOSE-60* UREA N-11 CREAT-1.0 SODIUM-143
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-31 ANION GAP-12
___ 06:48PM estGFR-Using this
___ 06:48PM ALT(SGPT)-356* AST(SGOT)-204* ALK PHOS-131*
TOT BILI-5.3* DIR BILI-3.0* INDIR BIL-2.3
___ 06:48PM LIPASE-17
___ 06:48PM ALBUMIN-4.2
___ 06:48PM WBC-9.2 RBC-4.78 HGB-13.5* HCT-40.9 MCV-86
MCH-28.2 MCHC-33.0 RDW-15.5 RDWSD-48.1*
___ 06:48PM NEUTS-55.9 ___ MONOS-7.4 EOS-2.1
BASOS-0.5 IM ___ AbsNeut-5.15 AbsLymp-3.10 AbsMono-0.68
AbsEos-0.19 AbsBaso-0.05
___ 06:48PM PLT COUNT-230
___ 06:48PM ___ PTT-31.9 ___
Discharge Labs:
___ 06:50AM BLOOD WBC-6.1 RBC-4.72 Hgb-13.4* Hct-40.9
MCV-87 MCH-28.4 MCHC-32.8 RDW-15.8* RDWSD-49.7* Plt ___
___ 11:19AM BLOOD Neuts-56.0 ___ Monos-8.5 Eos-2.5
Baso-0.5 NRBC-0.2* Im ___ AbsNeut-4.85 AbsLymp-2.77
AbsMono-0.74 AbsEos-0.22 AbsBaso-0.04
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___ PTT-31.3 ___
___ 06:50AM BLOOD Glucose-77 UreaN-11 Creat-1.0 Na-141
K-4.5 Cl-100 HCO3-29 AnGap-12
___ 06:50AM BLOOD ALT-298* AST-243* AlkPhos-117
TotBili-4.9*
___ 06:50AM BLOOD Calcium-9.5 Phos-3.8 Mg-1.8
___ 01:19AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 01:19AM BLOOD ___
___ 01:19AM BLOOD IgG-1485 IgA-338 IgM-140
___ 01:19AM BLOOD HCV VL-4.9*
___ 06:54PM BLOOD Lactate-1.5
___ 06:50AM BLOOD VARICELLA ZOSTER VIRUS DNA, PCR-PND
___ 06:50AM BLOOD HERPES SIMPLEX VIRUS, TYPE 1 & 2 DNA,
QUANTITATIVE REAL TIME PCR-PND
Microbiology:
BCx: pending x2
EBV '
___ VIRUS VCA-IgG AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
RPR: Negative
MONOSPOT: negative
Imaging:
MRCP ___:
Prominence of the CBD measuring up to 8 mm with mild
intrahepatic biliary
prominence but without definite filling defect or mass. Findings
are
nonspecific but could be seen in the context of ampullary
stenosis. Otherwise
unremarkable examination.
Abdominal USN: 1. Mildly dilated common bile duct to 7 mm with
no choledocholithiasis
detected, however the distal common bile duct is not imaged on
the current
ultrasound exam. MRCP is recommended to further assess for a
distal common
bile duct obstructing lesion.
2. Patent portal vein and normal hepatic parenchyma.
Brief Hospital Course:
___ with history of IVDU now on methadone for 3 weeks, seizures
___ trauma presenting with Jaundice and transaminitis.
ACUTE/ACTIVE PROBLEMS:
# Transaminitis
# Jaundice
# Direct hyperbilirubinemia: The patient was recently seen at
outside hospital for evaluation of transminitis with AST/ALT to
100's with Tbili elevated around 10. On admission to ___ his
bili and AST/ALT were downtrending and the patient's pain was
resolving. Found to have elevated HCV VL to 5.6 on log scale.
Negative ___, AMA, anti-smooth muscle, and normal immunoglobulin
levels make autoimmune hepatitis unlikely. Patient also admitted
to using anabolic steroids which could have been a precipitating
factor of a drug induced liver toxicity. An MRCP was done given
mildly abnormal bile duct on RUQUS, and the MRCP showed upper
level of normal (8mm) ductal dilation with ?concern for
ampullary stenosis, but only would be concerned if he had
persistent pain. We discharged the patient with plan for liver
clinic follow up as above for Hep C treatment discussion and
further workup of transminitis. He felt well on the day of
discharge. There were EBV, and HSV serologies pending on
discharge and VZV viral load.
#History of IVDU on methadone- Underwent detox and started on
methadone 3 weeks ago and is followed at ___ clinic at
___.
Received methadone 50mg in ED. Continue methadone 50mg daily
CHRONIC/STABLE PROBLEMS:
# Seizures- Seizure onset after trauma to head but has not had a
seizure for the past year. Continued Gabapentin 800mg QID
#Anxiety- Continued clonazepam 1mg BID
Transitional Issues:
==========================
[] F/u with hepatology, Dr. ___ treatment of hepatitis C
[] ___ clinic (last dose received on ___ of 50mg)
[] F/u with EBV, HSV, and VZV labs
[] Labs in 1 week to ensure continued improvement of
transaminitis
[] F/u final MRCP read
#Code: full (presumed)
#Contact: ___ (Mother) H: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO QID:PRN pain
2. Cetirizine 10 mg PO DAILY
3. ClonazePAM 1 mg PO BID
4. Amphetamine-Dextroamphetamine 20 mg PO BID
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
6. Methadone 50 mg PO DAILY
Discharge Medications:
1. Gabapentin 800 mg PO QID pain
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
3. Amphetamine-Dextroamphetamine 20 mg PO BID
4. Cetirizine 10 mg PO DAILY
5. ClonazePAM 1 mg PO BID
6. Methadone 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute hepatocellular injury
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- you had abnormal liver function tests and had recent abdominal
pain and yellowing of your skin
WHAT HAPPENED IN THE HOSPITAL?
- You had MRI imaging of your liver which did not show any major
abnormalities
- You had extensive lab workup for possible causes of liver
injury that were negative with the exception of hepatitis C
- You were seen by liver doctors for ___ and ___ need to
follow up with them for treatment of hepatitis C
- You were given your methadone doses on ___
WHAT SHOULD YOU DO AT HOME?
- You should avoid taking any medications that can injure your
liver such as steroids and other non-prescribed drugs
- You should follow up at ___ clinic to continue receiving
methadone. It is important that you remain sober and clean as
treatment of hepatitis C is not possible if you are using drugs
- Follow up with Dr. ___ at the liver ___ for follow up of
current liver injury and for treatment of Hep C
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10347072-DS-7 | 10,347,072 | 26,893,524 | DS | 7 | 2129-09-28 00:00:00 | 2129-09-30 11:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Amoxicillin / Sulfa (Sulfonamide Antibiotics) /
acetaminophen
Attending: ___.
Chief Complaint:
right iliac fracture extending to the acetabulum
Major Surgical or Invasive Procedure:
ORIF R acetabulum/pelvis
History of Present Illness:
This is a ___ woman who presents with several hours of
right-sided hip pain status post mechanical fall. The patient
speaks some ___ but relies on her family translate. She
reports that she was walking when she tripped over a small
discrepancy on the ground catching her foot, and falling
directly
on her left hip. She reports no other injury including no head
strike, or loss consciousness. She denies any prodromal symptoms
and denies chest pain, shortness of breath, or palpitations. She
reports having had a repair of the right proximal femur
approximately ___ years ago in ___. The patient was seen in
outside hospital ED prior to presentation, and diagnosed with a
UTI and pelvic fracture. The patient received IV ceftriaxone for
her UTI at the outside hospital.
Past Medical History:
hypothyroidism
DDD
OA
R THA
Social History:
___
Family History:
non contributory
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with right iliac fracture extending to the acetabulum.
Patient was taken to the operating room and underwent ORIF R
acetabulum. Patient tolerated the procedure without difficulty
and was transferred to the PACU, then the floor in stable
condition. Please see operative report for full details.
Musculoskeletal: prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status was
transitioned to TDWB RLE. Throughout the hospitalization,
patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by
oxycodone with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient's HCT was 25.9 on POD#1 morning and was
followed by a POD#1 afternoon HCT of 26.6. On the evening of
POD #1 (___), patient spiked a fever to 102. She had blood
cultures drawn which were no growth to date at the time of
discharge. Her POD#2 HCT was 23.0, and she received 2 units of
PRBCs. She responded appropriately and was discharged with a
HCT of 30.3.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. A CXR was obtained on
POD#1 due to fevers and concern for PNA, it was unremarkable.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored. At the time of admission, the
patient had already been treated with ceftriaxone at OSH for a
UTI. ___ urine culture and sensitivity eventually grew out
coag-negative staph aureus (resistant to levofloxacin, sensitive
to macrobid). She received 7 days of total antibiotics. A UA
drawn before discharge was unremarkable, and therefore the
patient was not sent out on any antibiotics.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection. On POD#1 she had several fevers, the highest to
102.1. Pt initially was started on Ciprofloxacin for UTI. Urine
cultures grew out coag-negative staph. A UA performed before
discharge was unremarkable.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #3, the patient was
doing well, afebrile x 48 hours with stable vital signs,
tolerating a regular diet, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
Levofloxacin
Ibuprofen
Percocet
Pyridium
Levothyroxine
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/SOB
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Vitamin D 800 UNIT PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
7. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 7
Days
8. Multivitamins 1 TAB PO DAILY
9. Levothyroxine Sodium 25 mcg PO DAILY
10. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
11. Senna 1 TAB PO BID:PRN constipation
12. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R acetabulum fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
******SIGNS OF INFECTION********
- Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
********Wound Care********
- You can get the wound wet/take a shower starting from 3 days
post-op. 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.
******WEIGHT-BEARING*******
Touchdown weight bearing, right lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
- Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
Take Lovenox for DVT prophylaxis for 2 weeks post-operatively
Followup Instructions:
___
|
10347400-DS-22 | 10,347,400 | 22,934,865 | DS | 22 | 2162-12-13 00:00:00 | 2162-12-25 18:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine / Levofloxacin
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ woman with hypertension, aortic stenosis, diastolic
heart failure, chronic overweight, COPD on 2L home O2, pulmonary
hypertension, sinus bradycardia, paroxysmal atrial flutter with
2:1 block who presents complaining of chest tightness and
pressure for approximately ___ days associated with dyspnea. She
reports the chest pain is constant and pleuritic in nature. Has
been using her normal oxygen at home. Denies any fevers, chills,
cough. No abdominal pain. She does report left lower leg
cramping and edema.
Patient was medicated by EMS with 4 baby asa and nitro sl.
In the ED, initial vs were: 98.3 82 148/72 20 96% 3L Nasal
Cannula.
Labs were remarkable for Ddimer elevated at 604, TropT 0.01, Cr
1.3 (at lower end of her recent baseline), normal WBC at 8.1, UA
with 17 WBC, mod leuk est and few bacteria. Patient was given
nebulizer tx in ER. EKG showed sinus rhythm with frequent PAC's,
and slight ST depression in lead 1 AND 2, otherwise no change
from previous.
On the floor, vs were: T98.1 P82 BP155/68 R22 O2 sat96%2.5LNC.
She was still complaining of the chest tightness and dyspnea.
Exam was remarkable for slight bibasilar crackles, a ___
systolic murmur heard best at the right upper sternal border,
and an irregular heart rhythm.
Review of sytems:
(+) Per HPI, also endorses chronic alternating diarrhea and
constipation
(-) Denies fever, chills, night sweats, recent weight loss.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, Denies nausea, vomiting, or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Ten point
review of systems is otherwise negative.
PAST MEDICAL & SURGICAL HISTORY:
-sinus bradycardia
-paroxysmal atrial flutter with 2:1 block
-CKD
-anemia
-osteoarthritis
-chronic overweight
- pulm HTN
- COPD on 2L O2 at home
- HCV
- asthma
- HTN
- hemolytic anemia
- hemorrhoids diverticulosis
- diastolic CHF
- mild AS
- s/p appy
- s/p TAH - ___
- s/p open CCY
- s/p splenectomy (for hemolytic anemia)
ALLERGIES:
Iodine
Penicillins
Levofloxacin
Medications:
The Preadmission Medication list may be inaccurate and requires
futher investigation
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
2. Ipratropium Bromide MDI 2 PUFF IH QID
3. Amlodipine 10 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. HydrALAzine 10 mg PO TID
6. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO TID:PRN pain
7. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation QID
8. Omeprazole 40 mg PO BID
9. Acetaminophen 325 mg PO Q6H:PRN pain
Do not take if also taking hydrocodone/acetaminophen.
10. Docusate Sodium 100 mg PO TID
11. Multivitamins 1 TAB PO DAILY
SOCIAL HISTORY: ___
FAMILY HISTORY:
Hx of cancers on both sides of family; dad with lung, cousin
with
breast, aunt with kidney, and sisters with lung, no heart
disease in the family
PHYSICAL EXAM:
VS - T98.1 P82 BP155/68 R22 O2 sat96%2.5LNC
on repeat-> left arm 144/43, right arm 140/60
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous
membranes, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - slight bibasilar rales in the lower lung fields
bilaterally, no r/wh, good air movement, resp unlabored, no
accessory muscle use
HEART - irregular rhythm, ___ systolic murmur heard best at the
right upper sternal border
ABDOMEN - NABS, soft/ND, mild TTP in the LLQ, no masses or HSM,
no rebound, positive voluntary guarding in the left lower
abdomen
EXTREMITIES - WWP, 1+ pitting edema in the lower extremities
bilaterally to the knees
SKIN - no rashes or lesions
LYMPH - no cervical, LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
LABS: Please see attached
STUDIES:
Final READ FOR ___ CHEST AP.
IMPRESSION: No acute intrathoracic process.
Spirometry:
Moderately severe obstructive ventilatory defect. The reduced
FVC may be due to gas trapping but a coexisting restrictive
ventilatory defect cannot be excluded. TLC was normal when
measured on ___ however the FVC has decreased by 0.57 L
(-29%) since that time. Suggest repeat lung volume measurements
to assess interval change if clinically indicated. Compared to
the prior study of ___ there has been no significant
change in FVC and FEV1.
ASSESSMENT & PLAN:
Patient is an ___ woman with PMH of hypertension, aortic
stenosis, diastolic heart failure, chronic overweight, COPD on
2L home O2, pulmonary hypertension, and paroxysmal atrial
flutter who presents with ___ days of pleuritic chest pain and
pressure in association with dyspnea, in setting of mildly
elevated D-dimer concerning for possible PE. She is also being
ruled out for coronary ischemia
#Chest tightness: Differential includes PE, ACS, pericardial
process, pneumonia, MSK pain. CXR was reassuring and in absence
of fever, cough, or elevated WBC count, pneumonia is unlikely.
There was no mediastinal widening on CXR aside from previous
enlarged heart, and no pulse deficit so aortic dissection is
unlikely. Given mild elevation in D-dimer and dyspnea, PE is
high possibility. VSS and no signs of hemodynamic compromise
currently. Troponin was not elevated and EKG showed freqeuent
PAC's with mild ST depressions in leads 1 and 2. Patient also
received aspirin 325mg from EMS. With normal troponin MI is
unlikely but will need to rule out acute ischemia.
-repeat troponin to rule out MI
-continue ASA 325mg daily for now
-___ u/s to r/o DVT, anticipate poor yield for V/Q scan
seconday to COPD
-V/Q scan to rule out PE
-heparin gtt for now
#Dyspnea: Patient's dyspnea may be multifactorial. She has known
COPD, and exacerbation is possible, although exam does not
demonstrate significant wheeze. PE is a concerning etiology and
will need to rule out with V/Q scan. CHF exacerbation may be a
component given clinical signs of volume overload, although CXR
findings are reassuring.
-heparin gtt for now
-await results of V/Q scan
-continue prn nebs, home COPD meds, defer treatment with
systemic steroids for now
#COPD/asthma: On home O2 2LNC. Patient reports no increased
cough, increased sputum production, or change in sputum quality.
Her dyspnea is unlikely a COPD exacerbation so will avoid abx
and steroids for now
-continue home meds
-prn nebs
#Chronic Diastolic CHF: Patient has diastolic dysfunction and
resultant CHF chronically. She has slight signs of volume
overload and the symptoms of dyspnea with exertion could
represent slight decompensation
-extra lasix 40mg PO x1, goal diuresis 1L overnight
-continue home lasix
#HTN: Stable
-continue home amlodipine, hydralazine
#Anemia: Hgb above recent baseline currently
# FEN: No IVF, replete electrolytes, low-salt diet
# PPX: On heparin gtt, senna/colace, pain meds
# ACCESS: peripherals
# CODE: FULL for now
# CONTACT:
# DISPO:___, pending above
___ MD ___
___
SIRS RESIDENT ACCEPT NOTE
PCP: ___
CC: CHEST tightness, DYSPNEA
agree w/ overnight admission note w/ additions
HISTORY OF PRESENT ILLNESS:
___ woman with hypertension, aortic stenosis, diastolic
heart failure, chronic overweight, COPD on 2L home O2, pulmonary
hypertension, sinus bradycardia, paroxysmal atrial flutter with
2:1 block who presents complaining of chest tightness and
pressure for approximately ___ days associated with dyspnea. She
reports the chest pain is constant and pleuritic in nature. Has
been using her normal oxygen at home. Denies any fevers, chills,
cough. No abdominal pain. She does report left lower leg
cramping and edema.
Patient was medicated by EMS with 4 baby asa and nitro sl.
In the ED, initial vs were: 98.3 82 148/72 20 96% 3L Nasal
Cannula.
Labs were remarkable for Ddimer elevated at 604, TropT 0.01, Cr
1.3 (at lower end of her recent baseline), normal WBC at 8.1, UA
with 17 WBC, mod leuk est and few bacteria. Patient was given
nebulizer tx in ER. EKG showed sinus rhythm with frequent PAC's,
and slight ST depression in lead 1 AND 2, otherwise no change
from previous.
On the floor, vs were: T98.1 P82 BP155/68 R22 O2 sat96%2.5LNC.
She was still complaining of the chest tightness and dyspnea.
Exam was remarkable for slight bibasilar crackles, a ___
systolic murmur heard best at the right upper sternal border,
and an irregular heart rhythm.
Review of sytems:
(+) Per HPI, also endorses chronic alternating diarrhea and
constipation
(-) Denies fever, chills, night sweats, recent weight loss.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, Denies nausea, vomiting, or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Ten point
review of systems is otherwise negative.
Past Medical History:
- pulm HTN
- COPD
- HCV
- asthma
- HTN
- hemolytic anemia
- hemorrhoids diverticulosis
- CHF
- s/p appy
- s/p TAH - ___
- s/p open CCY
- s/p splenectomy (for hemolytic anemia)
Social History:
___
Family History:
Hx of cancers on both sides of family; dad with lung, aunt with
breast, and sisters with lung
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T98.1 P82 BP155/68 R22 O2 sat96%2.5LNC
on repeat-> left arm 144/43, right arm 140/60
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous
membranes, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - slight bibasilar rales in the lower lung fields
bilaterally, no r/wh, good air movement, resp unlabored, no
accessory muscle use
HEART - irregular rhythm, ___ systolic murmur heard best at the
right upper sternal border
ABDOMEN - NABS, soft/ND, mild TTP in the LLQ, no masses or HSM,
no rebound, positive voluntary guarding in the left lower
abdomen
EXTREMITIES - WWP, 1+ pitting edema in the lower extremities
bilaterally to the knees
DISCHARGE PHYSICAL EXAM:
GENERAL - well-appearing woman in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucous
membranes, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - lungs CTA bilaterally, good air movement, resp
unlabored, no accessory muscle use
HEART - irregular rhythm, ___ systolic murmur heard best at the
right upper sternal border
ABDOMEN - NABS, soft/ND, mild TTP in the LLQ, no masses or HSM,
no rebound, positive voluntary guarding in the left lower
abdomen
EXTREMITIES - WWP,trace edema peripherally
Pertinent Results:
admission labs: ___ 07:30PM URINE COLOR-Straw APPEAR-Clear
SP ___
___ 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 07:30PM URINE RBC-2 WBC-17* BACTERIA-FEW YEAST-NONE
EPI-1
___ 07:30PM URINE MUCOUS-RARE
___ 03:59PM GLUCOSE-169* UREA N-50* CREAT-1.3* SODIUM-141
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
___ 03:59PM CK(CPK)-103
___ 03:59PM cTropnT-0.01
___ 03:59PM CK-MB-3 proBNP-1690*
___ 03:59PM D-DIMER-604*
___ 03:59PM WBC-8.1 RBC-3.71* HGB-12.5 HCT-38.6 MCV-104*
MCH-33.7* MCHC-32.4 RDW-14.9
___ 03:59PM NEUTS-71* BANDS-0 ___ MONOS-10 EOS-0
BASOS-0 ___ MYELOS-0
___ 03:59PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-OCCASIONAL POLYCHROM-NORMAL
OVALOCYT-OCCASIONAL TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL
___ 03:59PM PLT SMR-NORMAL PLT COUNT-169
Discharge labs:
___ 10:21AM BLOOD WBC-6.6 RBC-3.99* Hgb-13.3 Hct-41.7
MCV-104* MCH-33.3* MCHC-31.9 RDW-14.5 Plt ___
___ 07:20AM BLOOD ___ PTT-37.6* ___
___ 10:21AM BLOOD
___ 07:20AM BLOOD Glucose-95 UreaN-68* Creat-1.6* Na-140
K-5.3* Cl-101 HCO3-30 AnGap-14
___ 10:21AM BLOOD CK(CPK)-62
___ 10:21AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:20AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.3
Echo ___
Conclusions :
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild aortic stenosis. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Moderate pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
LUNG SCAN ___
INTERPRETATION:
Ventilation images obtained with Tc-99m aerosol in 8 views
demonstrate minimal
patchy defects not significantly changed from next most recent
lung scan of
___.
Perfusion images in the same 8 views show no segmental or
subsegmental defect. A
small rounded focus of decreased intensity likes represents
attenuation due to
overlying cardiac lead or similar external device.
Chest x-ray demonstrates mild cardiomegaly, but no acute
process.
IMPRESSION: No evidence of interval pulmonary embolism since
___.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Patient is an ___ woman with PMH of hypertension, aortic
stenosis, diastolic heart failure, chronic overweight, COPD on
2L home O2, pulmonary hypertension, and paroxysmal atrial
flutter who presented with ___ days of pleuritic chest pain and
pressure and dyspnea. No pneumonia on CXR and normal cardiac
exzymes. Echo did not show new structural pathology, with EF
55%. She had a VQ scan that was not suggestive of pulmonary
embolism. Her sypmtoms improved with diuresis and were felt to
be secondary to a flare of DCHF. She was discharge on home lasix
40mg daily and a 2L fluid restriction.
# Bradycardia: patient developed asymptomatic bradycardia during
her last two hospital days, as low as 35 beats per minute. She
was evaluated by cardiology who determined that this was sinus
bradycardia, likely secondary to progression of her diastolic
disease, with no intervention needed immediately, although she
should be evaluated for a pacemaker as an outpatient. She has
follow up scheduled with Dr ___ in cardiology.
.
#Creatinine bumped to 1.8 in setting of diuresis. Improved on
discharge at 1.6.
#COPD/asthma: On home O2 2LNC. Patient reports no increased
cough, increased sputum production, or change in sputum quality.
Continued home meds and discharged on home 2L NC.
#HTN: Stable, continued home amlodipine, hydralazine
#Anemia: Hgb above recent baseline currently
#Paroxysmal a. flutter w 2:1 block: continued to monitor, not
on anti-coagulation as outpatient, continued aspirin in house.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
2. Ipratropium Bromide MDI 2 PUFF IH QID
3. Amlodipine 10 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. HydrALAzine 10 mg PO TID
6. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO TID:PRN pain
7. ipratropium-albuterol *NF* 0.5 mg-3 mg(2.5 mg base)/3 mL
Inhalation QID
8. Omeprazole 40 mg PO BID
9. Acetaminophen 325 mg PO Q6H:PRN pain
Do not take if also taking hydrocodone/acetaminophen.
10. Docusate Sodium 100 mg PO TID
11. Multivitamins 1 TAB PO DAILY
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. HydrALAzine 10 mg PO TID
RX *hydralazine 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO TID:PRN pain
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
8. Ipratropium Bromide MDI 2 PUFF IH QID
9. Furosemide 40 mg PO DAILY
10. Docusate Sodium 100 mg PO TID
11. Nystatin Ointment 1 Appl TP QID
RX *nystatin 100,000 unit/gram apply to affected areas under
breasts twice a day Disp #*1 Tube Refills:*0
12. Supplemental Oxygen
2Litres Nasal Canula 24 Hours a day
Discharge Disposition:
Home
Discharge Diagnosis:
congestive heart disease exacerbation
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. ___,
You were admitted to the hospital for chest pressure and
difficulty breathing. Your did not have any blood clots in your
legs or lungs. You did not have any evidence of infection. You
did not have any evidence of a heart attack. Your breathing and
chest pressure improved after we gave you medications to help
you eliminate excess fluid from your body. You had a rise in
your kidney function test, which was likely due to the
medications used to treat your heart failure. Your kidney
function improved. Your heart rate was low temporarily but
improved. You were seen by cardiology for a low heart rate. They
thought that this was due to decreased conductivity in your
heart. They suggested that you have an evaluation in the next
two weeks for a pacemaker. Please discuss this with Dr ___
___ you see him on ___.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Followup Instructions:
___
|
10347400-DS-26 | 10,347,400 | 20,697,422 | DS | 26 | 2168-04-09 00:00:00 | 2168-04-09 12:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine / Levofloxacin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ COPD (2L resting, 4L walking), Afib/flutter (not on AC),
HFpEF, pulmHTN, asthma CKD (b/l Cr 1.7-2), hemolytic anemia (s/p
splenectomy), HTN presenting w/ SOB found to have
hypercarbic/hypoxemic respiratory failure requiring non-invasive
ventilation.
Patient was seen by Dr. ___ on ___ and reported
shortness of breath that was thought in part to be due to
deconditioning. Started on low dose prednisone 5mg daily.
Patient seen by her PCP, ___, on ___, for ongoing
severe shortness of breath with minimal exertion. She had
limited improvement with prednisone 5mg so prednisone was
increased to 10mg daily after discussion with Dr. ___.
During that appointment, the patient expressed that she very
much wants to do everything possible to improve her quality of
life and she would want everything done if her heart or lungs
were to stop if there was any chance that she would be able to
return to her quality of life.
The patient states she felt weak and fell onto her knees
yesterday. Was able to get up and went to bed. Otherwise feeling
well with no trouble breathing at that time. Reportedly fell out
of bed and called EMS from the floor. Found to be hypoxic to the
___ and tachypneic to the ___. Placed on BiPAP and transported
here. States she has some pressure in her chest. Unable to
characterize how long it is been. Has 1+ swelling in the lower
extremities that she says is ongoing. Takes her torsemide at
home. No abdominal pain.
In the ED:
- VS: Temp ___ BP 149/67 HR 77 RR 23 96% BiPAP ___ w/ 8L O2
- Labs notable for
- VBG: 7.18/122, lactate 1.1 -> repeat VBG ___
- CBC notable for plt 135
- trop 0.01 -> 0.02
- CXR: bibasilar atelectasis w/o consolidation, no frank
pulmonary edema
- CT head: no acute process
- EKG: Afib w/ ventricular rate 85, Q wave aVR & V1, largely
unchanged from prior ___
- Received: albuterol nebs, ipra nebs, azithro 500mg, IV
solumedrol 60mg
On arrival to the ___, patient reports history as above with
worsening SOB and fatigue over past month with acute worsening
with onset of lower extremity weakness this AM. She additionally
notes rhinorrhea secondary to allergies and sore throat over the
past few days. She has substernal chest pressure with ambulation
at baseline which has been stable. She has had no n/v/d. She has
urinary frequency at baseline, no dysuria.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
- COPD on home O2 (2L at rest and 4L with walking)
- CHF (EF >60%)
- Atrial fibrillation/flutter on warfarin
- Mild aortic stenosis
- Pulmonary hypertension
- Hypertension
- Asthma
- CKD (Baseline Cr 1.7-2.0)
- HCV s/p transfusion
- Obesity
- Diverticulosis
- Depression
- Hemorrhoids
- Rt knee osteoarthritis
- Hemolytic anemia s/p splenectomy
Social History:
___
Family History:
Hx of cancers on both sides of family; dad with lung,
aunt with breast, and sisters with lung
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 74| 158/73| 38| 90% 4L
GENERAL: Elderly woman, conversant, mild labored breathing
HEENT: Sclera anicteric, MMM, posterior oropharynx with erythema
no exudate
NECK: Supple, non-tender, no massed or LAD.
LUNGS: Poor air movement. No wheezes, occasional rales.
CV: Regular rate, irregular 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,
trace peripheral edema
SKIN: Skin type III. No lesions or eruptions.
NEURO: A&Ox3. No gross focal deficits. CN II-XII intact.
Strength ___ in lower extremities. Moving all extremities with
purpose.
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
VITALS: ___ ___ Temp: 98.4 PO BP: 167/78 R Lying HR: 64
RR:
18 O2 sat: 94% O2 delivery: 2L NC
GENERAL: Alert and in no apparent distress, breathing
comfortably
sitting up in a chair with nasal cannula in place
EYES: Anicteric, pupils equally round
ENT: MMM, OP clear
CV: Irregularly irregular, normal rate, no m/r/g. JVP not
elevated
RESP: Scattered expiratory wheezes, no rhonchi or crackles
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
=================
___ 11:00AM BLOOD WBC-9.1 RBC-3.66* Hgb-11.6 Hct-38.4
MCV-105* MCH-31.7 MCHC-30.2* RDW-16.3* RDWSD-61.4* Plt ___
___ 11:00AM BLOOD Neuts-59.5 ___ Monos-12.5
Eos-0.9* Baso-0.2 NRBC-0.2* Im ___ AbsNeut-5.40
AbsLymp-2.34 AbsMono-1.14* AbsEos-0.08 AbsBaso-0.02
___ 12:55PM BLOOD Glucose-90 UreaN-77* Creat-1.8* Na-148*
K-5.3 Cl-100 HCO3-39* AnGap-9*
___ 02:52AM BLOOD Calcium-8.5 Phos-4.9* Mg-2.3
___ 11:00AM BLOOD ___ pO2-29* pCO2-122* pH-7.18*
calTCO2-48* Base XS-10
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-10.0 RBC-3.74* Hgb-11.9 Hct-39.5
MCV-106* MCH-31.8 MCHC-30.1* RDW-15.6* RDWSD-59.4* Plt ___
___ 06:40AM BLOOD Glucose-88 UreaN-55* Creat-1.2* Na-149*
K-4.7 Cl-99 HCO3-39* AnGap-11
___ 06:40AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.2
MICRO:
BCx x2 (___): NGTD
UCx (___):
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
IMAGING AND STUDIES:
CXR ___
IMPRESSION:
1. Enlarged cardiomediastinal silhouette, slightly more
prominent compared to prior, likely due to patient rotation and
low lung volumes.
2. Bibasilar atelectasis without focal consolidation. No frank
pulmonary
edema.
CT HEAD ___:
IMPRESSION:
1. Motion limited exam without evidence for acute intracranial
abnormalities
or displaced calvarial fracture.
2. Partially visualized paranasal sinus disease.
Brief Hospital Course:
___ w/ COPD (2L resting, 4L walking), Afib/flutter (not on AC),
HFpEF, pulmHTN, asthma CKD (b/l Cr 1.7-2), hemolytic anemia (s/p
splenectomy), HTN presenting w/ SOB found to have
hypercarbic/hypoxemic respiratory failure requiring non-invasive
ventilation.
=================
ACTIVE ISSUES
=================
#) Hypoxemic/Hypercarbic respiratory failure
#) COPD on O2 ___ at home)
Presented with mixed hypercarbic/hypoxic respiratory failure. Hx
of COPD, ___ PFTs showed FEV1/FVC 66, FEV1 71% predicted,
consistent with moderate disease. Exam notable for poor air
movement and occasional rales. Worsening hypercarbia i/s/o COPD
with otherwise normal CXR concerning for COPD exacerbation. BNP
elevated at ___ though has been as high as >5000 in past, with
no signs of fluid overload. Infection unlikely given lack of
leukocytosis or infiltrate though with sore throat and URI
symptoms. Wells score 0, making PE highly unlikely. Continued to
treat for COPD exacerbation with prednisone 40 mg daily x 7 days
___ last day ___ and azithromycin 250 mg daily x 4
more days ___ last day ___. She improved with these
treatments and at the time of discharge was back to her baseline
home O2 requirement (___).
#Weakness
Patient ambulates with walker at baseline. Experienced weakness
ambulating to bathroom prior to admission in the setting of
worsening SOB. She experienced numbness in lower extremities.
Macrocytic anemia likely in setting of reticulocytosis ___
splenectomy though will rule out B12 deficiency. Sensation and
strength intact. B12 was wnl, but borderline. Pt was evaluated
by ___ who recommend rehab.
- As an outpatient, PCP could consider checking methylmalonic
acid as B12 was borderline
#) Elevated troponin
Troponin 0.01 -> 0.02 in the ED. EKG without acute ST changes or
T wave inversions. Patient with substernal chest
pressure/tightness. Likely type II NSTEMI i/s/o COPD
exacerbation.
#) Hypernatremia
Na 148 on admission. Possible a component of dehydration though
other labs are not hemoconcetrated. Will encourage oral intake
and monitor.
=================
CHRONIC ISSUES
=================
#) Atrial fibrillation
Patient has been off anticoagulation since previous
gastrointestinal bleed in ___.
- RC: Normal rate, not on rate control
- AC: not on AC. Continue aspirin 81 mg daily
- trend ___
#HFpEF
BNP elevated at ___ though weight stable and without gross
overload on exam or imaging. Initially held home torsemide in
setting of recent fall and weakness; this was resumed prior to
discharge.
#) CKD
Baseline Cr 1.7-2.0. Her Cr was better than baseline on
discharge (1.2).
#) Hypertension
On amlodipine, isosorbide ER, and hydralazine at home. BP stable
in the normal range. Her home regimen was initially held in the
FICU. On the medicine floor, her home amlodipine and isosorbide
was resumed. Her hydralazine was held until she can follow up
with her PCP and can be resumed as her blood pressure allows.
#) Chronic pain
#) Osteoarthritis
Continued her home gabapentin.
Held hydrocodone-acetaminophen 5 mg-325mg ___ tab q8h prn as she
was not having significant pain.
#) Chronic Thrombocytopenia
#) Hemolytic anemia s/p splenectomy
Hemoglobin and platelets currently at baseline.
Ms. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 100 mg PO QHS
2. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN Pain
- Moderate
3. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Omeprazole 40 mg PO BID
7. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
8. budesonide 0.5 mg/2 mL inhalation DAILY
9. melatonin 1 mg oral QHS
10. amLODIPine 10 mg PO DAILY
11. HydrALAZINE 10 mg PO Q8H
12. Polyethylene Glycol 17 g PO QID
13. Torsemide 60 mg PO DAILY
14. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild
15. Aspirin 81 mg PO DAILY
16. PredniSONE 10 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 1 Dose
Take for one more dose (last day ___
2. Cetirizine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. PredniSONE 40 mg PO DAILY Duration: 4 Days
Take for 4 more days (last day is ___
7. Acetaminophen 1000 mg PO Q12H:PRN Pain - Mild
8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
9. amLODIPine 10 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Budesonide 0.5 mg/2 mL inhalation DAILY
12. Gabapentin 100 mg PO QHS
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. melatonin 1 mg oral QHS
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Omeprazole 40 mg PO BID
18. Polyethylene Glycol 17 g PO QID
19. Torsemide 60 mg PO DAILY
20. HELD- HydrALAZINE 10 mg PO Q8H This medication was held. Do
not restart HydrALAZINE until you follow up with your primary
care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
COPD exacerbation
E.coli UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for shortness of breath and
were found to have a COPD exacerbation. You were initially in
the ICU and required BiPAP. You were treated with steroids and
antibiotics and improved back to your baseline oxygen
requirement. You were also found to have a UTI and you were
treated for that.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
You were evaluated by physical therapy and they felt that you
would benefit from rehab to prevent physical debilitation.
Best of luck with your continued healing!
Take care,
Your ___ Care Team
Followup Instructions:
___
|
10347400-DS-27 | 10,347,400 | 29,357,915 | DS | 27 | 2168-06-04 00:00:00 | 2168-06-04 18:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine / Levofloxacin
Attending: ___.
Chief Complaint:
Fall, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ y/o woman with COPD on 2L
home O2, asthma diastolic CHF (EF 65% ___, afib/flutter not on
anticoagulation, pHTN, CKD stage IIIb who presented after a fall
with generalized weakness. She has been lightheaded and weak for
the past few days. She states she was making oatmeal for
breakfast morning of admission and suddenly fell backwards onto
her buttocks and was too weak to get up off the floor. No head
strike or LOC. Called EMS and was brought to the ED. She denies
any preceding lightheadedness, dizziness, nausea, vomiting,
chest
pain, or loss of balance. She isn't sure why she fell. Has had
other falls in the past few weeks, and states sometimes when
getting up to use her walker she will fall back into her chair.
She denies any recent fevers/chills, change in her oxygen use,
dyspnea, palpitations, abdominal pain, n/v/d, dysuria.
ED Course: Afebrile and vital signs within normal limits. Became
very lightheaded on standing from bed and unable to complete
orthostatics. CBC wnl, UA unremarkable, troponins x2 at
baseline.
Na 149 (stable from ___. CXR with stable cardiomegaly. Knee
XR obtained due to recent fall on knees and ongoing knee pain
without fracture
On arrival to the floor, she reports being tired, and feeling
very dry and thirsty, but denies pain in her back, buttocks, or
legs other than her chronic knee pain. She states she rarely
drinks at home, except for a glass of wine with dinner
sometimes,
and that her torsemide makes her urinate a lot. Reports her
weight at home yesterday was 174 lbs. which is her baseline dry
weight.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
- COPD on home O2 (2L at rest and 4L with walking)
- CHF (EF >60%)
- Atrial fibrillation/flutter- off AC since GIB in ___
- Mild aortic stenosis
- Pulmonary hypertension
- Hypertension
- Asthma
- CKD (Baseline Cr 1.7-2.0)
- HCV s/p transfusion
- Obesity
- Diverticulosis
- Depression
- Hemorrhoids
- Rt knee osteoarthritis
- Hemolytic anemia s/p splenectomy
Social History:
___
Family History:
Hx of cancers on both sides of family; dad with lung,
grandmother
with stomach cancer, aunt with breast, and sisters with lung. No
hx of heart disease, heart attack.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp: 98.0 PO BP: 125/65 R Lying HR: 79 RR: 22
O2 sat: 90% O2 delivery: 3l Nc
GENERAL: Pleasant elderly woman, NAD
HEENT: Anicteric sclera, dry MM
NECK: supple
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: Decreased breath sounds throughout, scattered expiratory
wheeze, coarse bibasilar inspiratory crackles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Trace pitting edema to L knee no cyanosis, clubbing
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Bilateral patellar ecchymosis, L lower leg with ecchymosis
DISCHARGE PHYSICAL EXAM:
VS: Temp: 98.3 PO BP: 163/86 HR: 82 RR: 22 O2 sat: 93% on 2L O2
NC
GENERAL: pleasant elderly woman, NAD
HEENT: AT/NC, Anicteric sclera, moist mucous membranes
NECK: supple
CV: RRR, S1/S2, no murmurs appreciated
PULM: scattered wheezes bilaterally, no use of accessory muscles
of respiration
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Trace pitting edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: L leg below the knee with ecchymosis and healing abrasion
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-8.3 RBC-3.75* Hgb-12.0 Hct-39.6
MCV-106* MCH-32.0 MCHC-30.3* RDW-14.9 RDWSD-58.4* Plt ___
___ 04:00PM BLOOD Neuts-65.8 ___ Monos-10.9 Eos-1.3
Baso-0.7 NRBC-0.2* Im ___ AbsNeut-5.48 AbsLymp-1.69
AbsMono-0.91* AbsEos-0.11 AbsBaso-0.06
___ 04:00PM BLOOD ___ PTT-30.4 ___
___ 04:00PM BLOOD Glucose-104* UreaN-67* Creat-1.6* Na-149*
K-4.8 Cl-102 HCO3-32 AnGap-15
___ 04:00PM BLOOD CK(CPK)-34
___ 10:44PM BLOOD CK-MB-2 cTropnT-0.03* proBNP-4548*
___ 11:33PM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
___ 11:42PM BLOOD ___ pO2-174* pCO2-71* pH-7.33*
calTCO2-39* Base XS-8
___ 11:42PM BLOOD Lactate-1.4
___ 09:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
DISCHARGE LABS:
___ 05:50AM BLOOD WBC-9.9 RBC-3.45* Hgb-11.2 Hct-37.1
MCV-108* MCH-32.5* MCHC-30.2* RDW-15.1 RDWSD-59.8* Plt ___
___ 05:50AM BLOOD Glucose-98 UreaN-50* Creat-1.3* Na-146
K-5.3 Cl-95* HCO3-39* AnGap-12
___ 05:50AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
MICRO:
___ 9:15 pm URINE
URINE CULTURE (Final ___: NO GROWTH.
IMAGING REPORTS:
CHEST PA&LAT ___
IMPRESSION:
Persistent cardiomegaly. Basilar atelectasis without definite
focal
consolidation.
KNEE AP,LAT&OBLIQUE ___
IMPRESSION:
No acute fracture or dislocation.
Tricompartment osteoarthritis bilaterally, more severe on the
right.
CHEST PORTABLE AP ___
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Vessels in the lungs and mediastinum are engorged, but there is
no pulmonary edema. Cardiac silhouette, moderately enlarged, is
slightly smaller today than on ___. Pleural effusions small
if any. No pneumothorax.
Brief Hospital Course:
BRIEF SUMMARY:
___ y/o woman with COPD on 2L home O2, asthma diastolic CHF (EF
65% ___, afib/flutter not on anticoagulation, pHTN, CKD stage
IIIb who presented after a fall with generalized weakness and
hypernatremia.
ACTIVE ISSUES:
#Generalized weakness with a fall:
The patient presented after a fall and endorsed weakness and
orthostatic symptoms. She was given fluids and home torsemide
was held. Diuresis was resumed when patient experienced SOB.
After ___ evaluated the patient the generalized weakness appeared
to be more likely due to a combination of decreased fluid intake
and inactivity resulting from her COPD and HF. ___ recommended
continued work with ___ and discharge to rehab.
#Hypernatremia:
The patient endorsed minimal PO fluid intake at home, but
regularly takes torsemide 60 mg daily. Na on admission was 149.
Her torsemide was held and she was given fluids with improvement
of her Na. She experienced SOB and O2 desaturation, so she was
diuresed and sats improved with decreased O2 requirement.
Torsemide 40 mg PO was started.
CHRONIC ISSUES:
#Chronic diastolic heart failure:
-Torsemide was initially held, and after fluids patient
experienced SOB. Home Torsemide 40 mg PO was resumed
#COPD: continued home prednisone and inhalers
# HYPERTENSION: Held amlodipine and isosorbide held initially.
Amlodipine resumed prior to discharge.
TRANSITIONAL ISSUES:
[] Patient should participate in a rehabilitative program to
address her weakness.
[] Follow up blood pressure and resume isosorbide mononitrate as
needed.
[] Torsemide dose was reduced to 40 mg daily and need to monitor
volume status and adjust as needed.
[] iron supplementation decreased to every other day (given
decreased absorption with twice daily dosing)
#Code Status: DNR/DNI (MOLST in OMR)
#CONTACT:
Name of health care proxy: ___: cousin
Phone number: ___
Cell phone: ___
Proxy form in chart: ___
Comments: alternate proxy: ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Gabapentin 100 mg PO QHS
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Docusate Sodium 100 mg PO BID
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Omeprazole 40 mg PO BID
12. Polyethylene Glycol 17 g PO QID
13. Torsemide 60 mg PO DAILY
14. melatonin 1 mg oral QHS
15. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN
Pain - Moderate
16. Vitamin D 400 UNIT PO DAILY
17. Ferrous Sulfate 325 mg PO BID
18. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
2. Torsemide 40 mg PO DAILY dHF
3. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Gabapentin 100 mg PO QHS
9. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN
Pain - Moderate
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
q8h:PRN Disp #*9 Tablet Refills:*0
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
11. melatonin 1 mg oral QHS
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Omeprazole 40 mg PO BID
14. Polyethylene Glycol 17 g PO QID
15. PredniSONE 5 mg PO DAILY
16. Senna 8.6 mg PO BID:PRN Constipation - First Line
17. Vitamin D 400 UNIT PO DAILY
18. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until your BP is followed up with
your PCP or cardiologist.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Generalized weakness with a fall
Hypernatremia
Secondary Diagnosis:
Chronic diastolic heart failure
Chronic obstructive pulmonary disease
Hypertension
Chronic kidney disease stage IIIb
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were admitted for weakness leading to a fall
-You were also found to be dehydrated leading to high sodium
levels.
WHAT HAPPENED IN THE HOSPITAL?
-You were given fluids and then resumed diuretics (water pills).
You were given your home COPD medications. You worked with
Physical Therapy and were recommended rehab
WHAT SHOULD YOU DO AT HOME?
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
-Take your medications as prescribed
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10347411-DS-20 | 10,347,411 | 20,675,218 | DS | 20 | 2112-08-31 00:00:00 | 2112-08-31 13:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
general anesthesia
Attending: ___.
Chief Complaint:
RLQ abdominal pain
Major Surgical or Invasive Procedure:
1. laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ yo male, previously healthy, who presents with
2 days of right lower quadrant abdominal pain and nausea. His
appetite has been poor. Patient denies fevers, chills, diarrhea,
and vomiting. He states his pain has been stable and maybe
slightly improved. He has not had pain like this before.
Past Medical History:
PMH: None
PSH: left ear surgery
Social History:
___
Family History:
Noncontributory
Physical Exam:
Afebrile, hemodynamically stable
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, appropriately tender near incisions, no
rebound or guarding, normoactive bowel sounds, no palpable
masses. Port sites c/d/i.
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 12:13PM BLOOD WBC-8.6 RBC-5.06 Hgb-14.7 Hct-43.8 MCV-87
MCH-29.1 MCHC-33.6 RDW-12.8 RDWSD-40.1 Plt ___
___ 12:13PM BLOOD Neuts-64.8 ___ Monos-10.7
Eos-0.5* Baso-0.2 Im ___ AbsNeut-5.56 AbsLymp-2.02
AbsMono-0.92* AbsEos-0.04 AbsBaso-0.02
___ 12:13PM BLOOD Glucose-84 UreaN-16 Creat-1.1 Na-139
K-4.1 Cl-102 HCO___ AnGap-1
CT ___:
IMPRESSION: Acute appendicitis with reactive wall thickening at
the base of the cecum. No perforation or abscess.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission
abdominal/pelvic CT revealed acute appendicitis. The patient
underwent laparoscopic appendectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating clears, on IV fluids,
and with adequate pain control. The patient was hemodynamically
stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
1. acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for acute appendicitis and
underwent laparoscopic appendectomy. You did well
post-operatively and are being discharged home in stable
condition on post-operative day 1. Please follow the following
directions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10347477-DS-19 | 10,347,477 | 27,385,785 | DS | 19 | 2134-04-11 00:00:00 | 2134-04-11 13:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pleuritic chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo M with h/o right sided lung adenocarcinoma s/p
resection and enteropathy associated T cell lymphoma (+ celiac
serologies) s/p chemotherapy and small bowel resection now
undergoing planning for autologous stem cell transplant who
presents with one day of pleuritic chest pain. The patient was
recently on high dose Neupogen for stem cell mobilization. With
that therapy, he had bone pain, but no chest pain. Starting the
day before admission, he developed pleuritic chest pain with
deep breath. He denied cough, fevers, chills. Not really
positional. No preceding trauma. No abdominal pain. The pain was
under the left breast and radiated to the left shoulder. It did
not prevent him from doing activity. The patient presented to
the ED. EKG did not show ischemic changes. He underwent a CTA
that showed a small ground glass appearance in the lingula
concerning for early infection v infarct. The patient was given
lovenox and admitted to the floor for further evaluation.
On the floor, the patient is well appearing with normal vital
signs. He denies lower extremity pain, redness, or swelling. He
still has mild pleuritic pain. He is not dyspnic. He has a h/o
heterozygous prothrombin gene mutation, but has never had a
venous clot before. He has had a retinal artery occlusion, but
this was likely from atherosclerotic disease. He denies recent
travel, immobility, surgery, or FH of clots. He is a non-smoker.
REVIEW OF SYSTEMS: Had stress test in ___ without ischemia,
otherwise per HPI
Past Medical History:
PAST ONCOLOGIC HISTORY
Biopsy on ___ revealed an enteropathy type T-cell
lymphoma. Bone marrow was completed at this time, which did not
show any evidence of disease. PET-CT on ___ showed
three areas of small bowel thickening, which were significantly
FDG avid mesenteric lymphadenopathy as well as splenomegaly.
Since that time, he has undergone five cycles of therapy EPOCH
therapy. After both cycles 1 and 2, he developed bowel
obstructions, both of which initially were treated
conservatively; small bowel resection and lysis of adhesions on
___. Hematopathology showed no lymphoma in the small
bowel, but this was suggestive of an inflammatory response to
his chemotherapy rather than disease at this time.
PAST CHEMOTHERAPY HISTORY:
___: Cycle 1 EPOCH
___: Admitted to ___ hospital with small bowel
obstruction.
___ 2 EPOCH vincristine held.
___: Admit to the inpatient with small bowel obstruction.
___: OR for small bowel resection and lysis of adhesions.
___: Cycle 3 EPOCH: full dose vincristine, capped.
___: Cycle 4 EPOCH: full dose, vincristine capped.
___: Cycle 5 EPOCH: full dose, vincristine capped.
___: Cycle 6 EPOCH: full dose, vincristine capped.
___: Stem cell collection
PAST MEDICAL HISTORY:
- Enteropathy associated T cell lymphoma as above
- Celiac disease
- Hypertension
- NSCLC stage I adenocarcinoma
- Wolf ___ White syndrome
Social History:
___
Family History:
- No clotting disorders in family
- Mother: CHF
- Father: CVA
- ___: Denies
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VS: 98.3, 140/80, 78, 18, 98% RA
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
Rectal: Heme negative
EXT: Trace ___ edema, symmetric
PULSES: 2+DP pulses bilaterally
NEURO: A&O x 3, CN II-XII intact
SKIN: Warm and dry, without rashes
=======================
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tc 97.7F BP 120/78 mmHg P 76 RR 18 O2 98% RA
General; Well-appearing man, appearing his stated age, in NAD.
HEENT: PERRL; EOMs intact. Anicteric sclerae. OP clear; MMM.
Neck: Supple, no JVD.
Chest: Port site c/d/i.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended. NABS. No organomegaly.
Ext: Warm and well-perfused. No edema. 2+ pulses b/l.
Neuro: A&Ox3. CNs II-XII grossly intact. Distal sensation intact
to light touch. Narrow-based, steady gait.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 05:30PM BLOOD WBC-12.4* RBC-3.70* Hgb-11.3* Hct-33.3*
MCV-90 MCH-30.5 MCHC-33.9 RDW-13.9 RDWSD-43.6 Plt ___
___ 05:30PM BLOOD Neuts-85* Bands-4 Lymphs-6* Monos-2*
Eos-0 Baso-0 ___ Metas-2* Myelos-1* AbsNeut-11.04*
AbsLymp-0.74* AbsMono-0.25 AbsEos-0.00* AbsBaso-0.00*
___ 05:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:30PM BLOOD ___ PTT-29.5 ___
___ 05:30PM BLOOD Glucose-92 UreaN-15 Creat-0.9 Na-141
K-3.8 Cl-107 HCO3-25 AnGap-13
___ 05:30PM BLOOD ALT-21 AST-16 AlkPhos-132* TotBili-0.3
___ 05:30PM BLOOD cTropnT-<0.01
___ 05:30PM BLOOD Albumin-4.4
___ 05:30PM BLOOD D-Dimer-1352*
==============
DISCHARGE LABS
==============
___ 05:46AM BLOOD WBC-4.1 RBC-3.52* Hgb-10.7* Hct-31.6*
MCV-90 MCH-30.4 MCHC-33.9 RDW-13.7 RDWSD-42.8 Plt ___
___ 05:46AM BLOOD Neuts-70.7 Lymphs-11.2* Monos-15.4*
Eos-0.7* Baso-0.5 Im ___ AbsNeut-2.90# AbsLymp-0.46*
AbsMono-0.63 AbsEos-0.03* AbsBaso-0.02
___ 05:46AM BLOOD Plt ___
___ 05:46AM BLOOD ___ PTT-32.8 ___
___ 05:46AM BLOOD ___
___ 05:46AM BLOOD Glucose-139* UreaN-12 Creat-0.8 Na-138
K-3.9 Cl-104 HCO3-22 AnGap-16
___ 05:46AM BLOOD LD(LDH)-197
___ 05:46AM BLOOD Albumin-4.0 Calcium-8.7 Phos-3.5 Mg-2.2
UricAcd-6.0
============
MICROBIOLOGY
============
None
===============
IMAGING/STUDIES
===============
CHEST (PA & LAT) (___):
FINDINGS:
The cardiomediastinal silhouette and pulmonary vasculature are
stable since recent examination. There is no pleural effusion
or pneumothorax. The lungs are clear. A right-sided
Port-A-Cath is noted with its tip in the lower SVC region.
IMPRESSION:
No acute intrathoracic process. Please refer to subsequent CTA
for further details.
CTA CHEST AND CT ABDOME (___):
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
segmental level. Evaluation of subsegmental branches in the
left lower lobe and lingula is limited. The thoracic aorta is
normal in caliber without evidence of dissection or intramural
hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen. A right sided
Port-A-Cath is in place.
AXILLA, HILA, AND MEDIASTINUM: Prominent mediastinal lymph
nodes are noted, with the largest precarinal lymph node
measuring 1.2 cm. The prominent subcarinal lymph node measures
approximately 1.2 cm in diameter as well. There is no axillary
or supraclavicular lymphadenopathy.
PLEURAL SPACES: There is a small simple appearing left pleural
effusion.
LUNGS/AIRWAYS: Subtle ground-glass opacity in the inferior
lingula is best seen on series 2b, image 91. Mild dependent
atelectasis noted bilaterally. Otherwise lungs are clear
without worrisome nodule, mass, or consolidation. The airways
are centrally patent. There is an area of scarring and linear
atelectasis in the right middle lobe and an area of prior
intervention.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen is slightly enlarged, measuring approximately
14 cm in
greatest dimension, not significantly changed since recent
study.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of focal renal lesions
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach and visualized loops of small
bowel and colon are unremarkable. Suture material is seen in
the mid abdominal small bowel. The appendix is partially
visualized and is normal.
LYMPH NODES: Prominent mesenteric lymph nodes are noted,
particularly in the left upper quadrant, similar to prior
examination.
VASCULAR: There is no abdominal aortic aneurysm. No significant
atherosclerotic disease seen.
BONES AND SOFT TISSUES: There is no evidence of worrisome
osseous lesions or acute fracture.
IMPRESSION:
1. Subtle ground-glass opacity in the inferior lingula is
concerning for
pneumonia versus infarction. No definite pulmonary embolism
identified though small subsegmental branches difficult to
assess.
2. Mild splenomegaly.
BILAT LOWER EXT VEINS (___):
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
and
compressibility are demonstrated in the posterior tibial and
peroneal veins. There is normal respiratory variation in the
common femoral veins bilaterally. No evidence of medial
popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins
ECHO (___):
Conclusions
The left atrial volume index is normal. Normal left ventricular
wall thickness, cavity size, and regional/global systolic
function (biplane LVEF = 64 %). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be quantified. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Milldy
dilated ascending aorta.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram
is suggested in ___ years.
Brief Hospital Course:
___ is a ___ y/o man with a PMH of stage Ia lung
adenocarcinoma, celiac disease w/ SBO s/p resection and
enteropathy-associated T-cell lymphoma, s/p 6 cycles of EPOCH
and cyclophosphamide with stem cell collection, who presented
with pleuritic chest pain and findings on CTA concerning for
lingular infarction vs. infection.
============
ACUTE ISSUES
============
# Pleuritic chest pain. CTA did not demonstrate clot, and there
was no evidence of splenic infarction. ACS work-up negative
(negative troponin and no EKG changes). Initiated on therapeutic
dose Lovenox. Lower extremity ultrasound negative. TTE
demonstrated no right heart strain and no effusion. No
infectious symptoms. Evaluated by the pulmonary service; this
was deemed not to be pulmonary embolism, and may be
musculoskeletal in nature (as the pain had worsened by lying on
his side). Pain was wholly resolved by the time of discharge.
Lovenox was halted, with plan for follow-up imaging in 6 weeks.
# Enteropathy-associated T-cell lymphoma. Continued on home
acyclovir, Bactrim, and allopurinol.
==============
CHRONIC ISSUES
==============
# Hypertension. Continued home metoprolol succinate 25 mg and
spironolactone 25 mg daily.
===================
TRANSITIONAL ISSUES
===================
# Thrombophilia work-up. Will have discharge follow-up in
hematology to investigate possible thrombophilia (has history of
prothrombin gene mutation).
# Follow-up imaging. Recommend follow-up chest CT in 6 weeks to
evaluate for interval change.
# Repeat TTE. The patient has a mildly dilated ascending aorta.
Based on ___ ACCF/AHA Thoracic Aortic Guidelines, a follow-up
echocardiogram is suggested in ___ years.
# Contact: ___ (sister), ___
# Code status: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Acyclovir 400 mg PO Q8H
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Spironolactone 25 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- enteropathy-associated T cell lymphoma
- celiac disease
===================
SECONDARY DIAGNOSES
===================
- hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___. You were admitted because you had chest and
shoulder pain. We were initially concerned about blood clot in
your lungs (pulmonary embolism), and so you were started on
anticoagulation with Lovenox. You received an ultrasound of your
legs, CT of your chest, and echocardiogram of your heart. You
were also evaluated by our pulmonary specialists. Since the
likelihood of pulmonary embolism was low, Lovenox was stopped.
Your echocardiogram was normal, except that it showed a slight
dilation of your aorta. This should be followed up with a repeat
echocardiogram in ___ years.
Please continue to take all medications as prescribed. Your
discharge follow-up appointments are outlined below.
We wish you the very best!
Warmly,
Your ___ Team
Followup Instructions:
___
|
10347477-DS-21 | 10,347,477 | 20,028,434 | DS | 21 | 2134-10-11 00:00:00 | 2134-10-12 07:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SBO
Major Surgical or Invasive Procedure:
___ Adrenal vein sampling (___)
History of Present Illness:
Mr. ___ is a ___ yo male with hx of T cell lymphoma of the
small bowel s/p 6 cycles of chemo and autologous stem cell
transplant who presents with recurrent SBO. Patient's cancer
initially presented as a SBO that required LOA and a small bowel
resection. Since initiation of his therapy, he has not had an
obstructions. However, last night he had onset of severe
abdominal pain after dinner that felt like his prior
obstruction.
He has not had any flatus or BM since and feels distended. He
denies nausea or vomiting. He denies fevers, chills, and
malaise.
Of note, patient is being worked up for severe hypertension and
is due for adrenal vein sampling next week. Patient also had a
PET scan 3 days prior to presentation that demonstrated no
residual signals suggestive of cancer.
Past Medical History:
PAST ONCOLOGIC HISTORY
Biopsy on ___ revealed an enteropathy type T-cell
lymphoma. Bone marrow was completed at this time, which did not
show any evidence of disease. PET-CT on ___ showed
three areas of small bowel thickening, which were significantly
FDG avid mesenteric lymphadenopathy as well as splenomegaly.
Since that time, he has undergone five cycles of therapy EPOCH
therapy. After both cycles 1 and 2, he developed bowel
obstructions, both of which initially were treated
conservatively; small bowel resection and lysis of adhesions on
___. Hematopathology showed no lymphoma in the small
bowel, but this was suggestive of an inflammatory response to
his chemotherapy rather than disease at this time.
PAST CHEMOTHERAPY HISTORY:
___: Cycle 1 EPOCH
___: Admitted to ___ hospital with small bowel
obstruction.
___ 2 EPOCH vincristine held.
___: Admit to the inpatient with small bowel obstruction.
___: OR for small bowel resection and lysis of adhesions.
___: Cycle 3 EPOCH: full dose vincristine, capped.
___: Cycle 4 EPOCH: full dose, vincristine capped.
___: Cycle 5 EPOCH: full dose, vincristine capped.
___: Cycle 6 EPOCH: full dose, vincristine capped.
___: Stem cell collection
PAST MEDICAL HISTORY:
- Enteropathy associated T cell lymphoma as above
- Celiac disease
- Hypertension
- NSCLC stage I adenocarcinoma
- Wolf ___ White syndrome
Social History:
___
Family History:
- No clotting disorders in family
- Mother: CHF
- Father: CVA
- ___: Denies
Physical Exam:
Vitals: AVSS
Gen: AAOx3 NAD comfortable
CV: NRRR; mild atrial tachycardia to 110-120 intermittently,
asymptomatic
Chest: Clear without deformity
Abd: Soft, no ttp, no guarding, benign without masses or
organomegaly
Extrem: Without deformity or edema
Pertinent Results:
___ 06:03AM BLOOD WBC-2.8*# RBC-3.50* Hgb-11.2*# Hct-32.7*
MCV-93 MCH-32.0 MCHC-34.3 RDW-13.5 RDWSD-45.8 Plt ___
___ 07:08AM BLOOD WBC-6.1 RBC-4.63 Hgb-14.7 Hct-42.5 MCV-92
MCH-31.7 MCHC-34.6 RDW-13.8 RDWSD-46.5* Plt ___
___ 01:38AM BLOOD WBC-11.7*# RBC-5.00# Hgb-15.8# Hct-45.2#
MCV-90 MCH-31.6 MCHC-35.0 RDW-13.5 RDWSD-43.8 Plt ___
___ 01:38AM BLOOD Neuts-89.2* Lymphs-3.8* Monos-6.2
Eos-0.1* Baso-0.3 Im ___ AbsNeut-10.43*# AbsLymp-0.45*
AbsMono-0.72 AbsEos-0.01* AbsBaso-0.03
___ 06:03AM BLOOD Plt ___
___ 07:08AM BLOOD Plt ___
___ 01:38AM BLOOD Plt ___
___ 06:03AM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-140
K-3.2* Cl-108 HCO3-24 AnGap-11
___ 07:08AM BLOOD Glucose-116* UreaN-15 Creat-0.9 Na-140
K-3.6 Cl-103 HCO3-23 AnGap-18
___ 01:38AM BLOOD Glucose-138* UreaN-19 Creat-1.1 Na-143
K-3.7 Cl-101 HCO3-28 AnGap-18
___ 07:08AM BLOOD LD(LDH)-238
___ 01:38AM BLOOD ALT-25 AST-26 AlkPhos-128 TotBili-0.6
DirBili-<0.2 IndBili-0.6
___ 01:38AM BLOOD Lipase-24
___ 06:03AM BLOOD Calcium-8.1* Phos-2.1* Mg-2.1
___ 07:08AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
___ 01:38AM BLOOD Albumin-5.0 Calcium-9.8 Mg-2.2
___ 01:46AM BLOOD Lactate-1.8
___ CT AP
Small bowel obstruction, likely complete, with the transition
point in the
right upper quadrant. Mesenteric fluid suggesting bowel
ischemia. No
abnormal wall enhancement, pneumatosis, or pneumoperitoneum.
Brief Hospital Course:
Mr. ___ was admitted to ___ on ___ following
presentation to the ED with SBO. CT AP done in the ED identified
high grade small bowel obstruction with transition point in the
RUQ. He was placed on bowel rest, IVF resuscitation, and an NGT
was placed. He suffered from nausea and abdominal pain at the
time of admission but within 24 hours of admission, Mr. ___
reported that he was feeling much better, passing flatus and
stool, and free of abdominal pain/nausea. On HD1-2 he was noted
to be severely hypertensive per his recent baseline (170-200
SBP, 100 DBP). In addition he was intermittently noted to be
tachycardic to the 120-130s. Informal cardiology consultation
was completed, and review of Mr. ___ symptomatology and
EKG yielded diagnosis of atrial tachycardia perhaps related to
previous diagnosis of WPW for which he underwent ablation in
___. He remained asymptomatic from these short intermittent
bursts of tachycardia and it was recommended by cardiology that
no intervention was warranted, thus none was initiated. He was
monitored for symptoms closely throughout the course of his
hospitalizations. Per the recommendations of inpatient
Nephrology Service, his medication regimen was adjusted to
include Labetalol 300 mg PO TID for improved BP and HR control,
and he was discharged on this regimen to be followed up as an
outpatient.
Prior to discharge, Mr. ___ underwent previously scheduled
adrenal vein sampling procedure with ___ on ___ which was
uncomplicated. He will be followed as an outpatient by Dr.
___ the results of this procedure and subsequent
management of his refractory HTN.
Once appropriate, Mr. ___ diet was advanced to clear
liquids and ultimately to regular which he tolerated without
issue. He continued to pass flatus and bowel movements. At the
time of discharge he was eating, tolerating his medications and
with HTN within reasonable control (SBP 130, HR 90-110),
toileting himself, passing flatus, and ambulating. He was
discharged with follow up PRN.
Medications on Admission:
Medications - Prescription
ACYCLOVIR - acyclovir 400 mg tablet. 1 tablet(s) by mouth three
times per day
FUROSEMIDE - furosemide 20 mg tablet. ___ tablet(s) by mouth qd
prn
LISINOPRIL - lisinopril 20 mg tablet. 2 tablet(s) by mouth once
a day - (Dose adjustment - no new Rx)
LORAZEPAM [ATIVAN] - Ativan 0.5 mg tablet. ___ tablet(s) by
mouth every 6 hours as needed for anxiety
METOPROLOL SUCCINATE - metoprolol succinate ER 100 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth once a day
ONDANSETRON - ondansetron 4 mg disintegrating tablet. 1
tablet(s) by mouth every 6 hours as needed for chemotherapy
induced nausea or vomitting
POTASSIUM CHLORIDE [KLOR-CON M20] - Klor-Con M20 mEq
tablet,extended release. 2 tablet(s) by mouth Daily In lieu of
amiloride, needs extra Kcl
SERTRALINE - sertraline 50 mg tablet. 1 tablet(s) by mouth once
a day
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - Bactrim 400 mg-80 mg
tablet. 1 tablet(s) by mouth daily
Discharge Medications:
1. Acyclovir 400 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Labetalol 300 mg PO TID
4. Lisinopril 40 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
SBO
Atrial tachycardia, asymptomatic
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
SMALL BOWEL OBSTRUCTION (Conservatively Treated)
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. You have tolerated a regular diet, are
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
If you have any of the following symptoms please call the office
for advice or go to the emergency room if severe: increasing
abdominal distension, increasing abdominal pain, nausea,
vomiting, inability to tolerate food or liquids, prolonged loose
stool, or extended constipation.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities.
Good luck!
Followup Instructions:
___
|
10347675-DS-21 | 10,347,675 | 26,643,356 | DS | 21 | 2183-05-20 00:00:00 | 2183-05-20 16:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Headache, AMS
Major Surgical or Invasive Procedure:
___ - Right decompressive hemicraniectomy for clipping of
right MCA aneurysm, ___ evacuation
___ - Left frontal EVD placement
___ - Redo IPH evacuation
___ - PICC line placement
___ - Trach and PEG placement
___ - Left frontal EVD removal
History of Present Illness:
Eu ___, ___ is a ___ female hx of HTN and
mitral valve prolapse who c/o HA x 24 hours. On ___ she
developed nausea and vomiting with altered mental status at
home. EMS was initiated and she had a rapid decline in mental
status. She was intubated at OSH and head CT showed large right
IPH with high grade SAH.
Blood pressure was documented in the 220s. She was transferred
to ___ for further neurosurgical evaluation and care.
Past Medical History:
HTN, Mitral valve prolapse, hypothyroid
Social History:
___
Family History:
unknown
Physical Exam:
ON ADMISSION ___:
============
PHYSICAL EXAM:
Date and Time of evaluation:
___ and ___:
[ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity
[ ]Grade II: Moderate to severe headache, nuchal rigidity, no
neurological deficit other than cranial nerve palsy.
[ ]Grade III: Drowsiness/Confusion, mild focal neurological
deficit.
[ ]Grade IV: Stupor, moderate-severe hemiparesis.
[x]Grade V: Coma, decerebrate posturing.
Fisher Grade:
[ ]1 No hemorrhage evident
[ ]2 Subarachnoid hemorrhage less than 1mm thick
[ ]3 Subarachnoid hemorrhage more than 1mm thick
[x]4 Subarachnoid hemorrhage of any thickness with IVH or
parenchymal extension
WFNS SAH Grading Scale:
[ ]Grade I: GCS 15, no motor deficit
[ ]Grade II: GCS ___, no motor deficit
[ ]Grade III: GCS ___, with motor deficit
[ ]Grade IV: GCS ___, with or without motor deficit
[x]Grade V: GCS ___, with or without motor deficit
___ Coma Scale:
[x]Intubated [ ]Not intubated
Eye Opening:
[x]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[x]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[x]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[ ]6 Obeys commands
__4__ Total
ICH Score:
GCS
[x]2 GCS ___
[ ]1 GCS ___
[ ]0 GCS ___
ICH Volume
[x]1 30 mL or Greater
[ ]0 Less than 30 mL
Intraventricular Hemorrhage
[ ]1 Present
[x]0 Absent
Infratentorial ICH
[ ___ Yes
[x]0 No
Age
[ ]1 ___ years old or greater
[x]0 Less than ___ years old
Total Score: __3____
O:
T:95.8 BP: 143/80 HR:63 R: 16 O2Sats: 100%
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, Atraumatic
Neck: Supple.
Extrem: Warm and well-perfused. No C/C/E.
Neuro: Intubated
No EO
PERRLA ___
+ Corneals
+ cough, + gag
Extends bilateral UE
Triple Flex bilateral lowers
ON DISCHARGE
============
___:
General:
T97.5, HR: 77-109, BP: 102-178/70-114, RR: ___, SpO2: 97-100%
6L trach mask.
Bowel Regimen: [x]Yes [ ]No Last BM: ___
Exam:
Opens eyes: [x]spontaneous - intermittently, otherwise to voice
Follows commands: [x]simple (on right)
Pupils: PERRL 3-2mm bilaterally
Right gaze, does not look to left
Motor:
RUE squeezes hand repeatedly, shows two fingers, attempts to
lift
arm. Very slow and sluggish this morning.
LUE contracted - weak withdrawal to noxious
RLE wiggles toes to command
LLE triple flex
Wound:
[x]Clean, dry, intact
Pertinent Results:
See OMR for pertinent lab results and imaging.
Brief Hospital Course:
#SAH, IPH, IVH, MCA Aneurysm complicated by vasospasm and
epileptiform discharges
On ___, ___ presented with large right IPH, SAH,
IVH and MCA aneurysm. She was taken emergently to the OR with
Dr. ___ Dr. ___ right MCA aneurysm clipping and
decompressive hemicraniectomy with EVD placement. Please see
separate operative report in OMR for more information. Post-op,
patient had bright red blood in the EVD. STAT CT showed large
clot, so patient was taken emergently back to the OR for re-do
right evacuation of IPH. Subgaleal JP drain was placed. Please
see operative report in OMR for more details. MRI was done for
poor exam and showed stable hemorrhage and new right frontal
acute to subacute infarcts. Subgaleal drain was removed ___. On
___, cEEG revealed small right frontal discharges and diffuse
slowing/moderate encephalopathy, but no seizures. TCD on ___
showed no spasm. cEEG on ___ was negative for seizure
activity, and discontinued ___. TCD on ___ showed normal
velocities. On ___, CTA showed vasospasm; therefore, the
patient was initiated on milrinone gtt and vasopressors with
goal blood pressure SBP 160-180 for optimal perfusion. Her IV
fluids were increased and she was given boluses for insensible
losses due to sweating as there was no change in her weight
since admission. Her nimodipine was fractionated for low BP. She
was having storming episodes with HR in the 130's and
hypertension to 190s. Fenatyl was added for pain as oxycodone
was not providing relief. On ___ a NCHCT showed now
significant change in ventricle size. Patient was noted to have
eye fluttering. Patient was storming off versed x4hrs however
she opened her eyes and moved her R thumb to command. She was
restarted on the versed after exam. Patient was placed back on
cvEEG. In comparison to prior, EEG looked worse meaning that
there was left sided attenuation and right sided discharges but
no seizures. She had R eye deviation and L hand shaking for
about 10 seconds. She was restarted on keppra 1g bid. EVD noted
to stop draining on ___ and it was flushed distally. CTA
showed overall interval improvement in vasospasm, most notably
in the right MCA. Patient remained on cEEG on ___ as there was
continued right epileptiform discharges. Her EVD was slowly
weaned, starting on ___, and clamped at 5pm on ___. She
tolerated the clamp trial for 36 hours and head CT on ___ was
stable. Her EVD was removed on ___ post-pull head CT was
without hemorrhage. Prior to removal, CSF was passively
collected into sterile specimen cup, which was sent for culture;
as of ___ was without growth. On ___ patient began
sympathetic storming with diaphoresis, tachycardia and
tachypnea, labs were sent and stable, CXR was performed and
negative, bilateral LENIs were negative and CTA with mild
atelectasis on ___. MRI on ___ showed acute/early subacute
infarct in the right basal ganglia internal and external capsule
and late subacute right MCA distribution infarcts which were
vasospasm related. It also showed a left ICA terminus aneurysm
that will be followed up on after discharge. She was started on
provigil and her scheduled oxycodone was decreased on ___ to
help with arousal. On ___ patient was noted to have a rash on
bilateral shoulders and right buttock, appeared to be contact
dermatitis, lotion ordered and monitored closely by nursing.
Patient was transferred to the ICU on ___ due to tachypnea,
tachycardia, diaphoresis and LLL collapse. Pulmonology team
performed a bronch on ___ and patient was brought back to the
___ for close monitoring. Patient continued sympathetic
storming intermittently and stabilized on ___.
#Dysautonomia
Patient was started on clonidine, baclofen, and propranolol for
management of sympathetic storming. Clonidine increased to 0.2q8
on ___. As she became more alert and following commands on the
right side her baclofen was increased to 10mg TID and she was
monitored for sedation. Patient tolerated medication changes.
#Angioedema
The patient developed angioedema on ___ and was started on
dexamethasone for a 72hr course. Per pharmacy, possibility for
angioedema may have been nimodipine, but this medication was not
discontinued in the setting of vasospasm. Plans for bedside
trach and PEG were postponed. Her tongue became dry and was
wrapped with a moist gauze. ENT was consulted and recommend
increasing decadron to 10mg q8h and to consider an allergy
consult. Nystatin was ordered for possible thrush. As of ___,
her tongue was noted to be purple from constant biting likely
secondary to the neurological storming, and OMFS was consulted
for placement of a bite-block. Patient 's angioedema had
decreased and patient's ETT was removed at time of Trach
placement on ___.
#Hypernatremia/Uremia
Free water flushes were increased for hypernatremia, as well as
uptrending BUN.
#Fevers/Recurrent pneumonia
Patient was febrile to 102.6F on ___ and was pancultured.
Cranial bone flap culture prelim with GPRs on ___, ID was
consulted and recommended vancomycin 1g BID, which was started
on ___. ID later recommended stopping vancomycin, and it was
stopped on ___. C diff was sent on ___ and was negative. ID
signed off on ___. On ___, she was again noted to be febrile
with a wbc of 18. CSF was sent and she was restarted on
vancomycin. There did not appear to be any growth from the CSF
and the vancomycin was stopped on ___. On ___ her WBC were
25.3 and thought to be related to decadron but she was pan
cultured and CSF, urine and blood cultures were sent. ___
C-diff cultures were sent, vancomycin was started
prophylactically. Patient with increased yellow sputum that was
coag + staph aureus. Per ID the vanco and cefepime were d/c'd
and the patient was transitioned to ancef for treatment of her
pneumonia. She completed a 7 day course total of antibiotics.
She was again febrile ___ and ___ and pancultured. CTA of the
chest revealed LLL collapse and concern for ongoing persistent
pneumonia. The patient was restarted on broad spectrum
antibiotics and ID was re-consulted for recommendations. ID
recommended changing antibiotic regimen to Flagyl and cefepime
with end date ___. Pulmonary was consulted for LLL collapse
and the patient underwent bronchoscopy on ___. BAL cultures were
sent at that time which showed MSSA. She continued cefepime and
flagyl for 7 days after BAL. Her LFTs were slightly elevated and
monitored and her flagyl was stopped at day 6. Cdiff was sent on
___ and resulted as negative. Patient CBC was unremarkable on
day of discharge and a repeat CXR on ___ was stable compared to
prior imaging.
#Tachycardia
Medicine was consulted for tachycardia in the setting of
developing fevers and LLL collapse found on ___ Chest CT;
recommended fluid boluses and treatment of infection in
conjunction with ID.
#Respiratory failure
The patient remained intubated with multiple failed attempts for
weaning the ventilator. She underwent tracheostomy placement on
___.
#Pneumothorax
CXR on ___ revealed a tiny pneumothorax. Repeat CXR on ___
stable. Repeat CXR on ___ revealed moderate pneumothorax. ICU
attending placed a chest tube to suction. Chest tube was placed
to water seal. A repeat CXR showed resolving pneumothorax. Her
chest tube was clamped on ___ and removed.
#Dysphagia; Ventilator dependent respiratory insufficiency
She was started on tube feeds for nutrition. The patient had a
PEG and tracheotomy tube placed at the bedside on ___ while in
the Neuro ICU.
#?Seizure Activity
The patient was cvEEG negative for seizures ___,
___ but was continued on keppra 1000 mg BID
for prophylaxis.
#Dispo
Patient was medically ready for discharge however family wanted
to pursue ___ Rehab although it was not covered by her
insurance. MD letters were given to the family per their request
to give the insurance company. In the meantime case management
had her screened for other facilities. On ___, the patient's
family discussed this further with case management and agreed to
send Ms. ___ to the rehab covered by her insurance when
medically stable for discharge. Ms. ___ was discharged to
rehab on ___.
AHA/ASA Core Measures for SAH/ ICH:
1. Dysphagia screening before any PO intake? [X]Yes []No
2. DVT prophylaxis administered? [X]Yes []No
3. Smoking cessation counseling given? []Yes [X]No [Reason:
()non-smoker (X)unable to participate]
4. Stroke Education given in written form? [X]Yes []No
5. Assessment for rehabilitation and/or rehab services
considered? [X]Yes []No
Stroke Measures:
1.Was ___ performed within 6hrs of arrival? [X]Yes []No
2.Was a Procoagulant Reversal agent given? []Yes [X]No
[Reason: Not on any anticoagulants]
3.Was Nimodipine given? [X]Yes []No [Reason:]
Medications on Admission:
Levothyroxine, Lisinopril, Trazadone
Discharge Medications:
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q6H
2. Baclofen 10 mg PO Q8H
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
thrush
4. CloNIDine 0.2 mg PO Q8H
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
6. Heparin 5000 UNIT SC BID
7. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using REG Insulin
8. LevETIRAcetam 1000 mg PO BID
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Modafinil 200 mg PO DAILY
11. Multivitamins W/minerals 15 mL PO DAILY
12. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
13. Propranolol 10 mg PO Q12H
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aneurysmal SAH, IPH, right MCA aneurysm.
Left ICA terminus aneurysm
Recurrent PNA
Dysautonomia
Discharge Condition:
Nonverbal
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Surgery/Procedures:
You had a cerebral angiogram to coil the aneurysm. You may
experience some mild tenderness and bruising at the puncture
site (groin).
You had surgery to clip the aneurysm. You incision should be
kept dry until sutures or staples are removed.
You had surgery (craniectomy) to remove a portion of your
skull to allow the brain to swell. You must use your helmet at
all times when out of bed.
Activity:
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications:
Resume your normal medications and begin new medications as
directed.
Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin) until cleared by the neurosurgeon.
You were given a 21 day course of a medication called
Nimodipine. This medication is used to help prevent cerebral
vasospasm (narrowing of blood vessels in the brain).
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication until follow-up. It is important that you take this
medication consistently and on time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10347675-DS-22 | 10,347,675 | 20,850,856 | DS | 22 | 2183-06-29 00:00:00 | 2183-06-29 10:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ - Placement of Left frontal VP Shunt
___ - Right cranioplasty, left VP shunt placement
History of Present Illness:
___ year old female well known to the neurosurgery service after
she was admitted for a MCA rupture ___. During her
hospitalization, she was taken emergently for a clipping with
clot evacuation, followed by an immediate take back for a clot
reaccumulation with a hemicraniectomy. An EVD was placed in the
OR case that was later discontinued after minimal outputs and
stable ventricle sizes. She was discharged to rehab, but
returned today after a report of increased somnolence over the
past four days with a decline in her mental status. The patient
had been mouthing a few words and had been able to show a thumbs
up on the right prior to her decline. Of note, she was having
elevated
temperatures at her rehab. Here, she was found to have a
temperature of 102 rectally.
Past Medical History:
HTN, Mitral valve prolapse, hypothyroid
Social History:
___
Family History:
Unknown
Physical Exam:
ON ADMISSION:
-------------
O: T:102.4 rectally
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___
Right gaze deviation. Does not cross midline
Extrem: Warm and well-perfused.
Neuro:
Patient is non-verbal. Does not follow commands
Contracted bilateral upper extremities L>R
Withdraws bilateral lower extremities minimally to noxious.
-------------
ON DISCHARGE:
-------------
Opens eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [ ]Person [ ]Place [ ]Time [x]None Mouthed "hi"
Follows commands: [x]Simple - Smiled. Stuck out tongue
minimally.
Attempts to squeeze hand, show two fingers, show thumb to
command
on RUE. Wiggled toes briskly to command on right
Pupils: PERRL 3-2mm bilaterally
EOM: [x]Full [ ]Restricted - R gaze preference, tracks
Face Symmetric: appears symmetric at rest
Speech Fluent: [ ]Yes [x]No
Comprehension intact [ ]Yes [x]No
Motor:
Contracted upper extremities with increased tone L>R. Able to
lift distal RUE off bed to command.
Wiggles right toes to command
No movement LLE
Wound:
[x]Sutures open to air
[x]Clean, dry, intact
Pertinent Results:
___ 06:56AM BLOOD WBC-9.9 RBC-3.01* Hgb-8.7* Hct-28.8*
MCV-96 MCH-28.9 MCHC-30.2* RDW-14.4 RDWSD-49.5* Plt ___
___ 03:40PM BLOOD Neuts-80.5* Lymphs-9.3* Monos-9.0
Eos-0.2* Baso-0.5 Im ___ AbsNeut-7.67* AbsLymp-0.89*
AbsMono-0.86* AbsEos-0.02* AbsBaso-0.05
___ 06:56AM BLOOD ___ PTT-26.6 ___
___ 06:56AM BLOOD Glucose-116* UreaN-15 Creat-0.3* Na-142
K-4.6 Cl-104 HCO3-26 AnGap-12
___ 02:24AM BLOOD ALT-34 AST-21 LD(LDH)-238 AlkPhos-89
TotBili-<0.2
___ 06:56AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0
___ 03:40PM BLOOD Lipase-31
___ 12:23AM BLOOD CRP-101.9*
___ 03:47AM BLOOD CRP-131.2*
___:55PM BLOOD Lactate-1.4
Imaging:
CT HEAD W/O CONTRAST Study Date of ___ 5:34 AM
IMPRESSION:
1. Slightly limited exam due to patient head tilt.
2. Extra-axial collection deep to the right cranioplasty appears
slightly
decreased in size compared to ___ with stable small
amount of
hyperdense blood products. 5 mm leftward shift of midline
structures appear stable but comparison to the prior study is
limited by differences in patient head position.
3. Stable small intraventricular hemorrhage. Stable size of the
ventricles. Stable position of the VP shunt catheter.
4. New linear hyperdensity in a posterior left occipital sulcus
may represent a small focus of subarachnoid blood or
bone-related artifact.
CHEST (PORTABLE AP) Study Date of ___ 8:11 ___
IMPRESSION:
No evidence of pneumonia. Persistent suspected minor Left
basilar
atelectasis.
CT HEAD W/O CONTRAST Study Date of ___ 10:51 AM
IMPRESSION:
1. Postoperative findings after cranioplasty, aneurysm clipping
and
replacement of the cranioplasty flap are unchanged.
2. Slight interval decrease in size of the right fronta
convexityl extra-axial mixed density fluid collection, with
slightly decreased leftward midline shift measuring 3 mm.
3. Unchanged chronic encephalomalacia within the right MCA
territory in the region of the right frontal lobe, parietal
lobe, and temporal lobe.
4. No evidence of infarction or new hemorrhage.
CHEST PORT. LINE PLACEMENT Study Date of ___ 11:33 AM
IMPRESSION:
New right PIC line ends in the mid to low SVC.
MRI MSK PELVIS W&W/O CONTRAST Study Date of ___ 10:06 ___
IMPRESSION:
1. No abnormal edema or enhancement within the sacrum to suggest
osteomyelitis.
2. Otherwise stable examination compared with earlier on the
same date.
3. Please note that if the ulcer can be probed to bone, by
definition the
patient has osteomyelitis.
CT HEAD W/O CONTRAST Study Date of ___ 4:01 ___
IMPRESSION:
1. Right-sided encephalomalacia related to prior right MCA
hemorrhagic
infarction.
2. New large extra-axial CSF containing collection bulging
through the right craniotomy defect. This collection appears to
communicate with the fluid within the right encephalomalacia
bed.
3. No acute hemorrhage or signs of acute major infarction.
4. Ventricles appear minimally increased in size compared with
prior.
Brief Hospital Course:
#Hydrocephalus
___ who presented ___ from rehab with decline in exam and
fevers. CT head was concerning for enlarged ventricles compared
to prior indicating hydrocephalus. A left frontal EVD was placed
in the ED. Post-EVD CT showed good placement. She was admitted
to the neuro ICU for further monitoring. She was started on
Vancomycin for empiric meningitis coverage. CSF was sent and
showed no growth. EVD was lowered to 5 due to low output. On
___, the patient was taken to the OR and underwent placement
of a Left frontal VP shunt which was set at 0.5 and
cranioplasty. Patient tolerated the procedure well and was
transferred back to the Neuro ICU post-operatively. For a more
detailed report of the operative case please see OMR for
dictated OP Note. A subgaleal drain was placed intra-operatively
and is continued to be monitored for output. Patient underwent a
post-op CTH which revealed good placement of the VP Shunt. On
___, the subgaleal drain was removed. Patient exam remained
stable and she was transferred out to the NIMU. She had a NCHCT
and based on the result, her shunt was re-dialed to 1.0. On
___, her ventricles had only minimally decreased in size and
her shunt was re-dialed to 2.0. She went for a repeat NCHCT on
___ that was stable. Her neuro exam also remained stable.
Another repeat NCHCT was ordered for ___ that was stable.
#Decubitus ulcer
Patient was found to have a pressure ulcer on her coccyx
measuring 2 cm. Cefepime wad added to antibiotics. Wound consult
was placed. On ___, ACS debrided the ulcer x2. Wound culture
was sent and showed mixed bacterial flora. Patient continued IV
antibiotics per ID recommendations and a PICC line was placed.
Wound care nurse continued to follow and recommendations were
appreciated. IV antibiotics were tailored per ID recommendations
and final treatment plan was in place for ___ weeks of IV
cefepime and PO metronidazole. Vancomycin was added for
enterococcus on final culture, with instructions for possibility
to transition to zosyn after discharge if a graded dose
challenged to penicillin was performed due to rash (see separate
ID note). Her leukocytosis resolved on the recommended regimen.
The patient was afebrile on discharge.
#Respiratory
On ___, a cuffless trach was ordered. Patient tolerated
capping of the trach.
Medications on Admission:
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q6H
2. Baclofen 10 mg PO Q8H
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
thrush
4. CloNIDine 0.2 mg PO Q8H
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
6. Heparin 5000 UNIT SC BID
7. Insulin SC, Sliding Scale. Fingerstick QACHS, HS
Insulin SC Sliding Scale using REG Insulin
8. LevETIRAcetam 1000 mg PO BID
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Modafinil 200 mg PO DAILY
11. Multivitamins W/minerals 15 mL PO DAILY
12. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
13. Propranolol 10 mg PO Q12H
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. CefePIME 2 g IV Q12H Duration: 12 Days
Preliminary course until ___
3. Collagenase Ointment 1 Appl TP DAILY
See wound note for complete instructions
4. MetroNIDAZOLE 500 mg PO Q8H Duration: 12 Days
Preliminary course until ___.
5. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
6. Vancomycin 750 mg IV Q 12H Duration: 12 Days
Prelim course to end ___.
7. CloNIDine 0.3 mg PO Q8H
8. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
9. Propranolol 20 mg PO Q12H
10. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q6H:PRN
dry eyes
11. Baclofen 10 mg PO Q8H
12. Docusate Sodium (Liquid) 100 mg PO BID:PRN Constipation -
First Line
13. Heparin 5000 UNIT SC BID
14. LevETIRAcetam Oral Solution 1000 mg PO BID
15. Levothyroxine Sodium 25 mcg PO DAILY
16. Modafinil 200 mg PO DAILY
17. Multivitamins W/minerals 1 TAB PO DAILY
18. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
19. Senna 8.6 mg PO BID:PRN Constipation
20.Outpatient Lab Work
Please fax all lab results to ___. Fax # ___.
Weekly CBC w/diff, BUN, Cr, AST, ALT, tot Bili, Alk phos, CRP.
Vanco trough
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hydrocephalus
Cranial defect
Sacral ulcer
Discharge Condition:
Mental Status: Non-verbal. Can mouth 'Hi' at times.
Level of Consciousness: Alert and follows simple commands
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Surgery
You had a VP shunt placed for hydrocephalus. Your incision
should be kept dry until sutures are removed 14 days after
surgery.
Your shunt is a ___ Strata Valve which is programmable.
This will need to be readjusted after all MRIs or exposure to
large magnets. Your shunt is programmed to 2.0.
Please keep your incision dry until your sutures are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10348382-DS-8 | 10,348,382 | 27,710,043 | DS | 8 | 2147-12-20 00:00:00 | 2147-12-22 10:25:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
large bowel obstruction
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
___ prior RNYGB+CCY ___ who presents to the ED with LBO. Of
significance, patient started to experience weakness and has not
had a BM since ___. Patient also has not passed gas in the past
few days.Patient denies nausea/vomiting/fever/chills. Patient
tolerated regular meals well in the past 2 days. Patient at
baseline has lost weight since his surgery, and currently
remains active. Of importance, patient's last colonoscopy was
___ which demonstrated a 2cm polyp 20cm from the anal verge. In
the ED patient had a CT A/P which demonstrated marked dilation
of the colon, with cecum dilated to 12cm with focal transition
point at the proximal sigmoid colon, where there may be a
stricture,concerning for malignancy.
Past Medical History:
PMH: HTN, OSA, morbid obesity
PSH: eye surgery ___, RNYGB+CCY ___ ( ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
GEN: NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, No JVD
PULM: normal excursion, no respiratory distress
ABD: soft, NT, ND, no mass, no hernia
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
___ 07:18AM BLOOD WBC-5.7 RBC-4.89 Hgb-11.3* Hct-39.0*
MCV-80* MCH-23.1* MCHC-29.0* RDW-18.2* RDWSD-51.3* Plt ___
___ 08:05AM BLOOD WBC-5.5 RBC-4.75 Hgb-11.2* Hct-38.0*
MCV-80* MCH-23.6* MCHC-29.5* RDW-17.7* RDWSD-50.8* Plt ___
___ 07:50AM BLOOD WBC-6.3 RBC-4.64 Hgb-10.7* Hct-36.8*
MCV-79* MCH-23.1* MCHC-29.1* RDW-17.6* RDWSD-49.9* Plt ___
___ 12:55PM BLOOD Glucose-84 UreaN-7 Creat-0.8 Na-145 K-3.8
Cl-105 HCO3-30 AnGap-10
___ 07:18AM BLOOD Glucose-159* UreaN-6 Creat-0.9 Na-146
K-3.2* Cl-106 HCO3-28 AnGap-12
___ 11:20PM BLOOD Glucose-109* UreaN-7 Creat-0.8 Na-145
K-3.1* Cl-106 HCO3-28 AnGap-11
___ 12:55PM BLOOD Calcium-8.7 Phos-1.8* Mg-2.0
___ 07:18AM BLOOD Calcium-8.8 Phos-2.1* Mg-2.0
___ 07:50AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.4
___ 04:30PM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.6 Mg-2.4
Brief Hospital Course:
Mr. ___ is a ___ yo M PMHx obesity sp RYGBP who presents
with sigmoid narrowing causing large bowel obstruction with area
concerning for benign vs malignant stricture. He was admitted to
the colorectal service, NPO with fluids, serial abdominal exams
and stable. HD#2, patient underwent GI endoscopic stent
placement,3 cm mass was seen and biopsied, pathology pending.
Following procedure, patient diet was advanced to clears and
tolerated well. He was started on bowel regimen, Miralax daily.
HD#3, diet was advanced to regular, low residue and tolerated
well. HD#4 He was started on prophylaxis Lovenox 40 mg SC bid
for preoperative surgical plan.
Electrolytes were monitored closely and noted to have
hypokalemia and received potassium repletion and monitored on
telemetry. By HD#5, potassium had normalized to 3.8.
At time of discharge, patient was doing well, tolerating a diet,
passing gas and having bowel movements. He was discharged home
on prophylaxis Lovenox injections, timing of surgery to be
determined by Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 200 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 40 mg SC BID Prophylaxis
RX *enoxaparin 40 mg/0.4 mL 1 syringe sc twice a day Disp #*30
Syringe Refills:*0
2. Gabapentin 600 mg PO QHS Duration: 2 Doses
RX *gabapentin 600 mg 1 capsule(s) by mouth once a day Disp #*5
Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H preop
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth once a
day Disp #*4 Tablet Refills:*0
4. Neomycin Sulfate 500 mg PO AS DIRECTED
as directed in the pre-operative preparation
RX *neomycin 500 mg 1 tablet(s) by mouth once a day Disp #*8
Tablet Refills:*0
5. amLODIPine 5 mg PO DAILY
6. LamoTRIgine 200 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
LARGE BOWEL OBSTRUCTION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital for large bowel obstruction
and underwent GI endoscopic stent, a 3 cm mass was seen in the
sigmoid colon which was biopsied and results pending at
discharge. Your diet was slowly advanced to clear liquids to
regular diet and tolerated well. You were also started on bowel
regimen, Colace and Miralax that you should continue to take as
prescribed. During this admission, your potassium levels were
low and treated with potassium supplements. Your potassium
levels have since normalized.
You are being discharged home on Lovenox injections to prevent
blood clots in preparation for your surgery. You will take this
medication for a total of 30 days (including doses in hospital),
please finish the entire prescription. Please monitor for any
signs of bleeding: fast heart rate, bloody bowel movements,
abdominal pain, bruising, feeling faint or weak. If you have any
of these symptoms please call our office or seek medical
attention immediately. Please avoid any contact activity and
take extra caution to avoid falling while taking Lovenox.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
10348731-DS-2 | 10,348,731 | 28,641,644 | DS | 2 | 2159-02-07 00:00:00 | 2159-02-08 16:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
azithromycin / adhesive tape
Attending: ___.
Chief Complaint:
Left-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a very pleasant ___ M with history of HTN, HLD,
CAD, MI s/p stent in ___, psoriatic arthritis, OSA and asthma
who was transferred to ___ from ___ for code stroke after
left-sided weakness and decreased sensation.
He was in his usual state of health yesterday and went to bed
around 9pm. He did not notice any unusual symptoms at that time.
At 12:38am, he awoke to go to the bathroom and noticed that he
could not use his left arm. He tried to drink water, and it
dribbled down his face. He attemtped to put on his CPAP facemask
and was unable to do so. He had no limb shaking. His wife
noticed that he had significant dysarthria and called EMS, who
noted left-sided facial droop and took him to ___
___.
At ___, a head CT was unremarkable. He complained of asthma
exacerbation. He was given aspirin and an albuterol inhaler and
transferred to ___ for further care and possible intervention.
On arrival at ___ ED, a code stroke was called. VS were 97.2,
72, 114/84, 16, 100%RA.
He had some dysarthria at the time but could clearly communicate
the whole story.
He has never had similar symptoms in the past.
Past Medical History:
- HTN
- HLD (Last cholesterol checked 2 mos ago, TChol 162)
- CAD
- Atherosclerosis. He notes that he had a recent carotid artery
ultrasound that showed significant atherosclerosis of both
carotid arteries but not enough to merit CEA.
- MI s/p BMS in ___
- Psoriatic arthritis
- Asthma
- GERD
- OSA
- S/p appendectomy c/b wound infxn s/p washout, closure by
secondary intention, s/p 4cm colon resection with staged
re-anastomosis, s/p incisional hernia repair x3 & LOA
Social History:
___
Family History:
Sister with brain aneurysm with surgical complication leading to
stroke at age ___ with cognitive impairment. 7 other siblings in
good health. Father with psoriasis, HTN, age ___. Mother with
bone and hip problems, age ___.
Physical Exam:
Physical Exam on admission:
Vitals: T: 97.4 P: 72 R: 16 BP: 114/84 SaO2: 100%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: obese, soft, NT/ND, normoactive bowel sounds, no masses
or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. no pitting edema in either leg
Skin: no rashes or lesions noted.
Neurologic:
(If applicable)
___ Stroke Scale score was 9:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 2
5b. Motor arm, right: 0
6a. Motor leg, left: 2
6b. Motor leg, right: 0
7. Limb Ataxia: 1
8. Sensory: 2
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 0
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty (but some dysarthria) able to name ___
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Able to
follow both midline and appendicular commands. The pt. had good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation decreased to light touch over the left side.
VII: L NSF flattening with slight droop facial musculature
asymmetric.
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 2 ___ ___ 3 4 3 3 4 3 3
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Decreased to light touch, cold, vibration,
proprioception over entire L hemibody. Extinction could not be
tested
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on the right and mute on the left
-Coordination: (could not perform in the left arm) No intention
tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS
on the left
-Gait: defered
Pertinent Results:
Admission Labs:
___ 03:30AM BLOOD WBC-6.5 RBC-4.45* Hgb-13.4* Hct-39.5*
MCV-89 MCH-30.1 MCHC-33.9 RDW-12.7 Plt ___
___ 03:30AM BLOOD ___ PTT-28.6 ___
___ 10:18AM BLOOD Glucose-96 UreaN-15 Creat-0.7 Na-138
K-3.7 Cl-101 HCO3-27 AnGap-14
___ 06:20AM BLOOD ALT-25 AST-21 LD(LDH)-175 AlkPhos-48
TotBili-0.6
___ 03:30AM BLOOD cTropnT-<0.01
___ 10:18AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:20AM BLOOD Albumin-4.2 Calcium-9.7 Phos-3.7 Mg-1.6
___ 10:18AM BLOOD %HbA1c-5.5 eAG-111
___ 10:18AM BLOOD Triglyc-54 HDL-109 CHOL/HD-1.7 LDLcalc-61
___ 10:18AM BLOOD TSH-0.69
___ 06:00AM BLOOD ___ * Titer-PND
___ 01:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:50PM URINE Color-Straw Appear-Clear Sp ___
___ 1:50 pm URINE Source: ___.
URINE CULTURE (Final ___: <10,000 organisms/ml.
Reports:
EKG: Sinus rhythm. RSR' pattern in lead V1 (probable normal
variant). Early R wave transition. No previous tracing available
for comparison.
Rate PR QRS QT/QTc P QRS T
61 ___ 21
ED Head CT/CTA: Decreased blood flow with nearly complete
matched area of decreased blood volume in the anterior temporal
lobes. The mean transit time appears normal. There is a
hyperdense slightly expanded periphery of vessel in the region,
suspicious for a clotted vessel. These findings suggest an acute
infarction in the right anterior temporal lobe, however, given
the low sensitivity of CT in the evaluation of hyperacute
infarction, dedicated brain MRI is recommended for further
characterization. The right vertebral artery terminates in ___.
Bilateral calcified atherosclerotic plaques identified at the
cervical bifurcations as described above. Multilevel
degenerative changes throughout the cervical spine.
CXR: In comparison with the earlier study of this date, the
patient has
taken a better inspiration. Cardiac silhouette remains somewhat
enlarged,
though there is no evidence of vascular congestion, pleural
effusion, or acute focal pneumonia. Mild prominence of the
azygos region, raises the possibility of some right-sided heart
failure.
MRI Head: 1. Acute/subacute infarction in the right temporal
lobe, vascular distribution of the right middle cerebral artery
as described in detail above, with no evidence of hemorrhagic
transformation. Scattered foci of high signal intensity,
distributed in subcortical white matter, consistent with small
vessel disease. Bilateral mucosal thickening noted at the
ethmoidal air cells and maxillary mucous retention cysts.
Echo: The left atrium is mildly dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Transmitral and tissue Doppler imaging suggests normal
diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION:Mild symmetric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. No valvular pathology or pathologic flow identified.
No definite structural cardiac source of embolism identified.
Brief Hospital Course:
Upon arrival at ___, Mr. ___ symptoms appeared to be
improving as he had regained some function in his arm and leg.
He was outside of the 6-hour tPA window and so was not a
candidate for reperfusion therapy. He was admitted to the
Neurology Stroke service. ___ at ___ showed decreased
cerebral blood flow in right anterior temporal lobe with a
nearly completely matched area of decreased cerebral blood
volume. There was an area suspicious for a clotted vessel
nearby. MR at ___ showed a likely embolic stroke in the right
hemisphere. He had only scattered atherosclerotic plaques seen
on CT angoigram with no critical stenosis. He had no evidence
for other potential embolic sources, and an echocardiogram was
also unrevealing. Cardiac enzymes were negative.
Given his use of Remicade, drug-induced lupus was also
considered as a very rare but possible cause of the stroke,
although he lacked other stigmata of lupus. While the ___
returned as positive, his titer is pending at the time of this
summary. His home anti-hypertensives were held to allow him to
auto-regulate, and his SBP remained in the 130s-140s.
He was started on aspirin 325mg ___. He had previously self
discontinued his ___ aspirin as he was worried that together
with prednisone, he would have more problems with GI irritation.
Apparently there was some history of a "hole in his colon" which
required resection. His LDL returned back at ___, and
consequently his home dose of atorvastatin was not changed. He
was also recommended to undergo a holter monitor as an
outpatient so as to capture potential paroxysmal atrial
fibrillation. This recommendation was communicated directly to
his outpatient primary care physician, ___.
At the time of discharge, Mr. ___ was ambulatory and
independent for all ADLs. He had a mild left facial droop
without dysarthria or swallowing difficulties. He was notified
about his follow up appointment with his PCP an Dr. ___
the division of Stroke Neurology, here at ___. All of his and
his wife's questions were answered to the best of our ability.
TRANSITIONAL ISSUES:
- ___ titer
- Follow up results of 30 day holter monitor
- Ensure that patient is still taking a ___ aspirin
Medications on Admission:
lansoprazole 15 mg Cap, Delayed Release Oral
hydrochlorothiazide 25 mg Tab Oral
Combivent 18 mcg-103 mcg/actuation Aerosol Inhaler Inhalation
Nasacort AQ 55 mcg Nasal Spray Aerosol Nasal
Advair Diskus 500 mcg-50 mcg/dose for Inhalation Inhalation
amlodipine-atorvastatin 10 mg-20 mg Tab Oral
Remicade 100 mg IV Solution Intravenous
gabapentin 600 mg Tab Oral
folic acid 1 mg Tab Oral
prednisone 10 mg Tab Oral
multivitamins/minerals
Calcium 500 + D -- Unknown Strength
guaifenesin ER 600 mg Tab Oral
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet ___.
2. prednisone 10 mg Tablet Sig: One (1) Tablet ___.
3. gabapentin 600 mg Tablet Sig: One (1) Tablet ___ twice a day.
4. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: 0.5
Tablet,Rapid Dissolve, ___ ___.
5. multivitamin Tablet Sig: One (1) Tablet ___.
6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) ___.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
8. sodium chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal
BID (2 times a day) as needed for congestion.
9. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet ___ once
a day.
10. amlodipine-atorvastatin 10 mg-20 mg Tab Oral Sig: One (1)
Tablet ___
11. Remicade 100 mg Recon Soln Sig: One (1) Intravenous As
instructed by your PCP.
12. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One
(1) Tablet ___ once a day.
13. guaifenesin 600 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release ___ once a day as needed for cold
symptoms.
Discharge Disposition:
Home
Discharge Diagnosis:
Main DIAGNOSIS: Right MCA territory infarction
- Hypertension
- Hyperlipidemia
- Psoriatic arthritis
- Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Neurological Examination: Slight diminished left
nasolabial fold activation, left forearm and hand numbness to
pinprick and temperature. Left upgoing toe.
Discharge Instructions:
Dear Mr. ___:
It was a pleasure to care for you during your
hospitalization at ___. You
were admitted to the Neurology wards of the ___ for the
evaluation of your symptoms of left sided weakness and slurred
speech. Through a series of interviews, physical examinations,
laboratory studies and neuroimaging tests, we determined that
you sustained an ISCHEMIC stroke (caused by a blood clot) in the
right side of your brain. You have several risk factors for
stroke, including elevated cholesterol, high blood pressure and
a history of tobacco abuse. We examined the blood vessels in
your head and neck and found no evidence of major blockages or
aneurysms. We also performed an ultrasound of your heart, and
this showed no signfiicant abnormalities in the valves or pump
function of the heart.
- It is important that you continue to take your medications as
prescribed. The only new medication we added is ASPIRIN 325mg
___, which is available over the counter. Do not hesitate to
contact us if you have any questions or concerns.
- Please come to your nearest ___ ED should you have any of
the below listed unexplained symptoms.
- Please be sure to follow up with your primary care physician
and Dr. ___ the ___ of Stroke Neurology.
- Continue to stick to a healthy lifestyle. Try to exercise for
at least 30 minutes ___.
Followup Instructions:
___
|
10348831-DS-3 | 10,348,831 | 21,727,290 | DS | 3 | 2124-09-15 00:00:00 | 2124-09-16 18:29:00 |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
___ yo Caucasian Male with EtOH cirrhosis previously complicated
by Ascites and Esophageal varices (last EGD ___ and
Grade1 varices, last RUQUS ___ without ascites but with
Cirrhosis and Splenomegaly, last CScope ___ normal, not on
any medications) followed by Dr. ___. He presents with
subacute DOE, SOB, CP, Dizziness, exercise intolerance, and
significant pallor that was noticed in ___ and
significantly worsened in last two weeks.
Patient reports that when he last saw Dr. ___ in ___ his
ascites had improved and he was instructed to stop his diuretics
and propranolol. Since that visit he has done well from a liver
standpoint but has had progressively worsening excercise
tolerance. He used to walk on treadmill for 30min, that
decreased to 20 minutes and then he stopped exercising fully
around end of ___. During exertion notes symptoms of
significant griping anterior chest pain without radiation that
along with significant dizziness "seeing stars", and
lightheadedness without loss of consciousness. Symptoms would
fully resolve with rest or bending forward while resting. Over
the past few weeks chest pain with exertion has been increasing
in frequency and duration, and starting two days ago was
occuring at rest as well. He does have h/o HLD, HTN but ___
diagnosis of CAD, lifetime non smoker.
In ___ he could only walk for 10min without stopping to
catch his breath. He would also notice significant dizziness and
chest pain when ambulating that distance. Two weeks ago he
would have these symptoms start after only one trip down
stop/shop aisle, this week he could not fully complete walk down
grocery aisle. His AA support group noticed significant pallor
last week and encouraged him to call his doctor this week.
Patient called Dr. ___ the office PA encouraged patient
to go to ED yesterday.
He denies abdominal pain, nausea, vomiting. Did notice more
constipation and jet black stool in the last two weeks, worst
this past week. He has been taking Aleve BID for the past ___
years. Notes his did slip up and drink alcohol 1 month ago in
the context of social stressors including losing his job, his
parents being in the hospital, and having to move, none since.
Does attend AA meetings weekly.
___ fevers or chills. His weight has increased from 220 to 240 in
last 6months but the patient denies edema of extremeties. Does
note somewhat more distended abdomen. Denies new rashes. ___
other medications, ingestions, herbal supplements.
In the ER patient was noted to be tachycardic but normotensive.
Hct 19.6 with normal platelets and INR. Elevated RDW and low
MCV. Rectal exam with dark guaiac positive stool.
Past Medical History:
Well compensated Alcoholic cirrhosis- followed by Dr. ___
in the ___
-c/b varices (grad1 and grade 2 seen on EGD in ___
-___ ascites on Ultrasound in ___, ___ hx of hepatic
encephalopathy
Hypertension
HYperlipidemia
H/o alcohol dependence- last drink 1 mo ago per patient
Chronic arthtritis
Social History:
___
Family History:
Males on mother's side with heart issues
Mother alive with hip problems
Father alive with dementia, strokes
Brother alive with HLD, ___ MI
2 daughters, one graduated from ___ and now a ___, the
other graduated from ___ also a ___
Physical Exam:
VS: 98.7, 141/85, 98, 18, 100RA Wt 116.9kg
GENERAL: well appearing in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, ___ LAD, JVP at 8cm
LUNGS: CTA bilat, ___ wheezes or rales noted
HEART: RRR, ___ MRG, nl ___
ABDOMEN: normal bowel sounds, soft, ___,
___ rebound or guarding, ___ masses
EXTREMITIES: ___ edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs ___ grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, ___
asterixis, able to say days of th eweek backwards
Skin- ___ spider angioma, ___ palmar erythema
.
DISCHARGE:
VS: 98.3, 130/86, 81 (on tele ___, 100RA
Ambulatory pulse ox: 96% on RA ambulating 100ft
Orthostatics normal (SBP 130s laying --> 130s standing, HR ___
change, asymptomatic)
I/O: 1.8 / BRP, 3 BMs
GENERAL: well appearing in NAD caucasian male
HEENT: Good dentition, NC/AT, PERRLA, EOMI, sclerae anicteric,
MMM
NECK: supple, ___ LAD, flat neck veins
LUNGS: CTA bilat, ___ focal adventitious sounds
HEART: regular rhythm, rate in the ___, ___ MRG, nl ___
ABDOMEN: Obese, normal bowel sounds, soft, ___
rebound or guarding
EXTREMITIES: ___ edema, 2+ pulses radial and dp, slight palmar
pallor improved from prior days
NEURO: awake, A&Ox3, CNs ___ grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, ___
asterixis,
Pertinent Results:
ADMISSION:
Trop T 0.03
Hct 19
Plt 124
INR 1.1
.
MICRO:
- none
.
IMAGING:
-ECHO: The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. ___ aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is ___ pericardial effusion
- CScope - normal
- EGD - 4 cords of small grade ___ varices were seen in the
distal esophagus with overlying linear erythema at the GE
junction // Patchy erythema with erosions of the mucosa was
noted in the antrum. These findings are compatible with
gastritis, most likely due to NSAIDs. Cold forceps biopsies were
performed for histology at the antrum.
.
DISCHARGE:
Hct 29
MCV 77, RDW ___
Ferritin ___
Fe 13
PLT 238
ALT/AST ___, TBili .9, ALP 141
Chem 10 normal
TnT: .03 -> .07 -> .08
CKMB: 5 -> 4
Trig 152
HDL 30
LDLcalc 73
A1c - 5.4
Brief Hospital Course:
Mr. ___ is a ___ yo M w/ alcohol cirrhosis with known grade
1&2 varices who prsents with dyspnea on exertion and chest pain
and found to have HCT of 19.2 and TnT of .03. Admission EKG did
show TWI in V4, V5, with HR upper ___.
.
Brief Course:
# Anemia: Patient received a total of 3U pRBC with Hct
improvement 19 (___) --> 29 (___). Symptoms also substantially
improved. Patient was able to ambulate >100ft without sensation
of dizziness. Source of anemia found to be gastritis in stomach
and duodenum via EGD, likely ___ years of Alleve. Started on
PPI, Iron and instructed to avoid NSAIDs. Also, for his
___ Cirrhosis, patient was ___ on Propranolol
40mg/day, thiamine, and MVI. Biopsies taken during EGD and
pending on discharge. Patient instructed to ___ Hct in 3
days from discharge. Did receive 1 HepB vaccine while in
patient, needs 2 more with PCP or Dr. ___
# Demand Ischemia: In regards to cardiac issues, patient's
baseline status in ___ included 30 minutes on a treadmill
without any symptoms, but during the last several months noted
significant decline in exercise tolerance. Etiology most likely
the severe anemia. Patient was not in chest pain on arrival or
at any time during his stay. CKMB initially 5, was 4 on
___. EKG with Tachycardia and V4V5 TWI, which resolved
after RBC transfusions. ___ concerning events on Telemetry. Echo
done that was not concerning. Patient may have some underlying
CAD, but it is probably not significant as long as he is not
severely Anemic. Seen by Cardiology that recommended checking
lipids, starting statin, and aspirin. After discussion with GI
team, Aspirin deemed appropriate for patient. Risk benefits
discussion regarding use of Aspirin done and patient understands
with good insight and judgement. Recommended patient discuss
further cardiology evaluation after discusion with PCP, ___ acute
indication for stress test. Can consider ACEI if needs BP
control as an outpatient. Discharged with Pravastatin, and
Aspirin.
TRANSITIONAL:
- Hct check on ___
- PCP follow up this week
- 2 more Hepatitis B Vaccinations remaining
- F/U Biopsy results
- F/U Lipid and A1C (pending at discharge)
- Cardiology referral after evaluated by PCP
- ___ more NSAIDs
- Use Tramadol instad of NSAIDs for pain
- Restart Propranolol 40mg / day
- Start Aspirin 81mg for cardio protection, with food
- Pantoprazole 40mg BID x 8 weeks, EGD afterwards
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Naproxen 500 mg PO Q12H
3. Fish Oil (Omega 3) 1000 mg PO BID
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Aspirin 81 mg PO DAILY
Take with food
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*90 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*3
5. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q12H
continue for 8 weeks
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
7. Pravastatin 20 mg PO DAILY
RX *pravastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Propranolol 40 mg PO DAILY
RX *propranolol 40 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl [Vitamin ___ 100 mg 1 tablet(s) by mouth daily
Disp #*90 Tablet Refills:*0
10. Fish Oil (Omega 3) 1000 mg PO BID
11. TraMADOL (Ultram) 50 mg PO BID:PRN knee pain
RX *tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
- Gastritis due to NSAID use
- Suspected CAD with Demand Ischemia
SECONDARY:
- Alcohol Cirrhosis (Grade ___ Varices)
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
for significant dizziness, black stool, and shortness of breath.
You were found to have a very low blood count called Hematocrit.
The GI doctors performed ___ that determined the cause of
this low blood count is long term use of Alleve causing bleeding
in your stomach. You also had some changes on an EKG, these are
most likely related to the low blood count placing extra stress
on your heart. You received 3 units of blood in the hospital
and your functioning status improved. You were also started on a
medication to help platelets stop the bleeding in your stomach.
Please make sure to check your blood count on ___
either at your PCP office or ___. Also, do not restart any
pain medication with the word "NSAID", such as Alleve or
Ibuprofen. Do not start any other pain medication unless discuss
with doctor first. Also, please abstain from alcohol to protect
your liver and stomach.
See the medication changes attached.
Followup Instructions:
___
|
10349029-DS-11 | 10,349,029 | 20,678,690 | DS | 11 | 2175-12-29 00:00:00 | 2175-12-30 05:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydralazine And Derivatives / Bumex / Sulfa (Sulfonamide
Antibiotics) / Lactose / banax / Neurontin
Attending: ___.
Chief Complaint:
Left-sided abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with history of prior volvulus and C. Diff colitis,
presents with 2 weeks of melenic stool & 1 day of severe L-sided
abdominal pain with bloody diarrhea.
The patient states that her problems began roughly 2 weeks ago
when she noted intermittent dark black stool with constipation.
She was frequently straining to defecate leading to intense
abdominal pain. The patient has a longstanding history of
diarrhea thought to be due to IBS, and she usually has bowel
movements after every meal. For the past two weeks, however, she
has only been having ___ bowel movements per day, which were all
hard and melenic. She has chronic DOE, which she states has been
worse over the past 2 weeks and also associated with some
lightheadedness.
For the past week, she felt "chilled" with sweats throughout the
day, but no recorded fever. During this time she has had some
intermittent non-bloody diarrhea, but denies cough, nausea,
vomiting, UTI symptoms.
This AM, she started developing nausea with non-bloody emesis.
She had multiple episodes of nausea & vomiting with eventual dry
heaves. She felt extremely poorly during the day with
lightheadedness. Later in the day she developed severe L-sided
abdominal pain which prompted her to seek medical treatment. She
has never experienced this sort of pain in the past.
The patient has chronic dyspepsia and dysphagia (which is due to
a diverticulum, according to the patient's daughter), but denies
food avoidance and weight loss. Also denies eating raw foods of
any sort, drinking well-water, or being in contact with anyone
who shares her symptoms, recent travel, pets, or recent
antibiotics. Last colonoscopy was in ___ which was normal and
EGD showed a diverticulum in the esophagus. ACS saw patient in
the ED and determined that surgery was not necessary.
VS in ED: 97.6 87 120/79 18 99%. CT of abdomen showed L-sided
colitis that was also present in ___. CXR was negative. IV
protonix bolus and drip was started. IV cipro was started but
discontinued after arm itching. She was switched to IV
ceftriaxone 1mg. Guaic positive. The patient states that in the
ED she developed a couple of episodes of "loose, bloody stool"
although her daughter says it was brownish-red.
Patient has excellent long-term memory and able to record events
from her past. However, poor historian of recent events. This
morning, continues to complain of L sided abdominal pain only
when pressing her abdomen. Denies fevers/chills, sob, cp,
difficulty urinating, dysuria.
REVIEW OF SYSTEMS:
(+): As above
(-): Hematemesis, hematuria, dysuria, urinary frequency or
urgency, chest pain, headaches
Past Medical History:
- Gastric volvulus ___ yrs ago) s/p repair
- Internal hemorrhoids
- legally blind
- IBS
- C diff colitis
- HTN
- Hyperlipidemia
- CAD
- RBBB
- DOE s/p extensive negative work up
- Hypothyroidism
- OA
- PUD
- Prior GYN surgeries remotely
- GERD
- Depression
- s/p hiatal hernia repair
- s/p cholecystectomy
- s/p appendectomy
- s/p ORIF L radius ___
Social History:
___
Family History:
- Mother: CAD, CVA
- Aunt: ___ cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
98 110/62 72 18 98/RA
GEN: Resting in bed, appears weak, NAD.
HEENT: PERRLA, EOMI, NCAT. Dry MM, OP clear
NECK: Supple, no LADF
COR: + S1S2, RRR, no m/g/r.
PULM: CTAB no c/w/r
___: + NABS in 4Q. Soft with exquisite TTP of LUQ, LLQ which is
out of proportion to exam. No rebound or involuntary guarding.
Small umbilical hernia that is reducible. No masses felt.
EXT: WWP, no c/c. Mild edema b/l. Right hand with decreased
sensation and movement in ulnar aspects of hand.
NEURO: CN II-XII within normal limits given age, ___ strength
throughout, sensation to soft touch intact, A&Ox3, good long
term memory, however some difficulty remembering recent events
DISCHARGE PHYSICAL EXAM
97.4 138/63 72 20 98%RA
GEN: Resting in bed, NAD.
COR: + S1S2, RRR, no m/g/r.
PULM: CTAB no c/w/r
___: + NABS in $4Q. Soft, small 2cm umbilical hernia that can
be reduced. mild tenderness to palpation on one location at mid
L side of abdomen but much improved since admission, no rebound
or involuntary guarding.
EXT: WWP, no c/c. Mild edema b/l. 1+ ___ pulses.
NEURO: A&Ox3
Pertinent Results:
ADMISSION LABS
___ 02:42PM BLOOD WBC-15.9*# RBC-5.23 Hgb-13.9 Hct-43.4
MCV-83 MCH-26.5* MCHC-32.0 RDW-17.2* Plt ___
___ 02:42PM BLOOD Neuts-89.9* Lymphs-4.7* Monos-4.9 Eos-0.4
Baso-0.1
___ 02:42PM BLOOD ___ PTT-26.9 ___
___ 02:42PM BLOOD Glucose-171* UreaN-19 Creat-1.1 Na-137
K-3.4 Cl-98 HCO3-31 AnGap-11
___ 02:42PM BLOOD ALT-14 AST-24 AlkPhos-147* TotBili-0.4
___ 07:00AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.8
___ EKG: 73bpm, Sinus rhythm. Right bundle-branch block. Low
precordial lead voltage. Compared to the previous tracing of
___ the rate has slowed. The precordial voltage has
diminished. Atrial ectopy is absent. The repolarization
abnormalities previously recorded are less prominent in the
precordial leads. Otherwise, no diagnostic interim change.
RELEVANT LABS
___ 02:44PM BLOOD Lactate-2.8*
___ 08:17AM BLOOD Lactate-2.2*
___ 02:09PM BLOOD Lactate-1.0
DISCHARGE LABS
___ 07:45AM BLOOD WBC-5.9 RBC-4.13* Hgb-10.6* Hct-33.8*
MCV-82 MCH-25.7* MCHC-31.5 RDW-19.1* Plt ___
___ 07:45AM BLOOD Glucose-125* UreaN-3* Creat-1.0 Na-140
K-3.3 Cl-106 HCO3-27 AnGap-10
___ 07:45AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.5* Iron-PND
___ 07:45AM BLOOD Ferritn-PND TRF-PND
MICRO
___ 5:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 8:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:54 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
MODERATE RBC'S.
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.
___ 6:00 pm STOOL CONSISTENCY: NOT APPLICABLE
OVA + PARASITES (Preliminary):
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
IMAGING:
___ CTA ABDOMEN & PLEVIS
IMPRESSION:
1. Colitis involving the descending and sigmoid ___, which
may be ischemic, infectious, or inflammatory in etiology.
2. Major mesenteric vessels are patent.
3. Chronic intra- and extra-hepatic biliary ductal dilatation,
unchanged.
___ CXR:
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
___ F with chronic diarrhea, prior remote volvulus and C. diff,
internal hemorrhoids p/w 2 weeks melanotic stools, 1 week of
diarrhea & chills, and 1 day of severe L-sided abdominal pain &
bloody diarrhea.
# ISCHEMIC COLITIS: Patient's symptoms and imaging findings
reflect a process in ___. Colitis most likely ischemic
due to recent dehydration secondary to nausea/vomiting/diarrhea
coupled with concomitant use of diuretics, which precipitated a
low flow state. No fevers, C. diff negative, negative stool
cultures ruling out an infectious process. Inflammatory causes
like diverticulitis could be a possibility however last
colonoscopy in ___ did not show any diverticulosis and the
radiographic findings are not consistent with diverticulitis.
Patient was started in IVF and kept NPO. Orthostatics were
checked daily. Her lactate on admission was 2.8 but normalized
the following day. Leukocytosis also normalized the next day.
Patient was also started on ceftriaxone and metronidazole to
prevent an infection, which was discontinued on the day of
discharge as she showed no signs of infection and her cultures
were negative. She completed a 7 day course.Blood cultures
remained negative as well.
Patient's diet was advanced as tolerated. By discharge, she was
able to tolerate a regular diet with her baseline abdominal
cramping and loose stools. Her pain was significantly improved,
and she only experienced mild tenderness on palpation of the
left lower quadrant.
# GI BLEED: Pt endorsed 2 weeks of melenic stool which was
concerning for upper GI source. She has a h/o of PUD and
internal hemorrhoids. In ED, patient had BRBPR but subsequent
stools while on floor were guaiac negative. She was started on
protonix drip then switched to protonix 40mg BID. Aspirin was
held initially but then restarted at the time of discharge. GI
saw patient and determined that no interventions were needed.
Her hematocrit and BP remained stable throughout her
hospitalization. Her protonix was changed back to her home dose
on discharge.
# DIARRHEA: States that she has chronic diarrhea/constipation
with cramping pain associated with meals secondary to IBS.
Diarrhea was greenish, liquid, guaiac negative. GI was consulted
and recommended probiotics.
# WORSENING DYSPNEA: Reports worsening dyspnea and angina in
past few months. H/o CAD. During her hospitalization, she denied
any chest pain. Last ECHO was in ___ which showed LVH with
preserved systolic function and mild mitral regurgitation. CXR
on admission was normal, EKG demonstrated chronic RBBB and no
acute changes. She remained stable during this hospitalization
and did not require further work-up. Further evaluation and
management may be performed per her PCP. She was started on a
low-dose beta-blocker at the time of discharge for
cardioprotection.
# CHRONIC ISSUES:
-PUD: she was kept on protonix 40mg BID and switched to her home
dose at the time of discharge
-HTN: all antihypertensive medications were held during
admission due to dehydration. They were restarted once patient
was stabilized and had negative orthostatics. She was newly
started on a beta-blocker at the time of discharge
-HYPOTHYROIDISM: continued on levothyroxine
-DEPRESSION: Continued on citalopram
-HLD: Continued on simvastatin
# TRANSITIONAL ISSUES
- please follow-up with iron studies to determine etiology of
anemia
- please monitor blood pressure given the new addition of
metoprolol tartrate 12.5mg po BID
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Losartan Potassium 50 mg PO DAILY
2. Fosfomycin Tromethamine 3 g PO PRN UTI
Dissolve in ___ oz (90-120 mL) water and take immediately PRN
UTI
3. Multivitamins 1 TAB PO DAILY
4. Nystop *NF* (nystatin) 100,000 unit/g Topical TID
5. Aspirin 81 mg PO DAILY
6. Citalopram 20 mg PO DAILY
7. Clotrimazole 1 TROC PO TID:PRN thrush
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Omeprazole 20 mg PO BID
12. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Clotrimazole 1 TROC PO TID:PRN thrush
9. Fosfomycin Tromethamine 3 g PO PRN UTI
Dissolve in ___ oz (90-120 mL) water and take immediately PRN
UTI
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Nystop *NF* (nystatin) 100,000 unit/g Topical TID
12. Omeprazole 20 mg PO BID
13. Heparin 5000 UNIT SC TID
14. Metoprolol Tartrate 12.5 mg PO BID
Please hold for SBP < 100 or HR < 55. thank you.
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Left sided and sigmoid ischemic colitis
Secondary: Coronary artery disease, Peptic ulcer disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted because of left sided abdominal
pain. Imaging of your abdomen showed that there was a decrease
in the amount of blood flowing to your large intestines causing
the pain.
You were given fluids through your IV and antibiotics to prevent
an infection. You were also kept on bowel rest (nothing to eat
or drink) to allow your pain to resolve. The gastroenterologist
and surgery teams saw you and determined that no further
interventions were needed. You slowly began to take in food and
did well. Your left abdominal pain also improved. Your loose
bowels movements were returning to their baseline by the time of
discharge. Please continue to drink plenty of fluids to prevent
dehydration.
You had some blood in your stools when you were in the emergency
department. However, subsequent stools were negative for blood
or for an infection. Please contact your primary care physician
if you notice blood in your stools.
Followup Instructions:
___
|
10349029-DS-12 | 10,349,029 | 27,420,021 | DS | 12 | 2176-03-01 00:00:00 | 2176-03-01 13:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydralazine And Derivatives / Bumex / Sulfa (Sulfonamide
Antibiotics) / Lactose / banax / Neurontin
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ F with distant history of gastric volvulus s/p
repair, s/p appy and s/p CCY, recent admission for ischemic
colitis ___ and also with history of prior C.Diff colitis
who presents now with abdominal pain and vomiting that started
around noon ___. Daughter, ___, accompanies patient and
corrobarates story. The patient initiall started feeling
slightly unwell last week, with some stomach discomfort and so
starting eating a BRAT diet with improvement in symptoms.
Symptoms resolved until ___ when after dinne she
began feling unwell again, again symptoms resolved. Morning of
admission (___) she ate breakfast and then 1 hour later
began having terrible abdominal pain, nausea, vomiting and
profuse watery diarrhea. Patient reports that pain is mostly
left-sided and she has had frequent non-bloody, non-bilious
emesis thoughout the afternoon as well as non-bloody,
non-melanotic diarrhea. She has not had fevers, chills, has not
traveled and has no sick contacts.
In the ED, initial VS were: 97.5 89 146/75 16 97%. CT abdomen
was peformed showing evidence of colitis but without evidence of
obstruction. ED evaluation not concerning for mesenteric
ischemia or ischemic colitis and given CT abdominal findings not
showing obstruction surgery was not consulted. Lactate was
normal so no concern for end organ damage. She received 2L NS,
Cipro and Flagyl pior to transfer. Vitals prior to transfer 99.2
67 119/53 18 96
On arrival to the floor, the patient arrives overall stable
appearing, continued abdominal pain but without nausea, vomiting
or diarrhea. Cipro is infusing. She is in good humor and making
jokes throughout interview, she is also accompanied by daughter.
REVIEW OF SYSTEMS:
(+) pe HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, ___, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Gastric volvulus ___ yrs ago) s/p repair
- Internal hemorrhoids
- legally blind
- IBS
- C diff colitis
- HTN
- Hyperlipidemia
- CAD
- RBBB
- DOE s/p extensive negative work up
- Hypothyroidism
- OA
- PUD
- GERD
- Depression
- Prior GYN surgeries remotely
- s/p hiatal hernia repair
- s/p cholecystectomy
- s/p appendectomy
- s/p ORIF L radius ___
Social History:
___
Family History:
- Mother: CAD, CVA
- Aunt: ___ cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.2 125/59 62 18 98%RA
GENERAL - Acutely ill but non-toxic appearing robust ___ F,
wearing sunglasses an in good humor
HEENT - dry mucous membranes
NECK - no JVD no ___
LUNGS - Reduced air movement but clear to auscultation thoughout
all lung fields
HEART - PMI non-displaced, RRR S1-S2 clear and of good quality,
no MRG appreciated
ABDOMEN - Distended and obese, prior sugical scars are well
healed. Slightly tense with voluntary guarding, tender to
palpation over LLQ and LUQ but non tender on right. No rebound.
Hyperactive bowel sounds throughout.
EXTREMITIES - 1+ ___ bilaterally with tenderness
NEURO - awake, A&Ox3
DISCHARGE PHYSICAL EXAM:
VS - 97.7 115/50 61 18 96%RA
GENERAL - NAD
HEENT - mucous membranes moist
NECK - no JVD
LUNGS - CTABL, no crackles or wheezes, good air movement
HEART - RRR S1-S2 clear and of good quality, no MRG appreciated
ABDOMEN - Distended and obese, prior sugical scars are well
healed. 1 cm umbilical palpated above umbilicus, not reducible,
not painful. Minimal voluntary guarding, mildly tender to
palpation over LLQ but non tender on right. No rebound. Normal
bowel sounds throughout.
EXTREMITIES - 1+ ___ bilaterally
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS
___ 07:50PM URINE COLOR-Red APPEAR-Clear SP ___
___ 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-MOD
___ 07:50PM URINE RBC-3* WBC-46* BACTERIA-NONE YEAST-NONE
EPI-1
___ 07:50PM URINE HYALINE-2*
___ 07:50PM URINE MUCOUS-RARE
___ 06:11PM LACTATE-1.9
___ 05:30PM GLUCOSE-155* UREA N-20 CREAT-1.2* SODIUM-138
POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-28 ANION GAP-16
___ 05:30PM estGFR-Using this
___ 05:30PM WBC-13.7*# RBC-5.11 HGB-13.4 HCT-42.1 MCV-82
MCH-26.2* MCHC-31.9 RDW-17.7*
___ 05:30PM NEUTS-88.5* LYMPHS-7.4* MONOS-3.6 EOS-0.4
BASOS-0.1
___ 05:30PM PLT COUNT-283
CT abd and pelvis with contrast
1. Mild bowel wall thickening and mucosal enhancement with
surrounding inflammatory change of the sigmoid ___ and to a
lesser degree the descending ___ tapering to the level of the
splenic flexure, consistent with colitis with etiologies
including infectious, inflammatory or ischemic. Of note, the
ostia of the celiac and superior mesenteric and inferior
mesenteric arteriesdo not appear to have critical stenosis and
mesenteric vessels are overall patent.
2. Moderate stable intrahepatic and extrahepatic biliary ductal
dilatation, not significantly changed.
3. Prominent intermittent fluid filled loops of small bowel
with intervening areas of collapse without secondary evidence of
obstruction; however, if abdominal symptoms worsen, low
threshold to repeat scan to assess for developing small bowel
obstruction.
Stool Studies
___ 9:21 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
ADDON FOR CGD FEC CCU ROE ___ PER FAX BY ___
___
___ @ 1118.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___
___ 3PM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
DISCHARGE LABS
___ 06:55AM BLOOD WBC-5.2 RBC-4.06* Hgb-10.6* Hct-33.3*
MCV-82 MCH-26.0* MCHC-31.7 RDW-18.4* Plt ___
___ 06:55AM BLOOD Glucose-88 UreaN-7 Creat-0.9 Na-142 K-3.5
Cl-109* ___ AnGap-14
Brief Hospital Course:
The patient is a ___ woman with distant history of gastric
volvulus s/p repair, s/p appy and s/p cholcystectomy, recent
admission for ischemic colitis ___ and also with history of
prior C.Diff colitis who presents now with abdominal pain,
vomiting, and diarrhea, found to be C diff positive.
# C diff infection: likely causing abdominal pain, nausea,
diarrhea. The patient has a prior h/o C diff infection, and per
daughter she was told she had to take oral Vancomycin for that
infection. Since this represents a recurrent infection and the
patient required Vancomyin during last infection, we decided to
pursue PO vanc as treatment. GI also saw the patient and
recommends probiotics as well upon discharge. The patient was
able to tolerate a BRAT diet upon discharge, and pain was
greatly improved since admission. First day of oral Vancomycin
therapy was ___.
- Oral Vancomicin 125 mg Q6 for 2 weeks, followed by a taper (1
weeks of BID the 1 week QD). Thus, the patient will get a total
of 4 weeks of therapy including the taper. First day of therapy
was ___.
- Supplement with probiotics: Florastor (Take two sachets daily
during treatment with Vancomycin and once daily thereafter)
# Colitis: Recent CTA scan did not show evidence of ischemia,
lactate not elevated. IV fluids were continued in the hospital
to prevent ischemia from developing in the setting of
dehydration. HCTZ was held. The patient was also found to have
guiac positive stool. Patient was diagnosed with iron
deficiency. Because of the prior noted CT findings of extensive
colitis in ___ in ABSENCE of C.diff or mesenteric stenosis,
GI was consulted. They recommended outpatient follow up once
acute C diff infection resolved, and further discussion of the
need for colonoscopy vs flex sigmoidoscopy. The patient was also
started on iron supplimentation.
# Dirty UA: UCx shows contamination. No Sx of UTI
- no treatment indicated at this time
# PUD: Chronic, stable
- Hold off on Omeprazole 40mg BID given C.Diff
# CAD, stable angina: No acute changes in SOB or chest pain.
- hold HTN meds (See below)
- maintain hydration
# HTN: Chronic, stable. Held HCTZ and metoprolol on admission
given concern for prior ischemic colitis, and current
dehydration. Her BP remained well controlled without either of
these medications. Metoprolol was restarted at home dose and
HCTZ was continued to be held.
- recommend holding HCTZ indefinently given history of
questionable ischemic colitis and well controlled BP on
metoprolol
- Coninue Aspirin 81 mg PO DAILY
# HYPOTHYROIDISM: Chronic, stable
- Continue Levothyroxine Sodium 75 mcg PO DAILY
# DEPRESSION: Chronic, stable
- Continue Citalopram 20 mg PO DAILY
# HLD: Chronic, stable
- Continue Simvastatin 20 mg PO DAILY
# PPX: heparin SQ, hold off on bowel regimen given diarrhea
# CODE: DNR/DNI(confirmed with patient and HCP)
# CONTACT: Daughter and HCP ___ ___,
___ Son ___ ___
TRANSITIONAL ISSUES
- F/U with GI once infection resolved
- follow up with PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Fosfomycin Tromethamine 3 g PO PRN UTI
Dissolve in ___ oz (90-120 mL) water and take immediately PRN
UTI
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
9. Omeprazole 20 mg PO BID
10. Metoprolol Tartrate 12.5 mg PO BID
Please hold for SBP < 100 or HR < 55. thank you.
11. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
7. Simethicone 120 mg PO QID:PRN gas
RX *simethicone 125 mg 1 tablet by mouth 30 minutes before each
meal and at night as neede for gas pain Disp #*60 Capsule
Refills:*0
8. Florastor *NF* (saccharomyces boulardii) 2 packets a day
Oral daily Reason for Ordering: GI recommends starting this
medication
RX *saccharomyces boulardii [Flora___ Kids] 250 mg 2 Packet(s)
by mouth daily Disp #*60 Packet Refills:*0
9. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 14 Days
10. Fosfomycin Tromethamine 3 g PO PRN UTI
Dissolve in ___ oz (90-120 mL) water and take immediately PRN
UTI
11. Nitroglycerin SL 0.4 mg SL PRN chest pain
12. Vitamin B Complex 1 CAP PO DAILY
13. vancomycin *NF* 125 mg/2.5 mL Oral q6 hrs C.Diff Colitis
Take 125 mg every 6 hours for two weeks, then every 12 hours for
1 week, then once a day for 1 week (total duration 4 weeks)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Clostridium difficile infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - WALKER.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for abdominal pain, vomiting,
and diarrhea. You were found to have Clostridium difficile
colitis. You were started on Vancomycin oral antibiotics, and
should also take probiotics when you leave the hospital.
It is important that you keep all follow up appointments, and
take all medications as prescribed.
Followup Instructions:
___
|
10349029-DS-13 | 10,349,029 | 23,830,523 | DS | 13 | 2176-05-10 00:00:00 | 2176-05-10 14:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydralazine And Derivatives / Bumex / Sulfa (Sulfonamide
Antibiotics) / Lactose / banax / Neurontin / ciprofloxacin /
Flagyl
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ who is legally blind w PMH C diff, HTN,
HLD, CAD, s/p fall at home. The patient reports she got up at 3
AM to use the bathroom, and was turning around about to sit on
the toilet when she fell down. She believes she may have lost
her balance while trying to squat and turn at the same time, and
fell backwards into her tub. Denies preceeding lightheadedness,
palpitations, feeling of being flushed. Denies LOC. Tried to
grab onto the shower curtain but hurt a finger on her L hand,
then fell backwards into the tub and hit the L back of her head
on the tub.
She says she falls occasionally at home since she "feels
lightheaded once in a while". She says she has fallen about 5
times in the last year in her home, but does not usually hurt
herself. She normally has to use a walker to ambulate and feel
safe.
She has been having good PO intake recently. Occasional diarrhea
(continiues to follow with GI for this). She also has occasional
gas pain. Denies CP. No fevers. She says she does get SOB with
walking around her house or sweeping, which has not gotten worse
recently. She has recently been going to the geriatric gym
3x/week, where she is supervised and does the bike and other
machines well. She does endorse a 20 lb weight loss in the past
few months, which she attributes to hospitalization and diarrhea
recently.
Initial vitals in ED triage were T 97.7, HR 90, BP 130/72, RR
20, and SpO2 98% on RA. Basic labs were unremarkable with Hct
41.3, Cr 1.1 (at baseline), and Troponin <0.01. CT head showed
a small right frontoparietal scalp hematoma, but no evidence of
acute intracranial injury. CT C-spine showed no acute fracture
or malalignment. CXR showed stable left basilar atelectasis,
but no focal consolidation, pleural effusion, pneumothorax, or
evidence of acute intrathoracic injury. X-ray of her left hand
showed no fracture or dislocation. EKG showed sinyus rhythm at
63 bpm with RBBB (old).
She was admitted to medicine for further syncope workup. Vitals
prior to floor transfer were T 98.0, HR 65, BP 135/76, RR 18,
SpO2 98% on RA.
REVIEW OF SYSTEMS:
(+/-) Per HPI
Past Medical History:
- C diff colitis (___)
- Presumptive Ischemic Colitis, ___
- Gastric volvulus (___) s/p repair
- Internal hemorrhoids
- IBS
- PUD - in problem list, but pt recalls no history of ulcers
- GERD
- hematochezia ___ sessile polyp in hepatic flexure s/p
polypectomy
- legally blind
- HTN
- Hyperlipidemia
- CAD
- RBBB
- DOE s/p extensive negative work up
- Hypothyroidism
- OA
- Prior GYN surgeries remotely
- Depression
- s/p hiatal hernia repair
- s/p cholecystectomy
- s/p appendectomy
- s/p ORIF L radius ___
Social History:
___
Family History:
- Mother: CAD, CVA
- Aunt: ___ cancer
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.2 160/75 74 18 100% RA
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: + 3 cm R forehead hematoma with some dried blood,
moderately tender to palpation. No active bleeding. NCAT. Sclera
anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. No cervical lymphadenopathy. No carotid
bruits noted.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: WWP. Large hematoma on L ___ digit which is tender to
palpation and limits ROM of joint. Digital cap refill <2 sec.
No C/C/E. Distal pulses intact radial.
Neuro: CN II-XII grossly intact.
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
___ 07:25AM ___ PTT-32.7 ___
___ 06:50AM GLUCOSE-107* UREA N-21* CREAT-1.1 SODIUM-138
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-30 ANION GAP-13
___ 06:50AM estGFR-Using this
___ 06:50AM cTropnT-<0.01
___ 06:50AM WBC-8.3 RBC-4.96 HGB-12.8 HCT-41.3 MCV-83
MCH-25.7* MCHC-30.9* RDW-17.6*
___ 06:50AM NEUTS-73.7* ___ MONOS-5.7 EOS-0.8
BASOS-0.2
___ 06:50AM PLT COUNT-234
CT C spine ___
1. Allowing for profound diffuse osteopenia, no acute fracture.
2. Underlying moderate dextroscoliosis with mild alignment
abnormalities,
unchanged and likely degenerative.
CT Head ___
1. No evidence of acute intracranial injury.
2. Small right parietovertex scalp hematoma.
CXR ___
No evidence of acute intrathoracic injury.
Hand Xray ___
No fracture or dislocation.
Brief Hospital Course:
The patient is a ___ who is legally blind w PMH C diff, HTN,
HLD, CAD, s/p fall at home.
# Fall: likely mechanical fall given no LOC. Less likely
micturition syncope. Injury to L ___ finger with swelling around
joint, as well as R scalp hematoma. The patient could have lost
her balance while turning and sitting down at the same time.
Also, the patient is legally blind. No prodromal sx to suggest
vasovagal, and no LOC or incontinence makes cardiac syncope or
seizure less likely. Tele showed no events. However, the patient
does have a history of fairly frequent falls at home and feeling
lightheaded at some times. ___ recommended 24 hour care setting
to avoid future falls.
# Diarrhea: Not currently a problem for this admission. Follows
with outpatient GI. Continues to refuse flex sig as she says it
is not within her goals of care, although still thinking about
it.
- cont probiotics
- cont omeprazole
- cont simethicone
- avoid Cipro/Flagyl as this has caused C diff in the past
- Follow up with regularly scheduled GI appointments
Name: ___ MD
Email: ___
# HTN, HLD, CAD: Trop negative. Unlikely cardiac event. No CP.
EKG unchanged.
- cont ASA, simvastatin, metoprolol, HCTZ
# Mood
-cont Citalopram
# Hypothyroid
- cont levothyroxine
# PPX: Hepain SQ
# CODE: DNR/DNI, confirmed
# CONTACT: Daughter and HCP ___ ___,
___ Son ___ ___
TRANSITIONAL ISSUES
- ___ will manage ___ medical problems. Should follow up
with regularly scheduled GI appointments.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Simethicone 120 mg PO QID:PRN gas
6. Florastor *NF* (saccharomyces boulardii) 2 packets a day
Oral daily Reason for Ordering: GI recommends starting this
medication
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. Metoprolol Tartrate 12.5 mg PO BID
Please hold for SBP < 100 or HR < 55. thank you.
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
Please hold for SBP < 100 or HR < 55. thank you.
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. Simethicone 120 mg PO QID:PRN gas
9. Simvastatin 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Acetaminophen 650 mg PO Q8H:PRN pain
12. Florastor *NF* (saccharomyces boulardii) 2 packets a day
Oral daily Reason for Ordering: GI recommends starting this
medication
13. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
mechanical fall vs vasovagal/micturition syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted after you fell and hit your
head in the bathroom. Your fall may have been because you lost
your balance turning, or became lightheaded since you were about
to use the bathroom.
It is important that you take all medications as prescribed, and
keep all follow up appointments.
Followup Instructions:
___
|
10349208-DS-22 | 10,349,208 | 22,809,556 | DS | 22 | 2163-01-31 00:00:00 | 2163-01-31 12:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hemoptysis, dyspnea
Major Surgical or Invasive Procedure:
Supraglottic squamous cell carcinoma s/p resection &
reconstruction ___
History of Present Illness:
Ms. ___ is a ___ year old female with a past medical history
of COPD, HTN, and ongoing tobacco use with 50 pack-year history,
with supraglottic squamous cell carcinoma s/p
pharyngolaryngectomy, neck dissection, free flap reconstruction
on ___. Her postoperative course was complicated by neck
dehiscence requiring a pedicled
pectoralis major flap, which was further complicated by an
incisional dehiscence. She was seen in the ___ ED on ___ for
complaint of bleeding/blood clots from for blood clots from the
stoma. She was evaluated by ENT, who felt the bleeding was
likely due to aggressive suctioning and she was discharged ___.
She presented to the ED again today with complaints of
hemoptysis. She has noted blood-tinged secretions from her stoma
as well as a few large clots over the past few days. She
presented to ___ yesterday, where a CTA was
reportedly negative but was sent to ___ for further
evaluation. She was seen by ENT in our ED and fiberoptic scope
evaluation demonstrated small amount of bloody crusting along
right wall of the trachea but no sign of active bleeding. A
repeat CTA of the neck showed no active arterial extravasation
or fistulization. Planned for d/c ___ after ED observation but
became SOB and coughed up thick yellow sputum and blood clots
requiring frequent suctioning and decision made to admit to ICU
for monitoring/frequent suctioning and airway monitoring.
Past Medical History:
- COPD: on medical therapy, not on ___ O2, one COPD
exacerbation-related hospitalization in past
- HTN
- Gastric ulcer
- Supraglottic squamous cell carcinoma s/p resection
Social History:
___
Family History:
Noncontributory. Denies family history of CAD, DM, and cancer
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Gen: NAD, AVSS
Cardio: RRR
Abdomen: Soft, non tender, non distended. G tube in place
Resp: No respiratory distress; stoma widely patent
Extremities: Warm, well perfused
Pertinent Results:
ADMISSION LABS:
==================
___ 01:35PM WBC-11.7* RBC-3.18* HGB-9.4* HCT-31.2* MCV-98
MCH-29.6 MCHC-30.1* RDW-16.3* RDWSD-58.6*
___ 01:35PM GLUCOSE-78 UREA N-16 CREAT-0.5 SODIUM-138
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-24 ANION GAP-9*
___ 01:35PM CALCIUM-8.6 PHOSPHATE-5.6* MAGNESIUM-2.0
___ 01:35PM ___ PTT-24.7* ___
PERTINENT IMAGING:
====================
OSH CTA negative for fistula/active bleed, no CT evidence of
significant hematoma or brisk arterial bleed
CTA ___
1. No evidence of active arterial extravasation. No evidence of
fistula is between arterial structures in the trachea. No
evidence of cutaneous fistula.
2. No confluent fluid collection. No evidence for cellulitis.
3. The patient is status post total laryngectomy with flap
reconstruction. No definite recurrent or progressive disease.
4. Additional findings as described above.
CXR ___
No signs of pneumonia. Tracheostomy tube in place.
Brief Hospital Course:
Patient is a ___ year old female with history of COPD, HTN, and
supgraglottic ___ s/p pharyngolaryngectomy, neck dissection,
free flap reconstruction on ___ with Dr. ___, with
post-operative course complicated by wound dehiscence s/p
Bilateral neck washout, pectoralis neck flap (___), and
panendoscopy, bilateral neck debridement, skin graft from L
thigh to neck ___.
She initially presented to the ED for increased bleeding and
hemoptysis noted from stoma at ___, with associated dyspnea.
CTA at OSH and at ___ was negative for any evidence of active
arterial extravasation, and no evidence of fistula between
arterial structures in the trachea was noted. In addition, there
was no evidence for cellulitis or progression of disease. She
was initially cleared to be sent ___ by ENT after overnight
observation in the ED, however she was noted to experience
intermittent episodes of dyspnea without desaturation, as well
as coughing up blood approximately 5 times over 12 hours.
Because of her need for frequent suctioning and airway
monitoring, the patient was admitted to the SICU overnight.
She remained hemodynamically stable with no further episodes of
hemoptysis or desaturation noted in the SICU. Her ___
medications were ordered and continued as well as her tube
feeds. Humidified air was administered over her stoma.
Of note, she was recently admitted to ___ with a C.
diff infection, and was started on a 10 day course of PO
vancomycin. On ___ she reported that it was day ___ of her
antibiotic course, thus she was given a dose of PO vancomycin
during her hospital stay.
She received subcutaneous heparin for DVT prophylaxis.
TRANSITIONAL ISSUES:
=======================
-f/u with ENT as an outpatient
Medications on Admission:
Aspirin 81 mg daily
Calcium carbonate suspension 1250mg TID
Melatonin 3mg QHS
Metoclopramide 5mg TID
Levothyroxine 75mg daily
Ipratropium-Albuterol nebulizer QID PRN
Firvanq 25mg/ml 5ml Q6H x10 days, to finish ___ at 4pm
___ TFs: Vital 1.2 at 55cc/hr continuous
Discharge Medications:
1. Aspirin 81 mg NG DAILY
2. Calcium Carbonate Suspension 1250 mg NG TID
3. Ipratropium-Albuterol Neb 1 NEB NEB QID:PRN dyspnea
4. Levothyroxine Sodium 75 mcg PO DAILY
5. melatonin 3 mg PO/NG QHS
6. Metoclopramide 5 mg NG TID
7. Vital AF 1.2 Cal (nut.tx.impaired dige fxn-fiber) 0.08 gram-
1.2 kcal/mL NG at 55cc/hr continuous
Discharge Disposition:
___ With Service
Facility:
___
Discharge Diagnosis:
Hemoptysis
Dyspnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
You were admitted to ___ because of
your difficulty breathing and coughing up blood. You were
observed in the Emergency Department and then admitted to the
Surgical Intensive Care Unit for close monitoring.
While you were here, labs were drawn, which showed a stable
blood level. Your oxygen level was closely monitored. CT scan of
your chest did not show any fast bleeding from your airway or
trachea.
You are now safe to be discharged from the hospital. Please
return to the ED if you have any danger signs as listed below.
Please also follow up with Plastic Surgery and ENT at your
previously scheduled appointments.
We wish you the best in your health,
Your ___ care team
Followup Instructions:
___
|
10349402-DS-13 | 10,349,402 | 22,640,282 | DS | 13 | 2147-05-21 00:00:00 | 2147-05-26 15:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Agitation and aggression
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ with dementia who presents with agitation.
He was discharged from the ___ ED on the night prior to
admission following initial evaluation for aggressive behavior
and agitation. Although noncontrast head CT was negative at that
time, CXR revealed possible pneumonia, prompting initiation of
doxycycline regimen, and agitation improved following olanzapine
5mg x1 prior to transfer back to his dementia unit. In the
context of continuing agitation and aggression, as well as
hypotension, degree and duration unknown, he was brought back to
the ED for further evaluation.
He is a poor historian and when questioned on his recent
symptoms repeatedly states, "I don't remember." He gestures to
his chest and upper abdomen with a circular hand motion and
describes "constant confusion," localized only "slight shooting
pain" in the right lower quadrant of his abdomen. He also
endorses slight nonproductive cough, which his daughter believes
to be chronic, but denies shortness of breath. His only other
concern is "arthritis" pain in his hands.
The nursing staff at his dementia unit endorse occasional cough,
but deny falls, fevers, chills, chest pain, shortness of breath,
nausea, vomiting, urinary symptoms, diarrhea, constipation, or
back pain. His daughter notes a new abrasion on the bridge of
his nose, but neither the patient nor the nursing staff recall a
fall or other trauma to his nose.
His family moved him from an assisted living facility in ___ to
his current dementia unit 1 week prior to admission after his
wife died several months ago. His daughter lives in ___
and is his primary support in the ___ area. She describes her
father as angry, resentful, and confused over his relocation,
speculating that these emotions triggered his agitation
In the ED, initial vital signs were as follows: 97.8 80 91/56 20
100% 2L NC. Admission labs were notable for elevated lactate
(2.6), Wbc of 3.7, H/H of 12.5/38.6, and negative urinalysis.
Vital signs prior to transfer were as follows: 97.4 79 97/66 20
99% RA.
On arrival to the floor, he is resting comfortably.
Past Medical History:
Dementia
Bradycardia status post pacemaker placement
Hypertension
Coronary artery disease with unknown coronary anatomy
Chronic obstructive pulmonary disease
Benign prostatic hypertrophy
Familial tremor
Gastroesophageal reflux disease
Social History:
___
Family History:
Noncontributory.
Physical Exam:
On admission:
Vitals- 97.3 (PO), 111/84, 80, 20, 100 RA
General- Alert and oriented to person but not to place or date.
No acute distress, comfortable and calm.
HEENT- Sclerae anicteric, pinpoint pupils. MMM, oropharynx
clear. 0.25 cm diameter healing scab on bridge of nose. Poor
dentition.
Neck- Supple, no LAD. JVP not visualized because of patient's
limited mobility (due to suspected L3 fx).
Lungs- CTAB anteriority. No wheezes, rales, rhonchi. No
increased work of breathing; no accessory muscle use.
CV- RRR, Nl S1, S2, No MRG.
Abdomen- Soft, non-distended. Mild RLQ tenderness on palpation.
Scaphoid abdomen. Bowel sounds present but quiet. No rebound
tenderness or guarding, no organomegaly.
GU- No foley. No suprapubic tenderness on palpation.
Ext- Warm, well-perfused, 2+ pulses, no clubbing, cyanosis, or
edema.
Neuro- CNs grossly intact except CN3 pupils constricted. Moves
all four extremities; sensation grossly intact.
At discharge:
Vitals: no vital signs documented
Gen: Sleepy.
HEENT: Mucosa mildly dry.
Cardiac: Deferred.
Chest: Breathing comfortably on room air without use of
accessory muscles.
Abd: Deferred.
Ext: Moving all extremities well.
Skin: Warm and well-perfused.
Pertinent Results:
On admission:
___ 10:45PM BLOOD WBC-4.4 RBC-3.52* Hgb-12.5* Hct-35.9*
MCV-102* MCH-35.5* MCHC-34.8 RDW-12.9 Plt ___
___ 10:45PM BLOOD Neuts-66.7 ___ Monos-6.3 Eos-0.6
Baso-0.4
___ 10:45PM BLOOD Glucose-112* UreaN-18 Creat-0.8 Na-138
K-3.3 Cl-100 HCO3-28 AnGap-13
___ 10:45PM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
___ 11:40AM BLOOD cTropnT-<0.01
___ 10:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
At discharge:
___ 06:35AM BLOOD WBC-4.4 RBC-3.64* Hgb-12.6* Hct-37.4*
MCV-103* MCH-34.7* MCHC-33.7 RDW-13.1 Plt ___
___ 06:35AM BLOOD Glucose-83 UreaN-10 Creat-0.6 Na-142
K-3.9 Cl-107 HCO3-27 AnGap-12
___ 06:35AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
In the interim:
___ 11:40AM BLOOD ALT-18 AST-45* AlkPhos-99 TotBili-0.6
___ 05:50AM BLOOD 25VitD-38
Microbiology:
Blood Cx x2 (___): No growth
Urine Cx (___): No growth
Imaging:
Noncontrast head CT (___):
1. No acute intracranial abnormality.
2. Prominent sinus disease with some air-fluid levels and a
small amount of aerosolized fluid. Correlate with symptoms as
this could represent acute sinusitis.
ECG (___):
Underlying rhythm is likely atrial fibrillation. There is
ventricular demand pacing. No previous tracing available for
comparison.
IntervalsAxes
___
___
ECG (___):
Probable atrial fibrillation with demand ventricular pacing at a
rate
of 70. Conducted complexes have low voltage in the limb leads.
ST-T wave
abnormalities. Since the previous tracing of ___ no
significant change.
IntervalsAxes
___
___
CXR PA/lateral (___):
Bibasilar opacities better seen on the CT of the abdomen and
pelvis which may represent atelectasis or consolidation. Small
left pleural effusion is better seen on the concurrently
obtained abdomen-pelvis CT.
CT abdomen/pelvis with contrast (___):
1. Acute fracture of the left transverse process of L3 with
minimal
displacement.
2. Colonic diverticulosis without evidence of diverticulitis.
3. Asymmetric bladder wall thickening with trabeculations
consistent with chronic outlet obstruction.
ECG (___):
Atrial fibrillation with intermittent ventricular pacing. No
diagnostic change from previous tracing of ___.
IntervalsAxes
___
___
Brief Hospital Course:
Mr. ___ is an ___ with dementia who presented with agitation.
Active Issues:
# Agitation: Agitation was presumed secondary to confusion over
relocation superimposed on chronic progressive dementia, with
possible contribution from constipation, for which his bowel
regimen was escalated, with good effect. Although he was treated
initially with ceftriaxone and azithromycin for possible
healthcare associated pneumonia in the setting of questionable
subtle infiltrate on admission CXR, antibiotics were
discontinued soon after admission in the absence of clinical
signs of pneumonia. There were no other localizing signs or
symptoms of infection, and he was not found to be retaining
urine. There was low suspicion for occult acute coronary
syndrome in the absence of acute ischemic changes or
troponinemia. Initially calm and cooperative, he became
increasingly agitated on the evening of hospital day 1,
requiring olanzapine 5mg PO x1, followed by multiple doses of
haloperidol IV. On evaluation by the psychiatry service the
following day, standing haloperidol 2.5mg PO qhs with
haloperidol 2.5mg IV q6h as needed for refractory agitation was
initiated, with avoidance of further agitation; however, he was
noted to have dystonic neck movements concerning for
extrapyramidal signs, prompting discontinuation of standing
haloperidol, with plan for initiation of a more sustainable
antiagitation regimen in a monitored setting at his
rehabilitation facility. His home dementia and mental health
regimens, including donepezil, memantine, buspirone, and
sertraline, were continued throughout admission. Of note, QTc
was 247 at discharge in the setting of extensive antipsychotic
administration.
# Borderline hypotension: Blood pressure nadired in the ___
systolic versus uncertain baseline, though he carries a
diagnosis of hypertension, likely reflecting hypovolemia in the
setting of limited oral intake, with improvement following
gentle IV fluids. Artifact from use of a large blood pressure
cuff also likely contributed, with improvement in blood pressure
measurements following use of a more appropriately sized cuff.
Home metoprolol and furosemide were held throughout admission
and at discharge and may be resumed at the discretion of his
primary care physician in the event that he is found to be
consistently hypertensive and/or volume replete.
# Abdominal pain: He reported diffuse mild abdominal pain of
uncertain chronicity, with reassuring exam. CT abdomen/pelvis on
admission was negative for acute intraabdominal pathology, with
the exception of significant constipation. His bowel regimen was
escalated, with good effect.
# Lumbar spinous fracture: Acute fracture involving the L3
transverse process was noted incidentally on CT abdomen/pelvis
on admission. Although there was no clear history of trauma,
patient is a limited historian. According to the orthopedic
spine service, there was felt to be no need for brace or
weightbearing restrictions in the absence of low back pain or
neurologic deficits on exam. Maintenance vitamin D therapy was
initiated.
# Decubitus ulcer: He was noted to have a stage 1 to 2 decubitus
ulcer without evidence of superimposed infection that was
monitored and maintained per nursing protocol. Continue
surveillance is advised at his rehabilitation facility.
Inactive Issues:
# Macrocytic anemia: Hematocrit was 38.6 on admission in
association with MCV of 102, perhaps reflecting anemia of
chronic inflammation, though macrocytosis would be atypical,
raising the possibility of a megaloblastic anemia,
myelodysplastic syndrome, or alcohol-associated anemia in the
setting of prior heavy alcohol use. Hematocrit remained stable
throughout admission without signs of active bleeding. Further
work up of anemia is advised in the outpatient setting as
indicated.
# Benign prostatic hypertrophy: Home finasteride was continued.
# Bradycardia status post pacemaker placement: Formal review of
EKGs by the cardiology service revealed ventricular pacing with
likely underlying atrial fibrillation, suggesting prior
tachycardia/bradycardia syndrome, though outside records are
sparse. In the setting of CHADS score of 2 to 3 (heart failure
and age with or without hypertension), he remains on aspirin
81mg daily only, likely in the setting of significant fall risk.
# Coronary artery disease: In the setting of unknown coronary
anatomy, aspirin and metoprolol were continued.
# Compensated heart failure: In the setting of presumed heart
failure, with unknown LVEF, home metoprolol was continued while
furosemide was held in the setting of hypovolemia, but may be
resumed in the outpatient setting pending euvolemia at the
discretion of his primary care provider.
# Familial tremor: Home primidone was continued.
Transitional Issues:
* Initiation of sustainable antipsychotic regimen in a monitored
setting is advised at his outpatient rehabilitation facility.
* Home metoprolol and furosemide were held at discharge in the
setting of borderline hypotension and hypovolemic appearance,
but may be resumed in the outpatient setting if needed at the
discretion of his primary care provider.
* Continue surveillance of decubitus ulcer is advised in the
outpatient setting.
* Further work up of macrocytic anemia is advised in the
outpatient setting as indicated.
* Pending studies: None.
* Code status: DNR/DNI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PrimiDONE 50 mg PO TID
2. Finasteride 5 mg PO DAILY
3. Sertraline 50 mg PO DAILY
4. Memantine 10 mg PO BID
5. Donepezil 10 mg PO HS
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. BusPIRone 5 mg PO HS
9. Senna Dose is Unknown PO QOD
10. Guaifenesin ER 400 mg PO Q12H
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BusPIRone 5 mg PO HS
3. Donepezil 10 mg PO HS
4. Finasteride 5 mg PO DAILY
5. Memantine 10 mg PO BID
6. PrimiDONE 50 mg PO TID
7. Senna 8.6 mg PO BID
8. Sertraline 50 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Polyethylene Glycol 17 g PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Haloperidol 2.5 mg PO HS:PRN agitation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Dementia
Hypotension, likely due to hypovolemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted for agitation and low blood pressure. You were at times
very restless and received calming medications, which you will
continue to receive in the outpatient setting. Your blood
pressure was found initially to be slightly low, perhaps because
you had not been eating or drinking much, and improved with IV
fluids. It is important that you continue to drink plenty of
fluids after you leave the hospital. You also received
medications to help you have regular bowel movements; it is
important that you continue to take these when you leave the
hospital.
We will you all the best.
Followup Instructions:
___
|
10349402-DS-14 | 10,349,402 | 26,622,844 | DS | 14 | 2147-11-08 00:00:00 | 2147-11-08 20:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Leg swelling, failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with dementia, AF, presenting with leg swelling and FTT
after recent fall and diagnosis of pneumonia on ___.
The patient has a history of Alzheimer's dementia and lives in
___ facility and no further history can be obtained.
His records indicate he has a recent diagnosis of pneumonia, as
well as increasing leg swelling and weight loss at his
rehabilitation facility. His most recent contact with the
healthcare system was on ___ when he was seen in the ___
ED and diagnosed with a PNA. He was discharged with levofloxacin
for a 7 day course. Today was his last dose. Concern from
assisted living facility because of worsening leg swelling to
the point that patient having difficulty walking this AM. Pt's
daughter tried calling cardiologist but he/she is out of town.
Currently he is without complaints.
In the ED, initial vital signs were: 6 97.6 64 106/71 20 100%
Labs were notable for BG 60 (given orange juice), Lactate 2.6,
proBNP 3614, WBC 2.6, Hct 39.9, Plt 136, Coags: INR 2.6, PTT
42.5.
Studies performed include CXR
Vitals on transfer: 97.4 62 133/77 18 100% RA
Upon arrival to the floor, the patient is AAOx1.
Past Medical History:
Dementia
Bradycardia status post pacemaker placement
Hypertension
Coronary artery disease with unknown coronary anatomy
Chronic obstructive pulmonary disease
Benign prostatic hypertrophy
Familial tremor
Gastroesophageal reflux disease
Social History:
___
Family History:
Noncontributory.
Physical Exam:
Admission Physical Exam:
Vitals- 97.4, 131/78, 66 16 98 RA
General: NAD, appears stated age, gaunt
HEENT: EOMI, Perrl, Nares clear, Oropharynx clear
Neck: Thin, no LAD, left-sided JVP
CV: Irregularly irregular rhythm, normal S1, S2, ___ early
peaking systolic murmur best heard over RUSB
Lungs: Inspiratory crackles at bases bilaterally with rhonchi
Abdomen: Soft, tender on right side, no guarding, rebound or
rigidity
Ext: 2+ pitting edema bilaterally R>L, up to below knee, pulses
2+ and irregular
Neuro: CN ___ intact, moving all extremities
Skin: Crusting elevated plaque with minimal erythema right shin
Discharge Physical Exam:
Vitals: Tm 97.7 BP 104/53 (90s-130s/50s-70s) HR 64 (60s-80s) RR
16, ___ O2 sat 97-100% RA
General: NAD, appears stated age, gaunt, has irregular speech
pattern with muffled speech, and noticable tremor of head/cheek
HEENT: EOMI, Perrl, MMM
Neck: Thin, no JVP noted
CV: Irregularly irregular rhythm, normal S1, S2, ___ early
peaking systolic murmur best heard over RUSB. Pacer in place
under skin on right side
Lungs: Overall clear to auscultation bilaterally, no wheezes.
Rhonchorous sounds when coughing
Abdomen: Soft, non-tender, no guarding, rebound or rigidity, +BS
Ext: 1+ pitting edema bilaterally, up to below knee, slightly
improved from previous, teds in place, pulses 2+
Neuro: PERRL, EOMI, moving all extremities, AAOx1
Skin: Crusting elevated plaque with minimal erythema right shin
stable
Pertinent Results:
Admission Labs:
___ 01:06PM BLOOD WBC-2.6* RBC-3.70* Hgb-13.2* Hct-39.9*
MCV-108* MCH-35.7* MCHC-33.1 RDW-14.5 Plt ___
___ 01:06PM BLOOD Neuts-54.3 ___ Monos-7.3 Eos-1.8
Baso-0.8
___ 01:06PM BLOOD ___ PTT-42.5* ___
___ 01:06PM BLOOD Glucose-60* UreaN-12 Creat-0.8 Na-139
K-5.1 Cl-102 HCO3-31 AnGap-11
___ 01:06PM BLOOD ALT-15 AST-24 AlkPhos-67 TotBili-0.5
___ 01:06PM BLOOD Lipase-29
___ 01:06PM BLOOD proBNP-3614*
___ 01:06PM BLOOD TotProt-5.6* Albumin-3.7 Globuln-1.9*
___ 01:13PM BLOOD Lactate-2.6*
Pertinent Labs:
___ 08:17AM BLOOD Lactate-1.8
Discharge Labs:
___ 07:35AM BLOOD WBC-2.9* RBC-3.65* Hgb-12.7* Hct-38.7*
MCV-106* MCH-34.8* MCHC-32.8 RDW-14.0 Plt ___
___ 07:35AM BLOOD ___ PTT-43.1* ___
___ 07:35AM BLOOD Glucose-78 UreaN-15 Creat-0.7 Na-137
K-4.4 Cl-101 HCO3-29 AnGap-11
___ 07:35AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0
___ 07:35AM BLOOD Valproa-31*
Imaging:
- EKG ___ pacing with underlying fibrillation.
There appears to be some natively conducted beats. Low native
QRS complex voltage in the limb leads. Compared to the previous
tracing of ___ native conduction is present.
- CXR ___ Impression: Medial left lower lobe opacity has
slightly improved since the prior exam, however this was also
present in ___ and an underlying lesion is not excluded.
Dedicated non-emergent chest CT is recommended.
- Echo ___: Significant biatrial enlargement. Mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function. Moderately dilated right
ventricle with normal global sstolic function. At least moderate
tricuspid regurgitation.
- CT chest w/o contrast impression ___: 1. Area of abnormality
in the left lower lobe appears most consistent with an
area of rounded atelectasis.
2. Bibasilar traction bronchiectasis.
3. Moderate to severe upper lobe predominant emphysema.
4. Enlarged pulmonary arteries bilaterally.
5. Cholelithiasis and diverticulosis.
Micro:
- Urine Cx ___: URINE CULTURE (Final ___: <10,000
organisms/ml.
Brief Hospital Course:
___ with dementia here from ___ for increased lower extremity
edema as well as inability to care for himself with weight loss.
Concern for developing CHF in setting of chronic heart disease.
ECHO shows moderate TR with possible underestimation of
severity. CXR shows persistent area of opacity that prompted CT
scan to evaluate for lesion (in setting of FTT) but only
atelectasis/bronchiectasis seen. Initial labwork and previous
imaging concerning for MM that may be cause of FTT, deferred to
outpt work-up. Pt would also require goals of care discussion if
positive for MM. Pt with some episodes of hypotension and
+orthostatic during stay, but on day of discharge VSS with plan
for discharge to rehab for FTT and orthostasis.
Active Issues:
# TR: Moderate TR seen on echo, explains findings of elevated
JVP (now resolved) and leg edema (improving with compression).
# FTT: chronic deconditioning vs underlying cause. Concern for
multiple myeloma due to pancytopenia, recent CT c-spine with
lucencies. DGlobulin gap 3.7. eferred to outpatient work-up, pt
would likely need goals of care discussion if any treatment were
to be attempted.
# A fib: HR well controlled without anti-hypertensives. On
coumadin with dose adjustment during stay (5 mg -> 3 mg) to
maintain therapeutic INR.
# Dementia: Pt AAOx1. At baseline per daughter. Treated with
home memantine, primidone, donepizil.
# Lack of med rec: Pt arrived with medication list but unable to
verify with facility where he came from multiple times
Chronic Issues:
# Pancytopenia: chronic issue for past 3 months
# CAD: continued aspirin
# BPH: continued finasteride
# Depression/Anxiety: continued divalproex, previous med lists
showed other medications but unable to perform full med rec. Pt
without significant changes in mood during stay
# Constipation: continued home bowel regimen
Transitional Issues:
- Patient's warfarin dose will have to be adjusted for INR ___
goal for Atrial Fibrillation. While here, coumadin was dosed as
5 mg on ___, 3 mg on ___.
- Pt orthostatic with episodes of hypotension (none last 24
hours). Will require physical therapy for long term management
of likely chronic issue
- Continued work-up for pancytopenia including SPEP, UPEP to
evaluate for multiple myeloma
- Pt needs medicine reconciliation. attempted multiple times
while inpatient, followed most recent medication list while in
house
- F/u valproic acid level
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. BusPIRone 5 mg PO HS
3. Donepezil 10 mg PO HS
4. Finasteride 5 mg PO DAILY
5. Memantine 10 mg PO BID
6. PrimiDONE 50 mg PO TID
7. Senna 8.6 mg PO BID
8. Sertraline 50 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Polyethylene Glycol 17 g PO BID
11. Vitamin D 1000 UNIT PO DAILY
12. Haloperidol 2.5 mg PO HS:PRN agitation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Donepezil 10 mg PO HS
4. Finasteride 5 mg PO DAILY
5. Memantine 10 mg PO BID
6. PrimiDONE 50 mg PO TID
7. Senna 8.6 mg PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Warfarin 3 mg PO DAILY16
To be titrated by ECF for goal INR ___.
11. Divalproex Sod. Sprinkles 250 mg PO BID
12. Haloperidol 2.5 mg PO HS:PRN agitation
13. FoLIC Acid 1 mg PO DAILY
14. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Right heart failure
SECONDARY DIAGNOSES
Atrial Fibrillation
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:
Mr. ___,
You were admitted to ___ for leg swelling and overall
weakness. A work-up for congestive heart failure was performed
which showed that you have findings that show compromise of the
right side of your heart. Compression stockings were placed on
your legs to help the swelling. Physical therapy saw you and
recommended you go to a rehab, which your daughter was in
agreement with.
Please follow-up with your outpatient primary care provider and
cardiologist.
Wishing you well,
Your ___ Medicine Team
Followup Instructions:
___
|
10350231-DS-20 | 10,350,231 | 20,862,731 | DS | 20 | 2154-01-06 00:00:00 | 2154-01-06 10:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / metronidazole / lisinopril / aztreonam /
amlodipine / Penicillins
Attending: ___
Chief Complaint:
neck swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female history of dementia, insulin-dependent
diabetes, aortic stenosis, hypothyroidism, hypertension,
hyperlipidemia, umbilical hernia presents referred from ___
___ with concern of facial swelling. Patient was seen on
___ for diffuse abdominal pain and was diagnosed with
diverticulitis based on CT scan. She was discharged home on
cipro/flagyl. On ___ she noted neck swelling and concern for
stridor, so she re-presented to ___. She had a CT
of her neck which revealed nonspecific inflammation around the
right platysma and reactive nodes. She was transferred to ___
for ENT evaluation and further management. Prior to transfer she
received 125 Solu-Medrol, Pepcid, Benadryl.
On arrival to the ED her initial VS were 97.4 55 ___
RA. She was noted to be agitated and with a slight expiratory
wheeze but not stridor. ENT was consulted and stated there were
patent airways and no evidence of Ludwig's angina. They did not
think there was an indication for laryngoscopy at this time.
Basic labs were ordered and a CXR. Per patient's Atrius records
she has a history of an anaphylactic reaction to penicillin so
she was given clindamycin for her diverticulitis in the ED. She
was given olanzapine 5mg x1 and 10mg x1, methylpred 125mg,
clindamycin 600mg, APAP 1000mg, 500cc NS.
On arrival to the MICU, she is agitated and intermittently
answering questions. She is denying any abdominal pain, CP, SOB,
cough.
Past Medical History:
Hypothyroidism
Osteoarthritis
HTN
LVH
DM
Dementia
AS
Social History:
___
Family History:
Father ___ CAD/PVD
Maternal Grandfather ___ - Type II
Mother ___ CAD/PVD; Diabetes - Type II
Sister ___
Physical ___:
ADMISSION PHYSICAL EXAM
=======================
VITALS: HR 83, BP 160/55, RR 14, 92%2LNC
GENERAL: agitated
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
NECK: mild erythema but no swelling appreciated
LUNGS: exam limited by patient cooperation but no stridor or
wheezing appreciated, no increased work of breathing
CV: Regular rate and rhythm, normal S1 S2, ___ SEM
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, umbilical
hernia present and reducible
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: alert, not oriented to place or time, CN II-XII grossly
intact, moving all 4 extremities
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 98.0 128 / 75 80 20 93 Ra
GENERAL: agitated, hostile towards staff
EYES: PERRL, anicteric sclerae
ENT: OP clear, no stridor, mild neck fullness w/o obvious
erythema
CV: RRR, II/VI SEM with preserved S2, difficult to appreciate
JVP
RESP: faint end-expiratory wheezing b/l
GI: + BS, soft, mildly tender diffusely, reducible umbilical
hernia, no R/G
GU: No suprapubic fullness or tenderness to palpation
SKIN: No rashes or ulcerations noted
NEURO: AOx2 (person, hospital, not date), not able to
participate
in comprehensive testing but moves all extremities spontaneously
and sensation grossly intact
PSYCH: intermittently agitated, violent towards staff, pulling
at lines and IV's
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 07:40PM BLOOD WBC-11.2* RBC-4.66 Hgb-13.3 Hct-41.1
MCV-88 MCH-28.5 MCHC-32.4 RDW-15.7* RDWSD-49.7* Plt ___
___ 07:40PM BLOOD Neuts-90.6* Lymphs-7.6* Monos-0.4*
Eos-0.2* Baso-0.3 Im ___ AbsNeut-10.18* AbsLymp-0.85*
AbsMono-0.05* AbsEos-0.02* AbsBaso-0.03
___ 07:40PM BLOOD ___ PTT-27.7 ___
___ 07:40PM BLOOD Glucose-299* UreaN-23* Creat-0.9 Na-137
K-5.0 Cl-97 HCO3-19* AnGap-21*
___ 03:31AM BLOOD ALT-28 AST-81* LD(LDH)-413* AlkPhos-59
TotBili-0.3
___ 03:31AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.4
___ 09:36AM BLOOD ___ Temp-37.3 FiO2-40 O2 Flow-15
pO2-85 pCO2-43 pH-7.33* calTCO2-24 Base XS--3 Intubat-NOT INTUBA
___ 08:03PM BLOOD Lactate-4.1*
DISCHARGE LAB RESULTS
=====================
___ 06:10AM BLOOD WBC-14.0* RBC-4.27 Hgb-12.3 Hct-37.3
MCV-87 MCH-28.8 MCHC-33.0 RDW-15.6* RDWSD-49.4* Plt ___
___ 06:10AM BLOOD Glucose-161* UreaN-21* Creat-0.6 Na-143
K-4.2 Cl-103 HCO3-26 AnGap-14
___ 05:57AM BLOOD ALT-32 AST-42* AlkPhos-65 TotBili-0.4
___ 06:10AM BLOOD Calcium-9.0 Mg-2.2
___ 05:57AM BLOOD TSH-0.19*
IMAGING/STUDIES
===============
___ CXR:
Limited exam demonstrating interstitial pulmonary edema.
___ Second Opinion CT Torso from OSH:
Mild sigmoid colonic diverticulitis. No fluid collection or
free air.
___: bilateral knee films:
Post total bilateral knee arthroplasties, without evidence of
fracture or
hardware complication. Small bilateral effusions. \
MICROBIOLOGY
============
___ Blood Cultures: Negative
___ Urine Cultures: Negative
Brief Hospital Course:
The patient is a ___ female with a history of dementia,
insulin-dependent diabetes, aortic stenosis, hypothyroidism,
hypertension, hyperlipidemia, umbilical hernia, who presented
from ___ with facial swelling concerning for an
allergic reaction, and was treated for her diverticulitis.
#Neck swelling/erythema:
Seen by ENT in the ED and airway was patent and no concern for
Ludwig angina. Received 125mg methylpred x2. It is unclear
whether it was the ciprofloxacin or the metronidazole that
caused the allergic reaction. She was given duonebs PRN to treat
her wheezing, and her symptoms improved.
#Diverticulitis:
Diagnosed based on OSH CT, and that read was confirmed on
re-read by ___ Radiology. Because of her many drug allergies,
she received a dose of clindamycin in the ED. She was then
continued on meropenem given her anaphylactic allergies to
penicillin to complete a 7 day course (completed ___.
Leukocytosis was improving on discharge. Pt with minimal
abdominal tenderness. Pt unable to tolerate longer duration of
abx as she kept removing peripheral IV's and it would be of
unclear benefit anyway.
#Agitation: Pt noted to be very agitated and combative towards
staff during this admission. She frequently requested to go
home but was not deemed to have capacity to make this decision.
She frequently removed IV's and O2 and refused care. Agitation
was managed with prn IV Haldol, zydis, and occasional soft
restraints. Per discussion with her husband, ___, this
behavior is baseline for her every time she is hospitalized and
improves after she returns home.
#Dysphagia: Pt evaluated by ___ for ?dysphagia and she was noted
to have signs of aspiration with thin and nectar thickened
liquids. Pt declined a video swallow and given her agitation
and general refusal of medical care, it was felt that she would
not benefit from further work-up or placement of an NGT. Per
___ report, she has had signs of aspiration prior to
admission, felt to be likely from her advanced dementia. Her
husband was counseled that pt would likely always have a risk of
aspiration and developing aspiration pneumonias but we could
hopefully mitigate this risk some with trialing a thickened
liquid pureed diet for a while. If pt does not tolerate this,
then will accept the higher risk of just allowing her to do
whatever texture diet she would like. ___ expressed
understanding of this situation. ___ attempted to do modified
diet teaching with ___ on ___ but it was felt he would
benefit from further teaching with home SLP services. These
were set up on discharge.
#Hypernatremia: Pt's Na peaked at 149, likely free water
deficiency iso being kept NPO pending further SLP eval. She was
given close to 1 L D5W with improvement back to 143 on
discharge.
#Lactic acidosis:
Her lactic acidosis was deemed most likely from receiving
contrast while taking metformin. Her lactate trended down to
normal.
#DM:
Her home Janumet (sitagliptin-metformin) was stopped while pt
was in the hospital. She was maintained on an insulin sliding
scale and ___ home dose of lantus with subsequent BG's in the
low 100's-200's range. She was restarted on home dose of lantus
and glipizide on discharge but Janument will continue to be held
given her likely decreased PO intake.
#HTN:
Continued home atenolol and valsartan
#Hypothyroid:
Continued home levothyroxine 125mcg daily. TSH was checked and
was low at 0.19. Likely needs to be rechecked post-discharge.
TRANSITIONAL ISSUES
===================
- Metformin/sitgalipin discontinued because of lactic acidosis,
unclear if pt would need this medication for DM given her
decreased PO intake.
- 17 mm ectasia of the right common iliac artery. Likely hepatic
steatosis
- TSH low at 0.19. Please recheck and adjust dose of
levothyroxine prn.
# Communication: HCP: husband ___ ___.
Greater than 30 minutes spent on discharge counseling and
coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 10 mg PO DAILY
2. Glargine 24 Units Bedtime
3. Levoxyl (levothyroxine) 125 mcg oral DAILY
4. Janumet (SITagliptin-metformin) 50-500 mg oral DAILY
5. Atenolol 25 mg PO DAILY
6. Valsartan 320 mg PO DAILY
7. Simvastatin 10 mg PO QPM
Discharge Medications:
1. Glargine 24 Units Bedtime
2. Atenolol 25 mg PO DAILY
3. GlipiZIDE 10 mg PO DAILY
4. Levoxyl (levothyroxine) 125 mcg oral DAILY
5. Simvastatin 10 mg PO QPM
6. Valsartan 320 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Allergic reaction to antibiotics
Diverticulitis
Aspiration
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You came in with neck swelling. We think that this was due to
an allergic reaction to antibiotics you were getting for an
infection in your colon (a condition called diverticulitis). We
treated you for the allergic reaction and you tolerated the
other antibiotics we changed you to for completion of your
diverticulitis treatment.
We also found while you were here that you are likely aspirating
on some foods and liquids. This puts you at risk for developing
pneumonia. We can thicken your liquids and puree your foods
which would decrease the risk but definitely not eliminate it
altogether. We do not think you would benefit from or tolerate
a feeding tube.
We are going to send you home with services that can continue to
teach your husband how to prepare the best texture foods for
you.
Please return if you have worsening fevers, difficultly
breathing, chest pain, or if you have any other concerns.
It was a pleasure taking care of you at ___ ___
___.
Followup Instructions:
___
|
10350765-DS-12 | 10,350,765 | 29,272,804 | DS | 12 | 2121-10-27 00:00:00 | 2121-10-28 14:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
gait instability
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is an ___ old right-handed man with a
history
of hypertension and diabetes who presented to an OSH with
concern
for episodes of chest discomfort and who also had one week of
dyequilibrium and mild dysarthria. ___ revealed cerebellar
lesion concerning for mass so he was transferred to ___.
Neurology was consulted given the differential of stroke vs.
seizure.
One week ago, Mr. ___ awoke in the morning and found that
he
was unable to walk normally. He was "wobbly" and had to hold
onto
the wall to make his way to the bathroom. He was very unsteady,
but did not think that he was falling specifically to one side.
He also has noticed that his left leg is harder to pick up while
walking. He has not noticed any other associated symptoms but
five days ago his friend told him that his speech was slurred.
These symptoms have not resolved. He had an unused cane at home
which he has needed consistently for the past week; despite this
he fell four days ago. Otherwise, Mr. ___ has not noticed
new double vision, blurry vision, loss of vision, or clusiness.
He has not had headache.
Three days before the onset of the difficulty walking, he had
paroxysmal vertigo, nausea and emesis which lasted for minutes.
He had just sat down to eat lunch (change in position) when he
had the abrupt onset of room-spinning vertigo. He had to throw
up. Afterwards these symptoms resolved and he was able to eat
his
lunch. Nothing like this had ever happened before.
These symptoms occurred in the context of two weeks of chest
discomfort, which appears to be more a sensation of dyspnea than
pain or tightness. The sensation was most likely to occur when
he
is just getting up in the morning. He will have rapide breathing
and then will take his morning aspirin and losartan with
improvement in his symptoms. It has been occurring frequently
these past two weeks. These are the symptoms which brought him
in
for evaluation.
He has had a swollen right lower extremity for weeks but cannot
say exactly when it started. He did not think that it was abrupt
in onset or that it started after a long plane ride.
Past Medical History:
hypertension
DM2 c/p neuropathy
diastolic heart failure
pulmonary HTN
CKD
SVT
amebiasis
glaucoma, cataracts
BPH, elevated PSA
Social History:
___
Family History:
Mother and father with cancer, unsure what kind. Brothers with
"breathing quickly," (dyspnea on exertion per his description)
Physical Exam:
PHYSICAL EXAM on ADMISSION:
T 97.5 HR 80; BP 179/70; RR 18; SpO2 100% ra
General: Thin man, lying in bed with sheet pulled over his head,
rouses to touch.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR with occasional early beats,
Grade 1 systolic murmur at LLSB.
Abdomen: Thin, soft, nontender, nondistended
Extremities: Pitting edema in right lower extremity
Skin: Keloid over chest wall. no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, to person, place but thought it was ___. History is tangential and somewhat vague. Speech is fluent
and intact to reading, writing, repetition, comprehending
cross-body commands and naming high and low freqency objects.
Speech was not dysarthric. Registered 3 objects and recall ___.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation with finger counting.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: Did not cooperate with formal EOMI testing, would
not sustain lateral gaze. No clear nystagmus, no obvious palsy.
Saccades were hypometric in horizontal direction but unclear if
this was related to effort.
V: Facial sensation intact to light touch, temperature 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 tone throughout. No pronator drift bilaterally.
No
tremor or asterixis.
Wasting of intrinsic hand muscles bilaterally.
Delt Bic Tri WrE FFl FE IO
L ___ ___ 4
R ___ ___ 4
IP Quad Ham TA ___
L ___ 5 5 5 5
R ___ 4 5 4 4
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 1 0
R 3 3 3 1 0
- Plantar response was extensor bilaterally.
-Sensory: Decreased sensation to pin and temperature in
stcking-glove distributin in upper and lower extremities.
Vibration decrease at great toes ___ sec) bilaterally. No
deficit of proprioception throughout. No extinction to DSS.
-Coordination: Ataxia on left FNF and HKS. Finger and toe
tapping
with dysrhthmia.
-Gait: When standing tends to fall backwards unless using his
cane. Cannot walk two steps without falling toward the left.
Cannot stand with feet together thus Romberg not tested.
DISCHARGE EXAM
===============
Vitals: 99.2 67 137/60 18 99%RA
General: laying in bed, comfortable,
HEENT: wound on posterior head c/d/i. EOMI, Pupils 3mm minimally
reactive to light b/l. Conjunctiva clear, sclera anicteric
Neck: supple
Cardiac: RRR, no m/r/g
Chest: CTAB
Abdomen: soft, ND, NT
GU: Foley in place, red urine in bag
Ext: No edema, 2+radial pulses. 1+ pedal pulses. ___ cool.
Neuro: CNII-XII intact. Strength ___ in UE and ___. Reflexes 3+
UE and 2+ ___. Sensation intact throughout. Dysmetria in left
hand.
Skin: keloid on left upper chest
Pertinent Results:
LABS on ADMISSION:
=================
___ 07:26PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 07:30AM WBC-13.9* RBC-4.48* HGB-12.1* HCT-39.0*
MCV-87 MCH-27.0 MCHC-31.0* RDW-13.7 RDWSD-43.7
___ 07:30AM NEUTS-91.7* LYMPHS-2.7* MONOS-4.7* EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-12.80* AbsLymp-0.37* AbsMono-0.65
AbsEos-0.00* AbsBaso-0.04
___ 07:30AM GLUCOSE-543* UREA N-37* CREAT-1.4* SODIUM-139
POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-16* ANION GAP-36*
___ 07:40AM %HbA1c-10.7* eAG-260*
___ 12:15PM TSH-0.91
___ 12:15PM TRIGLYCER-93 HDL CHOL-72 CHOL/HDL-2.4
LDL(CALC)-85 ___
___ 12:15PM CHOLEST-176
___ 12:15PM cTropnT-<0.01 proBNP-504
___ 03:46PM ___ PO2-24* PCO2-54* PH-7.25* TOTAL
CO2-25 BASE XS--5
___ 11:04PM PSA-8.0*
==========
STUDIES:
==========
___ Chest XR:
In comparison with the study of ___ from an outside
facility, the cardiac
silhouette is normal in size and there is tortuosity of the
aorta. No definite vascular congestion or acute focal
pneumonia. Mild left basilar atelectatic changes are seen.
___: MRI HEAD W/ AND W/O CONTRAST
1. 1.4 x 1.0 cm left cerebellar lesion with peripheral
enhancement and slow diffusion centrally that is most concerning
for an abscess. Notably, there is little surrounding edema.
Characteristics would be atypical for tumors such as
glioblastoma or lymphoma.
2. Low gradient echo signal within the lesion described above
could represent hemorrhage or calcification.
___: CT HEAD W/O CONTRAST
1. 1.4 x 1.2 cm hypodensity in the left cerebellum corresponding
to lesion on recent MRI. No internal calcifications.
2. No evidence of hemorrhage. No additional lesions identified.
3. Chronic changes of cerebral atrophy and small vessel disease.
___ CT AB AND PELVIS
1. Massively enlarged heterogeneously enhancing prostate,
although findings could be related to severe BPH, prostate
malignancy is not excluded. Correlation with PSA is
recommended.
2. Multiple sclerotic bony lesions including in the left iliac
bone and L3 vertebral body these may represent bone islands. If
the patient has a history of prostate cancer metastatic disease
could not be excluded.
3. Incidental note made of bowel malrotation. No evidence of
obstruction.
4. 13 mm hepatic hypodensity not completely characterized on
this single phase study. This may represent a hemangioma.
Other etiologies cannot be excluded. Further evaluation with
ultrasound could be considered
5. 8.6 cm simple cyst in the left kidney
___: RUS
No focal hepatic lesion is identified corresponding to the
hypodensity seen on recent CT. This may represent a perfusion
anomaly on the CT scan.
___: CT HEAD W/O CONTRAST
1. Stable appearance of left cerebellar biopsy site with small
amount of
surrounding hemorrhage and edema.
2. No new bleeds or infarcts.
___ ECHO:
The left atrium is normal in size. The estimated right atrial
pressure is at least 15 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is mildly depressed (LVEF=
50-55 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is moderate to severe pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: No valvular vegetations or abscesses appreciated.
Low normal left ventricular systolic function. Increased left
ventircular filling pressure. Mildly dilated aortic root and
ascending aorta. Moderate to severe pulmonary artery systolic
hypertension. Mild mitral and tricuspid regurgitation.
___ Bilateral Lower Extremity Doppler:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins
================
PATHOLOGY
================
(___): Intraoperative frozen path stereotactic biopsy of
cerebellar lesion consistent with ischemic stroke.
=================
LABS on DISCHARGE:
=================
___ 04:55AM BLOOD Glucose-151* UreaN-13 Creat-1.0 Na-130*
K-3.8 Cl-95* HCO3-28 AnGap-11
___ 04:55AM BLOOD WBC-6.6 RBC-3.78* Hgb-10.3* Hct-31.3*
MCV-83 MCH-27.2 MCHC-32.9 RDW-14.3 RDWSD-41.5 Plt ___
___ 04:55AM BLOOD ___ PTT-61.3* ___
___ 04:55AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.8
___ 02:15PM BLOOD %HbA1c-10.7* eAG-260*
___ 09:15AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-LG
___ 09:15AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:15AM URINE RBC-92* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
Brief Hospital Course:
Mr. ___ is a ___ man with BPH w/ elevated PSA, HTN, DM,
diastolic CHF, pulmonary HTN, CKD, SVT, and glaucoma who was
admitted for dysequilibrium/dysarthria and found to have a
cerebellar lesion. He was also in DKA. 1.5 weeks prior to
admission, he had an episode of paroxysmal vertigo, nausea, and
emesis. Three days later, he awoke finding he was unable to walk
normally, was unsteady, and had difficulty picking up his left
leg. Two days afterwards, he developed slurred speech. On exam,
there was no papilledema, hyperreflexia, extensor plantar
response, L ataxia, and inability to walk without falling to the
left. Glucose was 526 on admission, and he was admitted for DKA
with neurology consulting. He was transferred to the general
neurology service on ___ for further workup of his cerebellar
lesion. Differential includes malignancy given the appearance of
the mass on MRI and the incongruency with vascular territory,
stroke (less likely), infection/abscess.
ACUTE ISSUES during ICU course:
# DKA: HbgA1c 10.7. While he is a Type II diabetic, he appears
to be ketosis prone. Likely secondary to not having received his
home insulin while in the ED. No infectious symptoms, UA
negative. Precipitating factor could also be due to CVA,
although less likely because his neuro symptoms preceded DKA.
Troponin x1 negative. Given 1L LR @250cc/hr with 40mEq K, placed
on insulin gtt, and converted to sc insulin once anion gap
closed and tolerating ___ followed.
# Cerebellar Lesion: Patient had a one week history of
dysequilibrium, ataxia, dysarthria with dysmetria on exam with L
cerebellar ring enhancing lesion on imaging. Strong concern for
infarct given sudden onset, though lesion does not appear to be
in a vascular distribution, although no DWI sequence was
available. Also concern for malignancy given appearance on MRI.
Infectious etiology also on the differential. Evaluated by
neurology and neurosurgery in the ED, and neurology followed.
# Dyspnea: On arrival at ICU he was asymptomatic with
unremarkable lung exam. Occurs every morning and is relieved by
losartan and aspirin. Non-exertional. Troponin negative in the
ED x1. While he does have a history of heart failure, he denies
orthopnea/PND. He also has a history of pulmonary hypertension,
though this does not necessarily account for symptoms occuring
solely in the morning. ECG sinus rhythm, only notable for left
anterior fascicular block, no ST abnormalities. ECHO showed EF
50-55%, with moderate to severe pulmonary artery systolic
hypertension, mild mitral and tricuspid regurgitation. Chest XR
showed no definite vascular congestion or acute focal pneumonia,
mild left basilar atelectatic changes. Bilateral lower extremity
dopplers showed no evidence of DVT.
# Acute kidney injury: Patient had Cr of 1.4 on admission and a
history of CKD, although baseline Cr unknown. Given setting of
DKA, he may have a component of pre-renal ___. Cr improving on
transfer from ICU. Held losartan and trended UOP. See below.
# Leukocytosis: Admitted to ICU without infectious symptoms. UA
negative. ___ be stress reaction. Leukocytosis continued to
downtrend. Chest XR showed no definite vascular congestion or
acute focal pneumonia, mild left basilar atelectatic changes.
Blood cx pending.
CHRONIC ISSUES:
HTN: Held losartan until baseline Cr obtained/ resolution ___
HLD: Cont. home pravastatin
BPH: Cont. home tamsulosin, hold if SBP<100
dCHF: pt not c/o chest pain. No edema. Does have history of SOB
(see above). ECHO showed EF 50-55% (see above for details).
FLOOR COURSE:
#B/l DVTs and PE: Imaging during the work-up of the cerebellar
lesion revealed bilateral subsegmental PEs. He was taken to the
OR for a sterotactic biopsy of the cerebellar lesion. Following
the procedure, we were only able to start subcutaneous heparin
24 hours following the procedure. An IVC filter was placed on
___ while awaiting being able to start systemic
anticoagulation. Systemic anticoagulation with a heparin drip
was started on ___ and titrated to a goal PTT of 50-70. A
head CT was obtained at goal PTT and showed no intracranial
bleeding. He was transitioned to lovenox on the day of discharge
with outpatient follow with ___ clinic. ___ will
remove the filter about a month after discharge.
#Stroke: Stereotactic biopsy of the cerebellar lesion on ___
confirmed an ischemic stroke. He completed a four day
dexamethasone taper following the biopsy. His neuro exam
improved over the course of the admission. He will follow up
with outpatient stroke clinic.
#Enlarged prostate: Pt has a known history of enlarged prostate.
PSA on this admission was elevated at admission to 8.0 and rose
to 26.2 (s/p placement of foley for retention). Enlarged
prostate noted on CT. Given multiple clots and sclerotic bony
lesions on the left iliac bone and the L3 vertebral body on CT,
this is concerning for malignancy as well. He will need
outpatient ___ for a biopsy of the bony lesions or the
prostate, so we set up outpatient bone biopsy of iliac crest
lesions, GU malignancy clinic f/u and outpatient urology f/u.
#Diabetes: Pt initially in DKA on admission (likely due to
missed insulin doses) now with sugars in the 100-200s, without
anion gap. ___ followed and adjusted the insulin sliding
scale along with the dexamethasone taper. He is being discharged
on his home insulin regimen.
#Hematuria: He developed gross hematuria for 2 days while on
heparin at the goal PTT of 50-60. There were some blood clots
which required flushing of the foley. Urology was consulted and
adjusted the foley but determined that he did not need CBI as
the hematuria self-resolved. Urology will see him in as an
outpatient for a cystoscopy.
#UTI. On ___ he developed some purulence at the tip of the
penis. Cultures were sent. He was given one dose of CTX and then
switched to bactrim for a 7 day course (___)
#Hyponatremia: Developed mild hypovolemic hyponatremia in the
setting of poor ___ intake is most likely. The patient is
asymptomatic. Given stroke, SIADH could be considered as well
though unlikely.
#Chest pain: He developed substernal chest pressure initially
___, resolving over 2.5 hrs on ___. He was initially given
nitroglycerin x3 with a drop in blood pressures to ___.
EKG wihtout changes from prior. Blood pressures increased to
180s and then stabilized in the 140s/70s-90s. O2 sats remained
in the high ___. He was treated with full strength aspirin, 1L
IVF, and morphine. He was continued on metoprolol 6.25mg BID.
Systemic anticoagulation was not an option as this was POD1 of
the cerebellar biopsy. He had a subsequent episode of chest
pressure on ___ without EKG changes and with negative trops.
These are most likely secondary to additional clot burden. He
had an additional episode of multifocal atrial tachycardia which
responded to metoprolol 5mg x1. Metoprolol was increased to
6.25mg Q6H.
#dCHF: He currently appears euvolemic and is not short of
breath. Echo shows a low normal EF of 50-55%. I/Os monitored and
lytes repleted as needed.
#SOB: His prior symptoms of shortness of breath were likely a
combination of pulmonary emboli and known mild pulmonary
hypertension noted on echo. He is currently breathing
comfortably and does not have an oxygen requirement.
#Liver lesions: Imaging of the abdomen also noted that he has a
hypodense lesion in the liver and a simple cyst of the left
kidney. Subsequent RUS did not identify the lesion.
#CKD: Likely acute on chronic renal failure secondary to ___ in
the setting of DKA. Creatine improved from 1.5-->1.0.
Medications were renally dosed as necessary.
#HTN: He has SBPs going into the 170s. He has been off his BP
medications for this hospitalization but is stable now and were
restarted. His Cr has also come back down. BPs stable at
140s/80s after chest pain resolved. He was continued on losartan
50mg ___ QD and hydralazine 10mg IV Q6H prn.
#HLD: Continued home pravastatin 40mg ___ QHS
TRANSITIONAL ISSUES
===================
Discharge vital signs: 99.2, 67, 137/60, 18, 99% RA
Discharge mental status: AAOx4. Fully conversant.
Discharge neurologic exam: Mild dysmetria left hand. Otherwise,
completely intact
Vital signs per routine
FSBG QACHS
Physical and occupational therapy
Diabetic diet
-On discharge, will need PCP ___. Would recommend calling
___ at ___ to set this up.
-ANTICOAGULATION: Will need to be set up with a PCP upon
discharge. Anticoagulation management needs to be set up with
the ___ clinic (___ ___. Lovenox dose
will be 1mg/kg BID.
-Is being discharged to ___ Living in ___ (___
___
-Insulin sliding scale adjusted in setting of dexamethasone
taper. Multiple adjustments were made and he is being discharged
on home regimen. Sugars should be followed carefully. Check FSBG
QACHS.
-Enlarged prostate: He is being scheduled for an outpatient bone
biopsy of iliac crest lesions. Urology will also do an
outpatient cystoscopy. He will follow up with Dr. ___ in GU
oncology.
-UTI: Will complete a 7 day course of bactrim DS (course
___. Follow up on chlamydia cultures which were
sent.
-SVT: Discharged on metoprolol succinate 25mg QD. ___ need to
monitor for further arrythmias.
EMERGENCY ___ (daughter): ___
CODE STATUS: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg ___ DAILY
2. Detemir 6 Units Dinner
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Vitamin D 50,000 UNIT ___ 1X/WEEK (SA)
4. Losartan Potassium 50 mg ___ DAILY
5. Tamsulosin 0.4 mg ___ QHS
6. Pravastatin 40 mg ___ QPM
7. Acetaminophen 650 mg ___ Q6H:PRN pain
Discharge Medications:
1. Aspirin 81 mg ___ DAILY
2. Glargine 6 Units Dinner
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 6 Units Dinner
3. Losartan Potassium 50 mg ___ DAILY
4. Pravastatin 40 mg ___ QPM
5. Tamsulosin 0.4 mg ___ QHS
6. Enoxaparin Sodium 70 mg SC Q12H
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
7. Sulfameth/Trimethoprim DS 1 TAB ___ BID
8. Vitamin D 50,000 UNIT ___ 1X/WEEK (SA)
9. Metoprolol Succinate XL 25 mg ___ DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Stroke
Pulmonary Embolism
Deep Vein Thrombosis
Supraventricular Tachycardia
Urinary Tract Infection
Type 2 diabetes
SECONDARY DIAGNOSIS
===================
Hypertension
Chronic kidney disease
Diastolic Congestive Heart Failure
Pulmonary hypertension
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 sent to ___ because of your gait problems and mild
speech difficulties likely due to a mass in your cerebellum.
While you were in the emergency room, your blood sugars were
very high indicating diabetic ketoacidosis. Because of this, you
were admitted to the ICU, and ___ was
consulted to help manage your care. Once your sugars normalized,
you were transferred to the neurology service for further workup
of your cerebellar lesion. Neurosurgery performed a biopsy of
the lesion and it was determined that the lesion was a stroke.
Imaging studies performed to evalute the lesion in your brain
revealed that you had clots in your lungs and right leg. Because
the biopsy performed on your brain we were unable to start
medication for these clots until five days after the biopsy, a
filter was placed in your leg to prevent the clot from further
spreading. The doctors, interventional radiology, who placed
this filter will take it out in a few weeks.
We started treating you with medication, heparin, for the clots
5 days after the biopsy. You were transitioned to another
medication, Lovenox, for the clots which you will be taking for
___. The Healthcare Associates ___ clinic will
be managing this medication along with your PCP.
Imaging also revealed lesions in several of your bones and an
enlarged prostate. We are concerned this may signify prostate
cancer. We will have you follow up with urology and oncology to
evaluate this.
It was a pleasure to take care of you. We wish you the very
best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10350826-DS-12 | 10,350,826 | 24,479,558 | DS | 12 | 2110-04-08 00:00:00 | 2110-04-09 06:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Labial wound infection
Major Surgical or Invasive Procedure:
___ Incision and drainage and excisional debridement
of a left groin necrotizing soft tissue infection.
___ Incision and debridement of left groin and labia
necrotizing fasciitis with sharp debridement of skin fat and
fascia.
___ Wound VAC change left groin
___ Change of vacuum-assisted closure dressing, 4 x 25 cm.
History of Present Illness:
___ with PMH of HTN & diabetes, presented to an OSH with 2 day
history of left labia pain. Patient refers having ___
cyst/abscesses a year that spontaneously drain and resolve by
there own but that his one has been getting a lot worse with no
resolution. She refers having subjected fevers and chills at
home, which have not resolved with ibuprofen. She refers that
the pain is ___, extending superior into her groin and feeling
of air ___ the area. She denies any nausea, vomiting,
constipation or diarrhea.
Past Medical History:
PMH: HTN, DMII, HLD, Arthritis, Back pain, OSA, Spinal stenosis,
obesity
PSH: C-Section x2, Right Hip replacement x 3
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: 99.9 105 111/56 17 91% RA
GEN: A&O x 3
HEENT: No scleral icterus, mucus membranes moist
CV: Tachycardic
PULM: non labored breathing
ABD: Soft, nondistended, nontender, no rebound or guarding,
Groin: Erythematous & TTP over the left groin/labia with no area
of drainage seen
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.1 127 / 70 L Lying 67 18 93 RA
GEN: ___ bed with TV on.
HEENT: PERRL, EOMI. pronounced forehead and facial hair noted.
Mucus membranes pink/moist. No dentition.
CV: RRR
PULM: Clear to auscultation bilaterally.
ABD: Obese, soft, non-tender. Active bowel sounds.
Ext: Obese, no edema. Warm and well perfused.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 05:22AM BLOOD WBC-7.3 RBC-3.83* Hgb-11.5 Hct-34.6
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.7 RDWSD-48.5* Plt ___
___ 04:19AM BLOOD WBC-7.2 RBC-3.65* Hgb-11.0* Hct-33.2*
MCV-91 MCH-30.1 MCHC-33.1 RDW-14.6 RDWSD-48.3* Plt ___
___ 05:24AM BLOOD WBC-8.5 RBC-3.89* Hgb-11.7 Hct-35.6
MCV-92 MCH-30.1 MCHC-32.9 RDW-14.6 RDWSD-48.6* Plt ___
___ 05:13AM BLOOD WBC-7.8 RBC-3.94 Hgb-11.9 Hct-35.9 MCV-91
MCH-30.2 MCHC-33.1 RDW-14.5 RDWSD-48.2* Plt ___
___ 06:08AM BLOOD WBC-8.4 RBC-4.08 Hgb-12.1 Hct-37.3 MCV-91
MCH-29.7 MCHC-32.4 RDW-14.7 RDWSD-48.7* Plt ___
___ 04:30AM BLOOD WBC-12.1* RBC-3.94 Hgb-11.9 Hct-36.1
MCV-92 MCH-30.2 MCHC-33.0 RDW-14.4 RDWSD-48.3* Plt ___
___ 05:36AM BLOOD WBC-12.2* RBC-4.31 Hgb-13.0 Hct-38.9
MCV-90 MCH-30.2 MCHC-33.4 RDW-14.3 RDWSD-47.0* Plt ___
___ 02:23AM BLOOD WBC-12.5* RBC-4.20 Hgb-12.5 Hct-38.2
MCV-91 MCH-29.8 MCHC-32.7 RDW-14.4 RDWSD-47.4* Plt ___
___ 04:30AM BLOOD WBC-12.4* RBC-4.37 Hgb-13.2 Hct-39.7
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.1 RDWSD-46.7* Plt ___
___ 06:48AM BLOOD WBC-12.9* RBC-4.45 Hgb-13.2 Hct-40.8
MCV-92 MCH-29.7 MCHC-32.4 RDW-14.3 RDWSD-48.1* Plt ___
___ 02:13AM BLOOD WBC-19.6* RBC-4.30 Hgb-13.2 Hct-38.3
MCV-89 MCH-30.7 MCHC-34.5 RDW-14.3 RDWSD-46.5* Plt ___
___ 08:00PM BLOOD WBC-22.1* RBC-4.66 Hgb-14.2 Hct-42.0
MCV-90 MCH-30.5 MCHC-33.8 RDW-14.4 RDWSD-47.1* Plt ___
___ 02:01PM BLOOD WBC-20.3* RBC-5.11 Hgb-15.5 Hct-45.4*
MCV-89 MCH-30.3 MCHC-34.1 RDW-14.0 RDWSD-45.5 Plt ___
___ 05:22AM BLOOD Glucose-147* UreaN-5* Creat-0.5 Na-139
K-4.0 Cl-103 HCO3-25 AnGap-15
___ 03:43AM BLOOD Glucose-143* UreaN-7 Creat-0.5 Na-138
K-4.0 Cl-102 HCO3-25 AnGap-15
___ 04:19AM BLOOD Glucose-188* UreaN-8 Creat-0.4 Na-137
K-3.9 Cl-103 HCO3-25 AnGap-13
___ 03:56AM BLOOD Glucose-167* UreaN-7 Creat-0.4 Na-138
K-3.8 Cl-102 HCO3-27 AnGap-13
___ 03:40AM BLOOD Glucose-167* UreaN-8 Creat-0.5 Na-137
K-4.3 Cl-100 HCO3-27 AnGap-14
___ 05:24AM BLOOD Glucose-197* UreaN-7 Creat-0.5 Na-134
K-4.2 Cl-96 HCO3-25 AnGap-17
___ 05:13AM BLOOD Glucose-196* UreaN-7 Creat-0.5 Na-135
K-3.7 Cl-96 HCO3-28 AnGap-15
___ 06:08AM BLOOD Glucose-175* UreaN-7 Creat-0.4 Na-139
K-3.9 Cl-98 HCO3-29 AnGap-16
___ 04:30AM BLOOD Glucose-335* UreaN-11 Creat-0.6 Na-132*
K-3.8 Cl-93* HCO3-25 AnGap-18
___ 04:43AM BLOOD Glucose-196* UreaN-8 Creat-0.5 Na-134
K-3.3 Cl-91* HCO3-29 AnGap-17
___ 05:36AM BLOOD Glucose-206* UreaN-10 Creat-0.6 Na-136
K-3.6 Cl-93* HCO3-29 AnGap-18
___ 04:52PM BLOOD Glucose-242* UreaN-13 Creat-0.6 Na-140
K-4.3 Cl-92* HCO3-33* AnGap-19
___ 01:00AM BLOOD Glucose-210* UreaN-11 Creat-0.5 Na-141
K-3.8 Cl-93* HCO3-34* AnGap-18
___ 04:02PM BLOOD Glucose-162* UreaN-12 Creat-0.4 Na-143
K-3.5 Cl-95* HCO3-34* AnGap-18
___ 02:02AM BLOOD Glucose-222* UreaN-15 Creat-0.5 Na-143
K-3.5 Cl-93* HCO3-40* AnGap-14
___ 11:18AM BLOOD Glucose-315* UreaN-16 Creat-0.5 Na-141
K-4.2 Cl-92* HCO3-37* AnGap-16
___ 01:56AM BLOOD Glucose-254* UreaN-15 Creat-0.5 Na-140
K-3.6 Cl-92* HCO3-39* AnGap-13
___ 02:46PM BLOOD Glucose-286* UreaN-13 Creat-0.5 Na-142
K-3.7 Cl-95* HCO3-36* AnGap-15
___ 05:38PM BLOOD Glucose-217* UreaN-9 Creat-0.4 Na-139
K-4.6 Cl-103 HCO3-24 AnGap-17
___ 02:00AM BLOOD Glucose-145* UreaN-12 Creat-0.5 Na-137
K-3.8 Cl-103 HCO3-24 AnGap-14
___ 01:37PM BLOOD Glucose-236* UreaN-15 Creat-0.5 Na-135
K-3.9 Cl-101 HCO3-23 AnGap-15
___ 02:13AM BLOOD Glucose-327* UreaN-17 Creat-0.6 Na-134
K-3.8 Cl-101 HCO3-20* AnGap-17
___ 08:00PM BLOOD Glucose-367* UreaN-15 Creat-0.7 Na-135
K-3.8 Cl-98 HCO3-21* AnGap-20
___ 02:01PM BLOOD Glucose-428* UreaN-15 Creat-0.8 Na-128*
K-4.0 Cl-91* HCO3-16* AnGap-25*
___ 02:02AM BLOOD ALT-27 AST-20 AlkPhos-106* TotBili-0.3
___ 03:03AM BLOOD ALT-53* AST-59* AlkPhos-98 TotBili-0.4
___ 02:02AM BLOOD ALT-27 AST-20 AlkPhos-106* TotBili-0.3
___ 03:03AM BLOOD ALT-53* AST-59* AlkPhos-98 TotBili-0.4
___ 02:13AM BLOOD %HbA1c-11.7* eAG-289*
___ 04:30AM BLOOD TSH-2.5
___ 04:36AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:00PM URINE Color-Straw Appear-Clear Sp ___
___ 04:36AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 08:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 02:01PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:36AM URINE RBC-2 WBC-9* Bacteri-NONE Yeast-NONE
Epi-2
___ 08:00PM URINE RBC-3* WBC-38* Bacteri-NONE Yeast-FEW
Epi-<1
___ 5:30 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).
___ 4:36 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 11:20 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
Time Taken Not Noted ___ Date/Time: ___ 8:21 pm
SWAB
PERINEAL WOUND NEOTOLIZING SOFT TISSUE INFECTION LEFT
GROIN LASIA. **FINAL REPORT
___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
GRAM POSITIVE COCCUS(COCCI). MODERATE GROWTH.
ENTEROCOCCUS SP.. MODERATE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
Work-up of organism(s) listed discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
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.
___ 2:01 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:01 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Ms. ___ was admitted to ___ on ___ for a labial necrotizing
soft tissue infection. For more information, please see
admission H&P. She was taken to the OR for debridement and was
then taken to the TSICU intubated, on Levophed and
Vanc/Zosyn/Clinda. Her pressors were weaned over the course of
the following day, and she returned to the OR on ___ for
further debridement. An Echo was performed, which showed
preserved ejection fraction without areas of hypokinesis or
significant valvular disease. A Vac dressing was placed on ___
and replaced every 3 days. She was extubated on ___. Her
leukocytosis increased, and she was taken to the OR on ___ for
further exploration and debridement. The wound appeared grossly
clean, and a Vac dressing was replaced. She was transferred to
the floor on ___.
Neuro: Ms. ___ was admitted intubated and sedated on fentanyl
and propofol drips. She was transitioned to precedex on ___,
but was switched back to propofol on ___ due to bradycardia.
She was restarted on precedex around extubation on ___. She was
started on Seroquel on ___ to help sleep/wake cycle.
CV:Ms. ___ was admitted to TSICU on levophed, which was weaned
by ___. An Echo was performed, which showed preserved ejection
fraction without areas of hypokinesis or significant valvular
disease. A RIJ CVL migrated out of position on ___, so this was
removed and a PICC was placed.
Pulm: Ms. ___ was admitted to the TSICU intubated. CXRs showed
bilateral pulmonary edema, and she required significant FiO2 and
PEEP to oxygenate. A Lasix gtt was started and her vent settings
were weaned slowly with continued diuresis. She was extubated on
___.
GI: The patient was kept NPO until ___, when tube feeds were
started. She was switched to Promote with fiber on ___. After
extubation she was evaluated by speech and swallow and started
on a regular diet with honey thickened liquids and pureed food.
Renal: Ms. ___ had a foley catheter placed on presentation and
underwent significant diuresis with a Lasix gtt starting on
___. The was stopped and intermittent boluses of Lasix were
started on ___.
ID: Ms. ___ initially started on Vanc/Zosyn/clinda. Clinda was
stopped on ___, and vanc/zosyn was stopped on ___. Zosyn was
restarted on ___ when her leukocytosis increased from 10 to 17.
Heme: Ms. ___ received SQH for DVT ppx.
Endo: Ms. ___ diabetes has been difficult to control. She
initially started on an insulin gtt. ___ was consulted, and
she was stabilized to a combination long acting insulin regimen
with additional sliding scale. An insulin gtt was also required
around changes ___ her tube feeds and PO intake around surgery
and extubation.
===================================================
Hospital Floor Course:
Neuro: Ms ___ was initially delirious, agitated, and
attempting to leave hospital. This improved with Haldol that was
weaned off. She was started on Seroquel at night to assist ___
regulating sleep wake cycles with good effect. Her mental status
improved and she is now alert and oriented x 3. Anxious at
times, but redirectable with verbal cues.
Cardiopulmonary: The patient remained stable from a
cardiopulmonary standpoint. Initally she required 6 L nasal
canula oxygen which was weaned to room air as tolerated. She
showed evidence of sleep apnea on the continuous pulse oxymetry
as she desaturated to 80's with sleep. Recommend outpatient
sleep study after rehab discharge.
GI/GU/FEN: The patient tolerated a regular diet and urine output
closely monitored with foley catheter. Urine cultures positive
for yeast on ___. Foley catheter changed out and treated
with diflucan. Repeat urine cultures negative for infection.
Stool sample sent for c.diff on ___ negative for acute
infection. Foley catheter was kept ___ place due to proximity to
wound and wound vac dressing to avoid contamination and
disruption on wound vac function. The patient was followed by
___ Diabetes and blood glucose control obtained
with insulin regimen.
Skin: Patient underwent wound vac changes every 3 days. These
were initially conducted under general anesthesia and then
successfully transitioned to bedside vac changes on ___. Last
vac change done on ___. Wound bases show progressive
granulation tissue and no signs/symptoms of infection.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. Patient completed last dose
of IV zosyn on ___ and this was last dose of antibiotics ___
hospital. She was given fluconazole for yeast ___ urine completed
on ___.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with assistance, making adequate urine with foley
catheter, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Rehab stay expected to be less than 30 days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Janumet (SITagliptin-metformin) 50-1,000 mg oral DAILY
2. GlipiZIDE 10 mg PO DAILY
3. Losartan Potassium 10 mg PO DAILY
4. Oxybutynin 5 mg PO TID
5. FLUoxetine 40 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Atenolol 50 mg PO DAILY
8. Simvastatin 40 mg PO QPM
9. Lantus (insulin glargine) 100 unit/mL subcutaneous QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Do not exceed 4 gram/ 24 hours.
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye care while
on sedtion
4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. DiphenhydrAMINE 25 mg PO Q6H:PRN itching/rash
7. Docusate Sodium 100 mg PO BID
8. Famotidine 20 mg PO BID
9. Gabapentin 300 mg PO QHS
10. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
11. Glucose Gel 15 g PO PRN hypoglycemia protocol
12. Heparin 5000 UNIT SC TID
13. Glargine 40 Units Breakfast
Glargine 42 Units Bedtime
Humalog 16 Units Breakfast
Humalog 16 Units Lunch
Humalog 16 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
14. Nicotine Lozenge 2 mg PO Q2H:PRN Smoking cessation
15. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: will dc
Take lowest effective dose.
16. QUEtiapine Fumarate 25 mg PO QHS insomnia
17. Sarna Lotion 1 Appl TP QID:PRN pruritis
18. Senna 8.6 mg PO BID:PRN constipation
19. Aspirin 325 mg PO DAILY
20. Atenolol 50 mg PO DAILY
21. FLUoxetine 40 mg PO DAILY
22. Losartan Potassium 10 mg PO DAILY
23. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Necrotizing skin 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:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with a necrotizing wound infection ___ your labial area. You were
given IV antibiotics and taken to the operating room to have the
infection portion removed. A wound vac dressing was placed
initially ___ the operating room and changed every few days until
you were able to tolerate vac changes at the bedside. Your blood
glucose was elevated and the ___ diabetes team was consulted
to help manage your insulin.
You are now doing better, tolerating a regular diet, and your
wound is progressively healing. You are now ready to be
discharged to rehab to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood ___ your
urine, or experience a discharge.
*Your pain ___ 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 ___ your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10351156-DS-16 | 10,351,156 | 28,542,882 | DS | 16 | 2181-05-02 00:00:00 | 2181-05-02 17:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
PACEMAKER PLACEMENT:
Date of Implant: ___
Indication: SSS
Device brand/name: ___ / ___ XT ___ ___: ___
A lead ___ date: MDT / ___ / ___
RV lead ___ date: ___ / ___
History of Present Illness:
Mr. ___ is a ___ y/o man with a
history of hypertension, ___ disease who initially presented
to an outside hospital with lightheadedness, found to have
arrhythmia and syncope, transferred for significant sinus pause
and for advanced cardiac care.
Patient reports that he was in his usual state of health until
___. He tells me that on ___, he was standing in the
kitchen with his son when he felt dizzy and nauseated and sat
down. His son told him that he was staring and not responsive to
his questions, but he does not think he lost consciousness.
Other
than the nausea and dizziness, he denies any antecedent symptoms
like chest pain, palpitations, shortness of breath.
On ___, he was at work as a ___ and was making his
rounds. He felt fine. He then came back to the security trailer
and again felt dizzy, nauseated, and lightheaded. He is unsure
if
he lost consciousness, but he cannot recall what happened next
and the next thing he remembers is paramedics arriving. He
denies
any other symptoms such as fevers, chills, cough, chest pain,
palpitations, shortness of breath, peripheral edema, vomiting,
abdominal pain, diarrhea. He has been eating and drinking
normally.
He was taken to ___. While there, his wife called
out to the nursing that he is having another episode. Per
report,
patient lost consciousness for a few seconds. Per report, pause
on monitor was ~30 seconds; strips provided from ___ be
incomplete, but a pause of at least 16 seconds is noted. CXR at
___ without acute process. CT head with "atrophy somewhat
out
of proportion to age. No acute intracranial abnormality." Labs
at
___ notable for magnesium 1.4, calcium 8.4, TSH
1.8.
trop I <0.04.
Cardiology at ___ thought that patient did require
a
pacemaker, but this could not be placed at ___ over the
weekend. It was not thought that the patient needed transvenous
pacing prior to transfer, and pacer pads were placed as a
precaution.
In the ED, initial VS were: 97.7 67 179/78 18 96% RA
Exam notable for: Per nursing note: Resp unlabored, BLLS clear.
Skin warm and dry, MMM. Abdm soft and non-tender, no signs of
pedal edema. Pulses +.
ECG: NSR, NA, PR 160, QRS 91, QTc 454, subtle STD in lateral
leads
Labs showed: H/H ___ BMP wnl
Imaging showed:
- CXR: PA and lateral views of the chest provided. Defibrillator
pads projects over the chest. Lungs are clear without evidence
of
pneumonia or edema. A linear density in the left midlung is most
suggestive of atelectasis. No pleural effusion or pneumothorax.
Heart size is normal. Mediastinal contour is s normal. Imaged
bony structures are intact. No free air below the right
hemidiaphragm is seen.
Consults: None
Patient received: Nothing
Transfer VS were: 98.1 69 176/78 19 96% RA
On arrival to the floor, patient reports that he feels well. He
denies any chest pain, palpitations, shortness of breath,
headache, nausea, dizziness, or lightheadedness at present. He
reports that he took his metoprolol this morning but not the
evening dose.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- Hypertension
- ___ disease
Social History:
___
Family History:
- Mother: ___
- Father: Unknown medical history
- 3 sisters: healthy
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.6 ___ Ra
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: BS+, soft, NTND
EXTREMITIES: No peripheral edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN II-XII intact, moving all 4 extremities with
purpose
SKIN: Warm and well-perfused, hyperpigmentation of skin
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM
NECK: supple, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: BS+, soft, NTND
EXTREMITIES: No peripheral edema
NEURO: A&Ox3, CN II-XII intact, moving all 4 extremities with
purpose
SKIN: Warm and well-perfused, hyperpigmentation of skin
Pertinent Results:
ADMISSION LABS:
===============
___ 08:31PM BLOOD WBC-7.2 RBC-4.02* Hgb-13.2* Hct-38.6*
MCV-96 MCH-32.8* MCHC-34.2 RDW-13.5 RDWSD-47.8* Plt ___
___ 08:31PM BLOOD Neuts-77.4* Lymphs-13.5* Monos-6.7
Eos-1.4 Baso-0.6 Im ___ AbsNeut-5.54 AbsLymp-0.97*
AbsMono-0.48 AbsEos-0.10 AbsBaso-0.04
___ 08:31PM BLOOD ___ PTT-26.0 ___
___ 08:31PM BLOOD Glucose-108* UreaN-12 Creat-0.9 Na-144
K-4.2 Cl-106 HCO3-17* AnGap-21*
___ 08:31PM BLOOD Calcium-9.0 Phos-3.2 Mg-2.2
PERTINENT/DISCHARGE LABS:
=========================
___ 06:35AM BLOOD WBC-7.6 RBC-4.31* Hgb-14.1 Hct-41.6
MCV-97 MCH-32.7* MCHC-33.9 RDW-13.6 RDWSD-48.4* Plt ___
___ 07:10AM BLOOD Neuts-64.3 ___ Monos-8.7 Eos-5.0
Baso-0.6 Im ___ AbsNeut-3.35 AbsLymp-1.09* AbsMono-0.45
AbsEos-0.26 AbsBaso-0.03
___ 06:35AM BLOOD Glucose-107* UreaN-9 Creat-0.9 Na-142
K-4.4 Cl-107 HCO3-20* AnGap-15
___ 09:26PM BLOOD cTropnT-0.02*
___ 06:35AM BLOOD cTropnT-<0.01
___ 06:35AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.0
IMAGING/STUDIES:
================
CXR ___:
PA and lateral views of the chest provided. Defibrillator padd
projects over
the chest. Lungs are clear without evidence of pneumonia or
edema. A linear
density in the left midlung is most suggestive of atelectasis.
No pleural
effusion or pneumothorax. Heart size is normal. Mediastinal
contour is s
normal. Imaged bony structures are intact. No free air below
the right
hemidiaphragm is seen.
CXR ___:
No pneumothorax post placement of a left chest wall dual lead
pacemaker.
CXR ___:
No acute cardiopulmonary abnormality.
EP Procedure: PPM Placement ___:
Successful implantation of a dual chamber (His) pacemaker.
There were no complications.
CXR ___:
Lungs are clear. Left-sided pacemaker leads are unchanged.
Cardiomediastinal
silhouette is stable. There is no pleural effusion. No
pneumothorax is seen
Brief Hospital Course:
Mr. ___ is a ___ y/o man with a history of hypertension,
___ disease who initially presented to an outside hospital
with lightheadedness, found to have sinus pause and syncope,
transferred for pacemaker placement, which he underwent on
___.
# Sinus node dysfunction/sinus node arrest:
# Syncope:
Patient presenting after two episodes of syncope, found on
outside hospital telemetry to have significant sinus pause
(~30s) that is the likely cause of his syncopal episodes. EKG
without ischemic changes, troponin I at outside hospital
negative. Uncomplicated placement of a ___ pacemaker on
___. Follow-up in device clinic and with cardiology.
# Hypertension:
Poorly controlled in house with frequent pressures in the 170s.
Metoprolol was stopped due to bradycardia. Lisinopril 20mg daily
was started as this is a first line anti-hypertensive. Recommend
check CBC in clinic as the combination of ACEi and
mercaptopurine has been observed to cause anemia/leukopenia. If
developing these findings, would recommend switching to
alternative medication for BP control.
# ___ disease: Symptoms well controlled. Has ___ stools per
day without blood. Has had previous bowel resections. Continued
mercaptopurine.
# Primary prevention: Continued home aspirin.
TRANSITIONAL ISSUES:
- Uncomplicated placement of a ___ pacemaker on ___.
Follow-up in device clinic and with cardiology.
- Lisinopril 20mg daily was started as this is a first line
anti-hypertensive. Recommend check CBC in clinic as the
combination of ACEi and mercaptopurine has been observed to
cause anemia/leukopenia. If developing these findings, would
recommend switching to alternative medication for BP control.
- Metoprolol stopped due to bradycardia and suboptimal BP
control.
#CODE: Full
#CONTACT: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mercaptopurine 50 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Mercaptopurine 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#Sick Sinus Syndrome s/p PPM placement
#Hypertension
#Chrons Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ for symptoms due to a low heart rate.
WHILE YOU WERE HERE:
- We placed a pacemaker to help your heart beat faster
WHEN YOU GO HOME:
- Please follow up with the below doctors
- Please continue all medications as directed
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10351179-DS-13 | 10,351,179 | 21,797,217 | DS | 13 | 2185-05-19 00:00:00 | 2185-05-26 04:51:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
events concerning for seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old man with past medical history
of bipolar disorder, depression and anxiety who presents to the
___ ED ___ with first generalized tonic clonic seizure 10
days
ago followed by daily episodes of loss of awareness. History is
provided both patient and girlfriend.
Pt states that he was incarcerated until 2 weeks ago. While in
jail, he was prescribed Depakote for bipolar disorder. When he
got out of jail, he was only given a 3 day supply. 10 days ago,
he had a generalized tonic clonic seizure. Girlfriend reports
him
collapsing and having generalized convulsions lasting ___ mins.
Pt then was confused following this event for ~30 minutes. Pt
does not recall this event; he just states that he suddenly
"couldn't walk" then recalls seeing his girlfriends face off and
on. He was brought to ___ where, per pt report, he had a NCHCT
that was normal. He was discharged home and he states epilepsy
___ was not arranged and he did not have an MRI or EEG.
At time of discharge from ___, he was given a 5 day supply of
Depakote and then ran out. Over the past 10 days, pt's
girlfriend
has noted that he is "doing funny things" and "cannot stay
awake". For instance, during a conversation, he may get stuck on
a word (e.g. video) and then say it repeatedly. Pt does not
recall this. This is followed by a drop of the pt's head. Pt's
girlfriend denies seeing any lip smacking or automatisms. Pt
will
sometimes have a whole body jerk before or after the head nod.
This entire episode will last about 30 secs. Pt does not recall
any of the episodes and episodes occur anywhere from 3 times a
day to 21+ times a day.
Pt's girlfriend brought him to the ED after he woke her up
because he thought she was his son ___. She was stressed by
how
he had been acting strange so wanted further evaluation.
At time of assessment, pt does report time lapses during
conversations. He denies any history of concussions, skull
fracture, meningitis, encephalitis, developmental delay, or
premature birth. He has no family history of seizures, including
extended family. He denies ever smelling a pungent smell that
other people do not smell or having any rising epigastric
sensations.
On neurologic review of systems, the patient denies headache or
lightheadedness. Denies difficulty with producing or
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal muscle weakness, numbness, parasthesia.
Denies loss of sensation. Denies bowel or bladder incontinence
or
retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
Bipolar disorder
Anxiety
Depression
IVDA (last used ___
Social History:
___
Family History:
Mother: ___ cancer
Does not know father
Physical ___:
ADMISSION AND DISCHARGE EXAM
Afebrile, VS WNL
General: NAD, disheveled, pleasant
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Drowsy but easily arouses. Oriented to person,
place and time. Able to recall a coherent history. Mildly
inattentive. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Normal prosody. No
dysarthria. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk on R, L pupil is oval and
minimally reactive (pt reports he had an injury to this eye). VF
full to number counting. EOMI, no nystagmus. V1-V3 without
deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri 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 or proprioception
bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. Negative Romberg.
Pertinent Results:
___ 04:20AM BLOOD WBC-7.5 RBC-4.35* Hgb-13.7* Hct-41.0
MCV-94 MCH-31.4 MCHC-33.4 RDW-14.6 Plt ___
___ 04:20AM BLOOD Neuts-38.3* Lymphs-50.0* Monos-7.0
Eos-4.0 Baso-0.8
___ 04:20AM BLOOD Glucose-101* UreaN-15 Creat-1.0 Na-140
K-3.6 Cl-102 HCO3-28 AnGap-14
___ 04:20AM BLOOD ALT-204* AST-83* AlkPhos-87 TotBili-0.4
___ 01:10PM BLOOD ALT-212* AST-115* AlkPhos-80 Amylase-53
TotBili-0.7
___ 07:00PM BLOOD ALT-287* AST-168* LD(LDH)-222 AlkPhos-92
TotBili-0.4
___ 01:10PM BLOOD Lipase-28
___ 07:00PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
___ 04:20AM BLOOD Valproa-<3*
___ 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:00PM BLOOD HCV Ab-POSITIVE*
EEG - ___
This continuous EEG recording period did not capture any
epileptiform activity. No fully waking background was captured
during this recording session, that ran approximately from
midnight to 7 a.m.
EEG - ___
This recording period captured a slower than average background,
but no epileptiform activity.
EEG - ___
This is a continuous video EMU EEG monitoring study because of
diffuse background slowing, indicative of a mild encephalopathy,
which is non-
specific with regard to etiology but may be due to various
causes such as
metabolic/electrolyte disturbances, infection, or medications.
There are no epileptiform discharges or electrographic seizures.
Compared to the prior day's recording, there is no change in the
background activity.
EEG - ___
This is a continuous video EMU EEG monitoring study because of
mild diffuse background slowing, indicative of a mild
encephalopathy, which is non-specific with regard to etiology
but may be due to various causessuch as metabolic/electrolyte
disturbances, infection, or medications. There are no
epileptiform discharges or electrographic seizures. There are no
pushbutton activations. Compared to the prior day's recording,
there is no change in the background activity.
EEG - ___
This is a continuous video EMU EEG monitoring study because of
mild diffuse background slowing, indicative of a mild
encephalopathy, which is non-specific with regard to etiology
but may be due to various causes such as metabolic/electrolyte
disturbances, infection, or medications. There are no
epileptiform discharges or electrographic seizures. There are no
pushbutton activations. Compared to the prior day's recording,
there is no change in the background activity.
ECG - ___
Sinus rhythm. Non-diagnostic Q waves in leads II, III, and aVF.
RSR' pattern in lead V2. Minor repolarization abnormalities,
probably normal for age. No previous tracing available for
comparison.
CXR - ___
No acute intrathoracic abnormality.
NCHCT - ___
No acute intracranial abnormality.
ECHO - ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. No mass or vegetation is seen on
the mitral valve. No mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No vegetations or clinically-significant valvular
disease seen (excellent-quality study). Normal global and
regional biventricular systolic function.
SEIZURE PROTOCOL MRI - ___
Normal MRI of the brain using seizure protocol.
Brief Hospital Course:
___ y/o M with PMH of bipolar, depression, anxiety, p/w GTC 10
days ago, with multiple daily episodes of loss of awareness. No
events captured on cvEEG. Following one night of recording,
patient did not wish to continue to EEG and wished to go home,
then stated that he may kill himself if discharged. Placed in
___ hold per psychiatry recs on ___. Hold lifted the
following day after psychiatry re-evaluation. cvEEG from
___ without any events captured, some background slowing
noted but no seizures. 256-lead routine EEG and MRI seizure
protocol done on ___. Will follow up with psychiatry at ___,
does not need neurology f/u. H/o hepatitis with transaminitis
while inpatient - so depakote not resumed. Will discharge on low
dose lamotrigine for mood. Will f/u with ___ GI/hepatology.
Medications on Admission:
Depakote 250 qAM, 500 qPM (out of supply so not taking)
Discharge Medications:
1. LaMOTrigine 25 mg PO QHS
RX *lamotrigine 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Ondansetron 4 mg PO ONCE MR1 nausea Duration: 1 Dose
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth as needed Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
events concerning for seizure
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 epilepsy monitoring unit at ___ for
continuous video EEG monitoring to help characterize events that
have been concerning for seizure activity. No events were
captured while you were inpatient, and following the first night
of admission, you did not want to continue EEG monitoring
further. Due to concern for suicidal ideation stemming from a
comment you made, we had psychiatry evaluate you for your
safety, and you were placed in a ___ hold. By the next
morning, you had remained calm and behaviorally well-regulated.
Following the ___ hold, you underwent continuous video
EEG from ___, without any events captured. You had a more
detailed routine EEG performed on ___, and MRI of the brain on
___. Your PCP ___ these results.
You will need to follow up with the ___ for
your remaining care. You currently have a psychiatry appointment
set up, which was made while you previously had ___. When
you have ___ again, please make appointment with the
following clinics:
- Hepatology (liver specialists) regarding your hepatitis
- Internal Medicine with Dr. ___. We recommend that you
discuss getting a sleep study ordered by her in order to
evaluate for narcolepsy or other sleep problems.
Please take care.
___ Neurology
Followup Instructions:
___
|
10351597-DS-22 | 10,351,597 | 26,656,908 | DS | 22 | 2128-01-04 00:00:00 | 2128-01-04 10:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
aphasia, right hemiparesis
Major Surgical or Invasive Procedure:
N/a
History of Present Illness:
Neurology at bedside for evaluation after code stroke
activation
within: 10 minutes
Time/Date the patient was last known well: 8:10 ___
___ Stroke Scale Score: 24
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: on Xarelto
CT scan done at outside hospital.
I reviewed the benefits, risks, and contraindications to IV tPA
with the patient and/or family who consented to this treatment.
Reason for Consultation:
___ Stroke Scale - Total []
1a. Level of Consciousness - 1
1b. LOC Questions - 2
1c. LOC Commands - 2
2. Best Gaze - 2
3. Visual Fields - 3
4. Facial Palsy - 3
5a. Motor arm, left - 0
5b. Motor arm, right - 4
6a. Motor leg, left - 0
6b. Motor leg, right -0
7. Limb Ataxia - 0
8. Sensory - 1
9. Language - 2
10. Dysarthria - 2
11. Extinction and Neglect - 2
HPI: Mrs. ___ is an ___ year old woman with a past medical
history significant for diabetes mellitus type 2 on metformin,
prior stroke in ___ (R cerebellar), afib on xarelto
(discovered after stroke in ___, htn, hld, and arthritis.
The patient was in her usual state of health in her apartment
where she lives with her daughter and grandchildren. The patient
was watching the superbowl with her daughter on the couch. At
around 8PM, the daughter and patient each left the living room
to
go to their respective rooms. A few minutes later, the patient
left her bedroom to go empty her trashcan in the kitchen.
Approximately 5 minutes later the patient fell down forwards
onto
the floor. The patient's daughter heard her fall immediately and
rushed to her side.
The patient was seen to be unable to speak or understand what
was
happening. She was moving her legs spontaneously as well ___
left arm but could move her right arm. They checked her pulse
and
saw that she was alert but could not speak. At this time they
proceeded to call ___ and she was taken to ___.
Patient was evaluated at ___ where CT/CTA was performed.
A
distal Left M1/Proximal occlusion was seen and patient was
subsequently transferred to ___ in ___ for intervention.
Patient was not a candidate for TPA given that she was on
xarelto. On speaking with the family, she had not missed any
doses of her anticoagulation and had taken the medicine at 5PM
on
the night of symptoms.
ROS unable to be obtained given the patient's aphasia and
neglect.
Past Medical History:
- DM
- HTN
- Afib (on ASA)
- neuropathy
- retinal detachment ___
Social History:
___
Family History:
- noncontributory
Physical Exam:
***ADMISSION EXAM***
Neurologic Examination:
- Mental Status -Patient awake, but has forced fixed deviation
to the left. Unable to answer any questions or follow commands,
completely aphasic. Neglecting R side.
- Cranial Nerves - [II] R pupil fixed, cataract and does not
react. L pupil 3-->2 mm reacting.
[III, IV, VI] Unable to assess, fixed forced deviation to the
left. R facial droop.
Sensorimotor: Patient ___ in L upper and lower extremity
and moves this side spontaneously. Patient briskly withdraws
right lower extremity to noxious, not stereotyped movement. R
arm
is completely plegic with no motion to noxious.
Plantar response extensor on R.
Coordination and gait deferred.
***DISCHARGE EXAM***
Vitals: T 99.7F/98.4F, BP 122-157/69-82, HR 69-94, RR 22, O2
100%
RA
Gen: awake, alert, comfortable, in no acute distress
HEENT: normocephalic atraumatic, no oropharyngeal lesions
CV: warm, well perfused
Pulm: breathing non labored on room air
Extremities: no cyanosis/clubbing or edema
Neurologic:
-MS: Eyes intermittently closed, but easily arouses to verbal
stimuli. Tracks/regards. Speech dysarthric, able to say "yes" to
questions.
-CN: L conjugate gaze deviation, does cross midline. R pupil
nonreactive (history of cataract), L pupil 3>2. R facial droop.
tongue midline
-Sensorimotor: Dense right-sided hemiparesis, affecting arm
greater than leg. R UE with some movement in plane of bed,
withdraws to noxious. R ___ with some movement in plane of bed
(moreso than arm) with brisk withdrawal to noxious. L UE/L ___ throughout.
-DTRs:
Bic Brac Quad Gas Plan
L 2 2 1 1 downgoing
R 2+ 2 1 1 upgoing
-Coordination/Gait: unable to assess
Pertinent Results:
Labs:
___ 06:13AM BLOOD WBC-14.3*# RBC-3.53* Hgb-11.5 Hct-34.3
MCV-97 MCH-32.6* MCHC-33.5 RDW-14.5 RDWSD-51.0* Plt ___
___ 06:05AM BLOOD Neuts-69.0 ___ Monos-10.2
Eos-0.5* Baso-0.2 Im ___ AbsNeut-4.32 AbsLymp-1.24
AbsMono-0.64 AbsEos-0.03* AbsBaso-0.01
___ 06:13AM BLOOD Glucose-185* UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-99 HCO3-24 AnGap-18
___ 06:05AM BLOOD ALT-10 AST-14 LD(LDH)-127 CK(CPK)-30
AlkPhos-76 TotBili-0.4
___ 06:13AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.7
___ 06:05AM BLOOD %HbA1c-8.2* eAG-189*
___ 06:05AM BLOOD Triglyc-74 HDL-45 CHOL/HD-4.0 LDLcalc-120
___ 06:05AM BLOOD TSH-2.4
Imaging/Studies:
-CT Head w/o contrast ___: Evidence of early ischemia involving
the left striatocapsular region, with some loss of grey-white
matter differentiation.
-CTA Head/Neck: notable for proximal left MCA segment
cutoff likely from an in situ embolus.
-MRI brain ___: Notable for Left basal ganglia acute to early
subacute infarction with areas of hemorrhage. Mild surrounding
edema exerting mass effect on the left frontal horn without
midline shift. Absence of flow void within the distal left M1
middle cerebral artery, compatible with an intraluminal thrombus
better delineated on recent CTA.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of Atrial
fibrillation on Xarelto, prior CVA in ___, diabetes on
metformin, HTN, HLD who is admitted to the Neurology stroke
service with right sided plegia and global aphasia, secondary to
an acute ischemic stroke in the L MCA syndrome. Her stroke was
most likely secondary to atrial fibrillation event given. We did
consider this a failure of Xarelto. She was started on aspirin
81mg daily. Anticoagulation was deferred until 1 week from onset
of symptoms due to some early hemorrhagic conversion. Her
deficits remained relatively stable, notable for global aphasia
and right hemiplegia. She will continue rehab at a rehab center.
Her stroke risk factors include the following:
1) DM: A1c 8.2%
2) Mild intracranial atherosclerosis - mild atherosclerotic
calcifications of the cavernous internal carotid arteries
3) Hyperlipidemia: LDL 120. Started on Atorvastatin 40mg daily
5) No Sleep apnea - she does not yet carry the diagnosis
An echocardiogram did not show a PFO on bubble study and was
within normal limits
TRANSITIONAL ISSUES:
-Please continue aspirin 81mg daily and Heparin 5000u SC BID for
now, HOLD Xarelto
-Starting on ___ start Apixaban 2.5mg BID. Discontinue
Aspirin AND SC heparin at that time
-Blood pressures well controlled with SBP<160 despite holding
home Verapamil. IF still elevated, resume home Verapamil
- Continue insulin sliding scale to treat hyperglycemia
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done 2. DVT Prophylaxis administered? (x) Yes - SC heparin
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes 4. LDL documented? (X) Yes (LDL = 120
5. Intensive statin therapy administered? Yes atorvastatin 40mg
6. Smoking cessation counseling given? (x) No [reason (x)
non-smoker
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
8. Assessment for rehabilitation or rehab services considered?
(x) Yes
9. Discharged on statin therapy? (x) Yes
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) No - due to early hemorrhagic
conversion, plan to start in 1 week
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 15 mg PO DAILY
2. Verapamil 240 mg PO Q24H
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Gabapentin 300 mg PO TID
5. Cyanocobalamin Dose is Unknown IM/SC Q WEEK
6. Digoxin 0.125 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. ___ DROP LEFT EYE QHS
8. ___ 128 (sodium chloride) unknown R eye BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Heparin 5000 UNIT SC BID
4. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
5. Digoxin 0.125 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. ___ DROP LEFT EYE QHS
7. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left MCA ischemic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of difficulty speaking and
right sided 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: your history of atrial
fibrillation, your prior stroke, diabetes, high blood pressure,
high cholesterol.
We are changing your medications as follows:
-We stopped your Xarelto
-We started you on Aspirin 81mg daily (baby aspirin) for the
time being
-You will start a new blood thinner, Apixaban, in 1 week from
onset of your stroke (to be started on ___
-Started on Atorvastatin 40mg daily for high cholesterol
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:
___
|
10351666-DS-15 | 10,351,666 | 22,143,890 | DS | 15 | 2154-10-18 00:00:00 | 2154-10-18 22:39:00 |
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:
None
History of Present Illness:
___ otherwise healthy man morning he woke up with severe ___
stabbing constant epigastric pain radiating to his back. He
presented to
___ where he was ruled out for ACS. A RUQ US was
reportedly normal. CT w IV contrast was performed which
demonstrated abnormality of the celiac artery and superior
mesenteric arteies concerning for thrombus or dissection. He
was transferred to ___ for further evalaution.
Past Medical History:
PMH: GERD
PSH: Ventral hernia repair x 3, b/l inguinal hernia repair
Social History:
___
Family History:
non-contributory
Physical Exam:
Temp: 98.1 HR: 59, BP: 109/52 RR: 18 Sat: 95% RA
Gen: no distress, alert, oriented, interactive
HEENT: non incteric
CV: regular rate, no murmurs, rubs, gallops
Resp: clear to auscultation bilaterally
Abd: ventral hernia, reducible, multiple previous surgical
scars, non tender to palpation, no rebound or guarding
Ext: palpable peripheral pulses throughout
Pertinent Results:
___ 06:45AM BLOOD WBC-9.1 RBC-4.76 Hgb-14.6 Hct-43.3 MCV-91
MCH-30.6 MCHC-33.7 RDW-14.8 Plt ___
___ 06:35AM BLOOD WBC-7.7 RBC-4.71 Hgb-13.9* Hct-43.3
MCV-92 MCH-29.6 MCHC-32.1 RDW-14.5 Plt ___
___ 07:42AM BLOOD WBC-8.3 RBC-4.66 Hgb-14.3 Hct-42.6 MCV-91
MCH-30.7 MCHC-33.6 RDW-14.5 Plt ___
___ 06:50PM BLOOD WBC-9.9 RBC-4.70 Hgb-14.4 Hct-44.3 MCV-95
MCH-30.7 MCHC-32.5 RDW-14.8 Plt ___
___ 06:45AM BLOOD ___
___ 07:42AM BLOOD ___ PTT-67.1* ___
___ 06:35AM BLOOD PTT-69.2*
___ 02:50PM BLOOD PTT-63.4*
___ 07:42AM BLOOD ___ PTT-67.1* ___
___ 12:33AM BLOOD PTT-70.4*
___ 07:08PM BLOOD PTT-67.6*
___ 01:00PM BLOOD PTT-103.2*
___ 06:45AM BLOOD Glucose-110* UreaN-15 Creat-0.9 Na-139
K-4.8 Cl-105 HCO3-23 AnGap-16
___ 06:35AM BLOOD Glucose-89 UreaN-12 Creat-0.9 Na-140
K-4.6 Cl-105 HCO3-26 AnGap-14
___ 07:42AM BLOOD Glucose-97 UreaN-9 Creat-0.9 Na-139 K-4.6
Cl-104 HCO3-25 AnGap-15
___ 07:15AM BLOOD Glucose-93 UreaN-9 Creat-1.0 Na-135 K-4.6
Cl-102 HCO3-25 AnGap-13
___ 06:50PM BLOOD Glucose-87 UreaN-11 Creat-1.1 Na-142
K-4.8 Cl-105 HCO3-29 AnGap-13
___ 06:50PM BLOOD ALT-28 AST-27 AlkPhos-92 TotBili-0.7
___ 06:45AM BLOOD Calcium-9.9 Phos-4.0 Mg-1.9
___ 06:35AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.1 Cholest-212*
___ 06:50PM BLOOD Albumin-4.3
___ 07:42AM BLOOD CRP-24.4*
___ 06:50PM BLOOD CRP-23.5*
___ 07:42AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 07:42AM BLOOD C3-144 C4-28
___ 07:42AM BLOOD HCV Ab-NEGATIVE
___ 10:26AM BLOOD Lactate-0.9
___ 07:10PM BLOOD Lactate-1.3
___ 07:42AM BLOOD SED RATE-4
CT angiogram ___
CTA: The arterial anatomy is conventional. The aorta maintains
a normal
caliber throughout. Just before its trifurcation, the celiac
trunk is
aneurysmal, with a maximum diameter of 1.5 cm. There is fat
stranding about
the celiac trunk in this region. Additionally, there is a thin
linear
intraluminal density proximal to the celiac bifurcation which is
concerning
for focal dissection (series 601b, image 47). The branches of
the celiac trunk
are patent. Near the origin of the SMA, the SMA narrows
significantly, which
may be due to mural atheroma (series 602b, image 83). Just
distal to the area
of narrowing, there is also a linear intraluminal density in the
SMA which is
concerning for a focal dissection flap (series 601b, image 47).
Distal to this
area, the SMA regains normal caliber and mild amount of soft
plaque is seen
(series 601b, image 49). The renal arteries are unremarkable.
The ___ is
patent. The common iliac arteries bilaterally are mildly ectatic
but not
frankly aneurysmal. There is only minimal calcified plaque in
the abdominal
aorta.
CT angiogram ___
1. No significant radiographic change in persistent dissections
within the
proximal celiac artery and proximal SMA with associatedm
perivascular fat
stranding consistent with vasculitis.
2. Stable dilatation of the proximal celiac trunk which has
pseudoaneurysmal
appearance, however, given that an artery arises from the
superior most aspect
of this dilatation this more likely represents focal dilatation
of the true
lumen.
3. Stable focal narrowing of the proximal SMA due to atheroma.
4. Few subcentimeter renal and liver hypodensities, too small
to
characterize.
5. 1 mm nonobstructing right renal stone. No hydronephrosis.
6. Unchanged omental fat and partial bowel-containing
wide-mouthed ventral
hernia without evidence of strangulation.
Brief Hospital Course:
The patient was admitted to the hospital after presenting with
epigastric pain and found to have a focal SMA dissection and
celiac artery aneursym with surrounding inflammation on CT exam.
He was admitted to the hospital started on a heparin drip and an
aspirin. He was made NPO and his pain was treated with Iv pain
medications. His hospital course by system is described below.
Neuro: The patient initially had a moderate to severe amount of
epigastric pain that radiated to his back. This pain was
initally treated with intermittent IV pain medications. He was
then put on a dilaudid PCA with good effect. He was also given
intermittent lorazepam for anxiety. Once the patient was
tolerating a regular diet his pain was treated with oral
oxycodone with good effect:
CV: The patient's blood pressure was initially elevated. It was
unclear if this was due to pre-existing hypertension or pain.
Nevertheless the patient's blood pressure was controlled
initially with intermittent IV hydralazine with a goal of a
systolic blood pressure under 120. On Hospital day #2 when he
was taking PO medication he was then started on an ace inhibitor
and beta blocker to provide better blood pressure control. He
was also started on a statin. He underwent repeat CTA on HD#3
which showed no interval change of the dissection.
Resp: There were no active respiratory issues
GI: The patient was initially made NPO given the concern for
compromise of the vasculature to the mesentery. On HD#2 he was
started on a regular diet which he tolerated without any
increase in pain, nausea, vomiting, or food fear.
Renal: The patient did not have any loss in urine production or
elevation in creatinine during the hospital stay.
Rheum: Given the presentation of the patient a vasculitis was
suspected and a rheumatology consult was obtained. Initial CRP
values were elevated 24 on HD#1 and 25 on HD#2. All other
laboratory tests including hepatitis serologies, ANCA
antibodies, sedimentation rate, and complement studies were
negative. Nevertheless given the presence of dissection in the
SMA, aneursym in the celiac trunk with associated inflammation
and elevated CRP he was empirically treated with steroids on
HD#4. which were scheduled to continue for one month. He was
scheduled for outpatient follow up with rheumatology to further
pursue a vasculitis diagnosis. He was also started on vitamin D
and calcium given the high dose (60 mg of prednisone) dosing of
the steroids.
Heme: The patient was initially treated with a heparin drip
which was titrated to therapeutic levels. On HD#4 it was
determined that he would require long term anticoagulation and
so he was started on coumadin and a lovenox bridge and the
heparin was stopped. His PCP was contacted and agreed to manage
his coumadin as an outpatient.
ID: The patient remained afebrile and there was no suspicion for
infection. Given the high dose steroids given for presumed
vasculitis he was started on bactrim prophylaxis.
Transitional issues:
1) patient started on prednisone 60mg daily for presumed
vasculitis origin of dissections. Consequently he will be on
bactrim prophylaxis as well as vitamin d and calcium
supplementation and will follow up with rheumatology in 2 weeks.
2) anticoagulation. patient was started on coumadin in house
with a lovenox bridge until he is therapeutic. This plan was
discussed with the patients PCP who agreed to manage his
coumadin as an outpatient.
3) dissection: the patient will follow up at vascular surgery
clinic in 1 month with both a CT and arterial ultrasounds to
monitor stability or interval change of dissection and aneursym.
4) the patient has been started on several medications for blood
pressure control and cardiovascular health including a statin,
ace-inhibitor, and beta-blocker he was told to follow up with
his PCP who will also be managing his coumadin for monitoring of
these medications.
Medications on Admission:
omeprazole 20
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
3. Enoxaparin Sodium 100 mg SC TWICE DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 1 injections SC twice daily Disp #*10
Syringe Refills:*0
4. Lisinopril 10 mg PO DAILY
REFILLS/MONITORING PER PCP.
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
5. Metoprolol Tartrate 12.5 mg PO BID
REFILLS/MONITORING PER PCP
6. Nicotine Patch 21 mg TD DAILY
available over the counter
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ as needed for
pain Disp #*20 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. PredniSONE 60 mg PO DAILY
RX *prednisone 10 mg 6 tablet(s) by mouth DAILY IN AM Disp #*200
Tablet Refills:*0
10. Senna 8.6 mg PO BID
over the counter
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth DAILY Disp #*30 Tablet Refills:*0
12. Vitamin D 1000 UNIT PO DAILY
available over the counter
13. Docusate Sodium 100 mg PO BID
available over the counter
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Warfarin 5 mg PO DAILY16
until further instructions from Dr. ___ on ___.
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth DAILY Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Dissection of the celiac/superior mesenteric arterie.
Celiac artery aneurysm
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 here at ___
___. You were admitted to our hospital
with severe abdominal pain. We did several tests that showed
abnormalities in 2 of your abdominal arteries. You were treated
with blood thinners, blood pressure medications and a statin
medication. We also consulted the rheumatology team for their
options if these abdormalities were related to an underlying
blood vessel weakening. They did testing and started you on a
brief course of steroids to decrease the inflammation at the
site of the tears and decrease your pain. These measures
improved your pain. A repeat CT scan showed no change in the
area. You are now ready to be discharged to home.
Please refer to the medication section for directions regarding
your new medications. Please make every effort to stop smoking!
THis is imperative for your vascular health.
Followup Instructions:
___
|
10351666-DS-17 | 10,351,666 | 28,306,532 | DS | 17 | 2159-09-27 00:00:00 | 2159-09-27 15:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
atorvastatin
Attending: ___
___ Complaint:
Coffee ground emesis
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ PMHx HTN, SMA dissection, nephrolithiasis, recently
diagnosed LLE DVT on ___ who p/w several days of coffee
ground emesis.
Patient reports 3 days of nausea, vomiting with coffee ground
emesis, approximately about 10 times.
In regards to hx of DVT, he had a RLE DVT after a hip
replacement
and was on 6 months of warfarin and had stopped. However, he
developed LLE pain, and had an ultrasound done revealing DVT and
was started on apixaban on ___. The day he started taking
apixaban, he subsequently developed coffee ground emesis. He
reports he would eat food and liquids and then would vomit up
black emesis. He denies any abdominal pain. He has not had any
stools since he started having hematemesis. No recent fevers,
chills, chest pain, dyspnea. He denies any hx of GI bleed. He
has
undergone screening colonoscopy, but states he is due for one.
In regards to his hematuria, he was seen by urology on ___ for
hematuria. He had CT scan which revealed 2 small stones at the
UVJ per his urologist. He had a cystoscopy was done, which did
not reveal any mass in the bladder. A stone was seen at the R
ureteral orifice. Plan was for him to take Flomax and
re-evaluate
in a month. He reports that over the course of a month, his
urine
has lightened in color.
In regards to his hx of opiate use disorder, he reports good
control of cravings with his suboxone.
In the ED,
Initial VS: 98 76 120 /64 15 97% RA
Exam with rectal exam w/o stool in the rectal vault and was
guaiac negative.
Labs notable for hgb 11.4. Cr of 2.8. INR 1.7. Lactate 2.4 ->
1.0
CT A/P:
1. No evidence of hydronephrosis or obstructive stones
identified. Of note, the distal ureters are not well-visualized
on the current study due to extensive streak artifact emanating
from bilateral hip prostheses.
2. Few punctate nonobstructive stones at the right upper renal
pole.
3. Previously seen focal dissection of the SMA with focal
dilatation, as well as focal dilatation of the celiac trunk, are
not well-visualized on the current study and are better assessed
on prior MRI from ___.
Patient given IV pantoprazole, 1L LR
On arrival to the floor, he reports hx as above. He had trialed
some food for dinner, and denies any N/V.
ROS: Pertinent positives and negatives as noted in the HPI.
Other 10 point ROS were negative. "
Past Medical History:
PAST MEDICAL
celiac artery aneurysmal dilation and SMA dissection
HTN
arthritis
gout
GERD
Nephrolithiasis
Hx of opiate use disorder
HLD
PAST SURGICAL HISTORY
bilateral TKA
right hip replacement
left shoulder replacement
3 hernia surgeries
left and right carpal tunnel release
Social History:
___
Family History:
Mother with nephrolithiasis. Grandmother with colon cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.4 74 106/60 16 96% RA
GENERAL: Alert and in NAD
EYES: Anicteric, PERRL
ENT: Ears and nose unremarkable. MMM
CV: RRR. S1, S2. No mrg
RESP: Unlabored breathing. CTA b/l
GI: +BS. Soft, NTND.
GU: foley not present
MSK: WWP. No ___ edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric. Speech fluent, moves all
limbs.
PSYCH: pleasant, appropriate affect
================
DISCHARGE EXAM:
VITALS: 24 HR Data (last updated ___ @ 822)
Temp: 97.8 (Tm 98.2), BP: 105/68 (105-143/68-90), HR: 57
(57-65), RR: 18, O2 sat: 96% (95-96), O2 delivery: RA
GENERAL: Alert and in no apparent distress, appears comfortable,
conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Moist
mucus membranes.
CV: RRR, no murmurs/rubs, no S3, no S4. 2+ radial pulses
bilaterally.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No GU catheter present
MSK: Moves all extremities. Trace LLE edema.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented x3, face symmetric, speech fluent, moves
all limbs
PSYCH: Pleasant, appropriate affect, calm, cooperative
Pertinent Results:
LABS ON ADMISSION:
___ 09:15AM BLOOD WBC-8.0 RBC-3.86* Hgb-11.4* Hct-34.9*
MCV-90 MCH-29.5 MCHC-32.7 RDW-14.3 RDWSD-47.0* Plt ___
___ 09:15AM BLOOD Neuts-65.9 ___ Monos-12.1 Eos-1.1
Baso-0.2 Im ___ AbsNeut-5.30 AbsLymp-1.63 AbsMono-0.97*
AbsEos-0.09 AbsBaso-0.02
___ 09:15AM BLOOD ___ PTT-33.0 ___
___ 09:15AM BLOOD Glucose-91 UreaN-38* Creat-2.8*# Na-135
K-4.4 Cl-93* HCO3-25 AnGap-17
___ 09:15AM BLOOD ALT-30 AST-44* AlkPhos-121 TotBili-0.8
___ 09:15AM BLOOD Albumin-4.5 Calcium-9.6 Phos-3.8 Mg-2.4
___ 09:26AM BLOOD Lactate-2.4*
___ 04:22PM BLOOD Lactate-1.0
___ 02:40PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 02:40PM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-150* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 02:40PM URINE RBC->182* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
___ 02:40PM URINE CastHy-12*
=====================
LABS ON DISCHARGE:
___ 05:15AM BLOOD WBC-4.7 RBC-4.11* Hgb-12.0* Hct-37.8*
MCV-92 MCH-29.2 MCHC-31.7* RDW-14.1 RDWSD-47.2* Plt ___
___ 05:15AM BLOOD ___
___ 05:20AM BLOOD Glucose-90 UreaN-14 Creat-1.1 Na-142
K-4.6 Cl-105 HCO3-24 AnGap-13
=====================
___ 2:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
=====================
CT ABDOMEN/PELVIS WITH CONTRAST ___:
1. No collecting system obstruction. No ureteral or bladder
stones, although the distal ureters and lower bladder are not
well-visualized on the current study due to extensive streak
artifact emanating from bilateral hip prostheses.
2. Punctate nonobstructive right upper pole renal stones.
3. Previously seen focal dissection of the SMA with focal
dilatation, as well as a celiac trunk aneurysm, are not
well-visualized on the current study and are better assessed on
prior MRI from ___.
EGD ___:
- Mucosa suggestive of ___ esophagus
- Erythema and friability in the stomach compatible with
gastritis
- Normal mucosa in the whole examined duodenum
Brief Hospital Course:
Mr. ___ is a ___ yo man with HTN, SMA dissection,
nephrolithiasis, provoked RLE DVT in ___ (treated with 6
months of warfarin) and recently diagnosed LLE DVT on
___ on Apixaban, who presented with 3 days of nausea,
vomiting, with about 10 episodes of coffee ground emesis. He
was hemodynamically stable with stable anemia, not requiring
transfusion, and no signs of active bleeding. EGD revealed
gastritis with scant blood in cardia, without active bleeding.
He was being bridged with heparin drip while on warfarin, then
switched to Lovenox injections for bridging as outpatient, while
continuing warfarin.
#Coffee ground emesis
#UGI Bleed
#Gastritis:
Patient presented with coffee ground emesis in the setting of
recently taking apixaban. His Hb was 12 in ___ and was 11.4
on admission, ranging from 10.5-12.0, without active bleeding.
EGD on ___ revealed gastritis. GI recommended oral Protonix
40mg BID for ___ weeks. Stopped Apixaban and restarted
anticoagulation with warfarin and Lovenox, without signs of
bleeding. He had no coffee ground emesis after EGD. Hb was 12.0
on discharge.
#Likely ___ esophagus: Seen on EGD on ___. Will need
repeat EGD in ___ weeks to sample likely ___ esophagus
and ensure mucosal healing.
#Recently diagnosed LLE DVT: He had provoked RLE DVT in ___
that was treated with 6 months of warfarin and also had a large
hematoma per ___ records. He had left total hip
replacement in ___. He was diagnosed with LLE DVT on
ultrasound at ___ on ___ and was started on Apixaban.
His hematologist is Dr. ___. INR was 1.7 on admission
but down to 1.1 on ___, which is subtherapeutic. Stopped
Apixaban in the setting of acute GI bleed on admission. Started
Warfarin 5mg daily on ___ and increased to 10mg daily on ___
(usual dose when previously on for last DVT) as this is
reversible compared to Apixaban, which is preferable given risk
of bleeding, and the patient preferred warfarin over Apixaban.
He was started on heparin drip for DVT treatment to bridge till
INR is therapeutic, but he had no bleeding, so he was switched
to Lovenox injections for bridging on ___. He will continue
Lovenox injections and warfarin 10mg daily for anticoagulation
and will have ___ to check INR. He will follow up with Dr.
___. His last dose of warfarin was 10mg on ___. His INR
goal is ___.
___: Cr was 2.8 on admission and improved to 1.4 after IV
fluids and down to 1.1 on ___. Baseline Cr is 1.0. Most likely
prerenal due to GI bleeding. CT A/P on ___ showed no
obstruction, though non-obstructive right upper pole renal
stones.
#Elevated lactate: Lactate of 2.4 improved to 1.0 with IV
fluids, likely due to dehydration.
#Nephrolithiasis: Appears that there are new non-obstructive
renal stones in the right upper pole compared to in early
___, when only stones were found at the UVJ, on ___ CT
abd/pelvis. Pain control with acetaminophen and continue
Tamsulosin.
#Chronic pain: Continue Cymbalta, and home Suboxone
#Depression: Was on mirtazapine in the past, but stopped due to
obesity. Continued Cymbalta.
#Hypophosphatemia: Low Phos of 2.6 and orally repleted.
#History of SMA dissection: CT A/P on ___ showed focal
dissection of SMA with focal dilatation as well as celiac trunk
aneurysm, not well visualized but seen on MRI in ___.
=========================
Transitional issues:
- Check CBC, INR, BMP, Phos on ___
- Continue Lovenox injections for bridging till INR is
therapeutic, then stop injections - advised him to follow up
with Dr. ___ to determine when to stop Lovenox.
- Needs repeat EGD in ___ weeks for suspected ___
esophagus
=========================
Mr. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care today was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DULoxetine ___ 60 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Apixaban 5 mg PO BID
4. Tamsulosin 0.4 mg PO QHS
5. Buprenorphine-Naloxone Tablet (8mg-2mg) 2.5 TAB SL DAILY
Discharge Medications:
1. Enoxaparin Sodium 110 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 1 mL SC every twelve (12) hours Disp
#*14 Syringe Refills:*0
2. Warfarin 10 mg PO DAILY16
RX *warfarin 5 mg 2 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (___)
hours Disp #*60 Tablet Refills:*0
4. Buprenorphine-Naloxone Tablet (8mg-2mg) 2.5 TAB SL DAILY
5. DULoxetine ___ 60 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gastritis
Upper GI bleed
Left leg DVT
Nephrolithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized with GI bleeding likely due to gastritis.
You had an upper endoscopy (EGD) performed that showed gastritis
of your stomach without an ulcer or active bleeding. The GI
specialists recommend that you take oral Pantoprazole twice
daily for ___ weeks. Your red blood cell count has been
stable, ranging from 10.5-12.0. Your Apixaban was stopped.
After discussion with you and Dr. ___ were started on
warfarin again and a heparin drip to keep your blood thin until
you are therapeutic on the warfarin. You will need to take the
Lovenox injections twice daily and have your INR checked by
visiting nursing. Please follow up with Dr. ___ the
next 1 week to make sure that your INR level is therapeutic and
guide when to stop the Lovenox injections.
You will need to have your blood count and INR checked within
the next 2 days to make sure they are stable.
You will need another endoscopy (EGD) in ___ weeks to make
sure that the gastritis is healing and also to take a tissue
sample. The GI doctors ___ help ___ this appointment.
Your CT scan showed some kidney stones of your right kidney, but
these are not causing obstruction. If you have pain with
urination, decreased urination, blood in urine, please contact
your primary doctor for further follow up.
Followup Instructions:
___
|
10351725-DS-10 | 10,351,725 | 29,344,962 | DS | 10 | 2178-06-16 00:00:00 | 2178-06-16 16:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine Sulfate / Percocet /
Darvocet-N 100 / Codeine / tramadol / aspirin / ibuprofen /
caraway seed / pentazocine
Attending: ___
___ Complaint:
s/p fall - R inferior and superior rami displaced fx, b/l pubic
symphysis fx, L sacral fx
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: ___ year-old female with a PMHx significant for ___
disease, multiple sclerosis, osteoporosis, pulmonary embolism
(on
Xarelto last known dose p.m. of ___, atrial fibrillation;
and numerous recurrent falls (6 within the last 6 months, 3 of
which required hospitalization with known prior fractures of the
right humerus, left hip, left clavicle, and ribs) who presents
to
the hospital with anterior pelvic pain after suffering a
ground-level fall at home on ___. Patient reports living
at
home with her husband daughter and dog, she ambulates with a
walker at baseline. She states she was walking from her living
area when she suffered an event where she states her "legs just
gave out from under her". She denies chest pain, palpitation,
difficulty breathing, or presyncopal symptoms prior to her fall.
She denies head strike or loss of consciousness. Her fall was
not witnessed however her husband was in a nearby room and found
her on the floor. Patient denies numbness, tingling, weakness
to
the lower extremities.
Patient presents as a transfer from an outside hospital where CT
scan of the C-spine was negative for acute fracture or
dislocation, x-ray was demonstrating of multiple chronic
fracture
deformities including the surgical neck of the right humerus,
bilateral ribs, T8 and L1 vertebral bodies with vertebroplasty
changes noted, and other vertebral compression deformities,
diffuse osteopenia as well as a CT scan of the pelvis
demonstrates mildly displaced fractures of the superior pubic
rami/pubic symphysis bilaterally, as well as the bilateral
inferior pubic rami with a small left sacral alar fracture with
extension to the SI joint all consistent with a LC 1 type pelvic
injury. There is also concern for possible new moderate volume
intrapelvic hematoma/hemoperitoneum surrounding the bladder and
rectosigmoid colon of mixed density and could not be confirmed
as
either arterial or venous in origin per outside hospital report.
Upon further review of these images with our in-house
radiologist
the ___ units of this and strip pelvic fluid is
consistent
with that of hemorrhage however could not confirm or exclude
active extravasation.
The patient has been hemodynamically stable since arrival to the
emergency department here at ___. Her hemoglobin at outside hospital was reported 11.7 on
___ and 18:16, with a hematocrit of 35. Patient denies
hematuria, hematochezia, melena.
Past Medical History:
PMH:
Osteoporosis,
___ disease
Multiple sclerosis
Pulmonary embolism on Xarelto
Atrial fibrillation
Recurrent falls
Known fractures to the right humerus, left clavicle, ribs, and
left hip as a result of recurrent falls
PSH:
left trochanteric femoral nail
Cholecystectomy, hysterectomy, appendectomy, gastric bypass
Social History:
___
Family History:
F - coronary artery disease
M - COPD
Physical Exam:
Physical Exam:
VS: temp 98.2, BP 112/72, HR 69, RR 16, O2sats 95 RA
Gen: [X] NAD, [] AAOx3
CV: [X] RRR, [] murmur
Resp: [X] breaths unlabored, [] CTAB, [] wheezing, [] rales
Abdomen: [X] soft, [] distended, [] tender, [] rebound/guarding
Ext: [X] warm, [] tender, [] edema
Pertinent Results:
___ 12:40AM BLOOD WBC-7.7 RBC-3.14* Hgb-10.0* Hct-31.2*
MCV-99* MCH-31.8 MCHC-32.1 RDW-14.2 RDWSD-51.5* Plt ___
___ 03:55AM BLOOD Neuts-74.2* Lymphs-16.6* Monos-7.9
Eos-0.3* Baso-0.5 Im ___ AbsNeut-4.69 AbsLymp-1.05*
AbsMono-0.50 AbsEos-0.02* AbsBaso-0.03
___ 12:40AM BLOOD ___ PTT-29.8 ___
___ 03:55AM BLOOD Glucose-120* UreaN-22* Creat-0.6 Na-136
K-4.6 Cl-105 HCO3-20* AnGap-11
___ 11:08AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.9
___ 12:51AM BLOOD Glucose-113* Lactate-0.9 Creat-0.55
Na-138 K-4.4 Cl-111* calHCO3-21
___ 09:19AM BLOOD WBC-7.9 RBC-2.77* Hgb-8.7* Hct-27.5*
MCV-99* MCH-31.4 MCHC-31.6* RDW-14.5 RDWSD-52.4* Plt ___
___ 09:19AM BLOOD Plt ___
___ 09:19AM BLOOD Glucose-108* UreaN-13 Creat-0.5 Na-139
K-4.4 Cl-104 HCO3-24 AnGap-11
___ 09:19AM BLOOD Calcium-8.3* Phos-1.9* Mg-2.0
CXR ___
IMPRESSION:
1. No pneumothorax, pleural effusion, or evidence of lung
injury. Nonspecific
streak like opacity over the right lower lung is probably the
edge of
atelectasis or pleural thickening in the right major fissure.
Multiple healed
fractures of ribs on both sides of the chest and a large
fracture deformity of
the incompletely healed proximal right humerus. Acute fracture
could be
missed. Consider rib detail views.. Likely chronic fracture
deformity of the
right humeral neck.
CTA ___
IMPRESSION:
1. No visualized active extravasation. Mild hemorrhagic pelvic
ascites has
not increased in volume from the prior outside hospital CT.
2. Bilateral comminuted superior and inferior pubic rami
fractures which
extend from the pubic symphysis on both sides. Additional
moderately
displaced and foreshortened fracture of the right inferior pubic
ramus. Small
bony fragments are displaced superiorly which may lie within the
anterior
abdominal wall (series 2, image 65).
3. Mildly displaced left sacral fracture which involves the left
sacroiliac
joint.
4. Lack of distension of the bladder limits assessment for
injury.
5. No significant change in moderate-severe height loss at the
L1 vertebral
body status post vertebroplasty.
6. There is a moderate stool ball within the rectum.
Brief Hospital Course:
The patient presented as a transfer from an outside hospital
where she was managed after her fall. Multiple imaging were
performed which were negative for acute fracture or dislocation,
x-ray was demonstrating of multiple chronic fracture
deformities including the surgical neck of the right humerus,
bilateral ribs, T8 and L1 vertebral bodies with vertebroplasty
changes noted, and other vertebral compression deformities,
diffuse osteopenia as well as a CT scan of the pelvis
demonstrates mildly displaced fractures of the superior pubic
rami/pubic symphysis bilaterally, as well as the bilateral
inferior pubic rami with a small left sacral alar fracture with
extension to the SI joint all consistent with a LC 1 type pelvic
injury. She got additional imaging at ___. The final injuries
are R inferior and superior rami displaced fx, b/l pubic
symphysis fx, L sacral fx. We were trending serial Hct for the
patient which were stable. Patient was seen and evaluated by
Physical therapist who recommended Rehabilitation facility.
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: tolerating regular diet during hospitalization.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
Prophylaxis:Initially Xeralto (home medication, which patient
takes for Afib and PE) was held initially and restarted on HD 3.
The patient received subcutaneous heparin and ___ dyne boots
were used during this stay when Xeralto was held. At the time of
discharge, the patient was doing well, afebrile and
hemodynamically stable. The patient was tolerating a diet,
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:
Med:
Rotigotine 8 mg TD QHS
Multivitamin 1 tab PO daily
Vitamin E 400 mg PO QHS
Zoledronic acid/Mannitol Watwr 100 mg IV yearly
Sinemt ___ 2 tab PO 5XDnITROGLYCERIN 0.4 MG sl q5m prn
Gabapentin 1200 mg PO at 1300
Gabapentin 900 mg PO at QAM and HS
Melatonin 5 mg PO QHS
Xarelto 20 mg @ 1600
Sertraline 50 mg PO daily
Vicodin 1 tab Q6H PRN
levothyroxine 100 MCG po DAILY
Nystatin/Trimacin Cream 1 app TD BID PRN
Rantidine 300 mg DAILY
Ativan 40 mg PO QHS
Carbidpoa 25 mg PO 5XD
Calcium carbonate 2 cap PO daily
Ferrou suldate 324 mg PO daily
Discharge Medications:
1. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
Please do not drive or drink alcohol while taking this
medication.
RX *hydromorphone 2 mg 2 tablet(s) by mouth Q4-6 hrs Disp #*8
Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. Calcium Carbonate 1000 mg PO DAILY
5. Carbidopa-Levodopa (___) 2 TAB PO 5X/DAY
6. carbidopa 25 mg oral 5 times daily
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 1200 mg PO AT 1300
9. Gabapentin 900 mg PO QAM AND QHS
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Ranitidine 300 mg PO DAILY
12. Rivaroxaban 20 mg PO DINNER
13. rotigotine 8 mg/24 hour transdermal QHS
14. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right inferior and superior rami displaced fracture
bilateral pubic symphysis fracture
left sacral fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___.
___ call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow up with your PCP ___ 1 week and discuss
risk/benefits of your anticoagulation in regards to frequent
falls. Please follow up in ___ clinic in 4 weeks.
Thank you.
Best wishes.
___ Acute Care Surgery Team.
Followup Instructions:
___
|
10351739-DS-17 | 10,351,739 | 24,743,370 | DS | 17 | 2133-08-29 00:00:00 | 2133-08-29 12:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Epigastric abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and stone extraction
History of Present Illness:
Mrs ___ is a ___ with pAF on Coumadin, HTN, GERD, anxiety,
and cholelithiasis s/p CCY last year who presented to ___ with
epigastric abdominal pain and was transferred to ___ out of
concern for gallstone pancreatitis.
She was in her usual state of good health until ___ days ago
when she noticed epigastric pain, something between gassy and
gnawing, nonradiating, moderate intensity, in the mornings. She
would belch, pass flatus, have BM, and it would subside.
However, on the day of presentation she developed a similar
pain, but it became progressively worse instead of resolving.
She then developed a profound sense of fatigue and weakness, and
her husband became worried and called EMS, who took her to ___.
Labs at ___ were consistent with pancreatitis, elevated LFTs.
Report of tachycardia initially, but initial EKG reported as HR
___ in SR. No report of fevers. She was given 2L IVF, Zofran,
morphine, and Zosyn. CT performed, report not sent with pt, per
records "suggests CBD involvement." She was transferred to ___
as ERCP services were not available until ___. No labs were
transmitted with the patient.
Here, she had stable vital signs. Labs confirmed transaminitis
and lipasemia. No CBC was sent. INR 3.2. CXR was interpreted as
"possible pneumonia" and she was ordered for Levaquin -- not
actually given in ED but finished on the floor after arrival.
She was otherwise given 2L NS and morphine.
Here, she has no complaints apart from mild abdominal pain
similar to that described above, along with very dry mouth. No
f/c/s, n/v, cough/cp/sob.
ROS is negative in 10 points except as noted above
Past Medical History:
PMH: pAF on Coumadin, HTN, GERD, anxiety, and cholelithiasis
PSH: CCY, appendectomy
Social History:
___
Family History:
No family history of GI malignancy or gallstones that she knows
of
Father died of leukemia
Mother died of stroke at an old age
Physical Exam:
Vitals AVSS, came to us on some supplemental O2, weaning quickly
Gen NAD, quite pleasant
Abd soft, NT, ND, bs+
CV RRR, no MRG
Lungs CTA ___
Ext WWP, no edema
Skin no rash, anicteric
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro nonfocal, moves all extremities, steady gait
Psych normal affect
Pertinent Results:
Labs on admission:
___ 11:50PM BLOOD ___ PTT-32.1 ___
___ 11:50PM BLOOD Glucose-162* UreaN-13 Creat-0.9 Na-135
K-3.1* Cl-96 HCO3-25 AnGap-17
___ 11:50PM BLOOD ALT-292* AST-617* AlkPhos-151*
TotBili-3.4* DirBili-2.7* IndBili-0.7
___ 11:50PM BLOOD Lipase-845*
___ 11:50PM BLOOD Albumin-3.6
___ 12:02AM BLOOD Lactate-2.5*
Imaging here
RUQUS -
1. CBD dilatation up to 1.7 cm in the region of the pancreatic
head. Mild
intrahepatic biliary dilatation. No ductal stone detected.
2. Post cholecystectomy.
CXR - no acute process
EKG
RBBB, inferior q, otherwise no overt ischemic changes
ERCP ___:
Impression: The scout film was normal.
A single non-bleeding diverticulum with small opening was found
on the rim of the major papilla.
Cannulation of the biliary duct was performed using a free-hand
technique.Contrast medium was injected resulting in complete
opacification.
A moderate diffuse dilation was seen at the main duct, left
main hepatic duct and right main hepatic duct with the CBD
measuring 15 mm.
There was no evidnece of biliary stricture causing the upstream
dilation.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Evidence of post sphincterotomy mild oozing was noted, 6 cc of
epinephrine were injected with stop oozing.
Balloon sweeps were performed multiple times with extraction of
small amount of sludge.
Post balloon sweeps good contrast drainage was noted both
endoscopically and fluoroscopically.
Otherwise normal ercp to third part of the duodenum
Recommendations: NPO overnight with aggressive IV hydration
with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Return to ward under ongoing care.
No aspirin, Plavix, NSAIDS, Coumadin for 5 days.
Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.
Please refer the patient for further evaluation with MRI/MRCP
in 1 month
Follow Hgb/HCT trend
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
INR last checked on ___ was 1.4
Total bilirubin normalized
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 08:05 135* 77* 106* 73 1.4
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD
Plt Ct
___ 08:20 11.0* 3.32* 10.7* 31.5* 95 32.2* 34.0 13.5
47.1* 129*
Plts rising throughout hospitalization, WBC falling; suspect
both were from bloodstream infection, improving with ongoing
therapy
Brief Hospital Course:
___ y/o F with PMHx of Afib on Coumadin, HTN, GERD, as well as
prior cholelithiasis s/p CCY, who was transferred here for
concern for gallstone pancreatitis.
# Choledocholithiasis / Bile Duct Obstruction / Pancreatitis:
Per report, OSH CT showing "CBD involvement". RUQ U/S here
showing CBD dilatation. ERCP initially delayed ___ elevated INR,
but was completed following INR reversal with vitamin K. Report
as above. Pt. tolerated procedure well and diet was advanced
following without difficulty.
# GNR Bacteremia: due to biliary obstruction and bile duct
infection. Pt was placed on IV zosyn pending speciation /
sensitivities. Ultimately found to have e coli, resistant to
fluoroquinolones, ampicillin. ___ to ceftriaxone. Started on
2 grams daily of ceftriaxone for planned ___ mid
line (placed). Home infusion arranged. will have check of cbc,
bun/cr, LFTs drawn ___ and results sent to primary MD as
surveillance mid-therapy. This was ordered by me through the
home infusion company, discussed with pt. and home infusion RN
over at bedside, and I also called primary care MD office and
informed them of this.
Surveillance cultures negative/no growth.
Called ___ -they had not drawn any cultures prior
to transferring pt here.
# Coagulopathy: On coumadin for Afib. S/p 5 mg IV vitamin K for
reversal given plan for ERCP, management as above.
# Relative thrombocytopenia. Likely due to infection/sepsis.
Improving now and throughout hospitalization here. Will get
repeat CBC, arranged for ___ as above.
# AFib: On home Atenolol and dronaderone. continued. Warfarin
held as above, until ___ given sphincterotomy. Chads-2
score is 2 (age/htn). Bridging therapy back to therapeutic
range not indicated based on BRIDGE trial.
# HTN: Antihypertensives transiently held during hospitalization
given npo status, infection, ___, except atenolol.
Can resume at discharge.
# GERD: Continued home famotidine.
# Anxiety: continued home alprazolam.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 6.5 mg PO DAILY16
2. ALPRAZolam 0.25 mg PO BID:PRN anxiety/insomnia
3. atenolol-chlorthalidone 50-25 mg oral DAILY
4. Dronedarone 400 mg PO BID
5. Famotidine 20 mg PO BID
6. Ramipril 2.5 mg PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
last dose is on ___, following this Midline (IV) should be
removed
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV Daily
Disp #*12 Intravenous Bag Refills:*0
2. ALPRAZolam 0.25 mg PO BID:PRN anxiety/insomnia
3. Dronedarone 400 mg PO BID
4. Famotidine 20 mg PO BID
5. atenolol-chlorthalidone 50-25 mg oral DAILY
6. Ramipril 2.5 mg PO DAILY
7. Warfarin 6.5 mg PO DAILY16
DO NOT TAKE UNTIL ___ AS WE DISCUSSED. NEXT INR CHECK ON
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gallstone Pancreatitis
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 from
gallstones causing inflammation in your pancreas (pancreatitis)
and infection of your bile ducts and bloodstream. Your Coumadin
level was elevated, so you were given vitamin K to lower it.
You will need IV antibiotics for a total of 14 days (12 days at
home) as below. Following this (last dose on ___ - the
IV line can be removed by the visiting nurse team.
You will need to resume your Coumadin on ___ at your usual
dose as we discussed, as you cannot have any for 5 days
following the procedure you had here due to the risk of
bleeding. You should have your Coumadin level checked with
results sent to your primary MD Dr. ___ as per usual, on
___.
We will check your blood levels on ___ (the visiting RN
will do so) and send the results to Dr. ___ to make sure
you are tolerating the antibiotic therapy.
You should follow up with Dr. ___ immediately on your
return to ___ in three weeks.
Report back to ___ Cod ___ with any concerning symptoms
(see warning signs below).
Followup Instructions:
___
|
10352268-DS-2 | 10,352,268 | 28,386,581 | DS | 2 | 2135-08-30 00:00:00 | 2135-08-30 16:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
Bronchoscopy with stenting
History of Present Illness:
Ms. ___ is a ___ female with a past medical
history of stage IV NSCLC metastatic to the adrenals, who
presented to clinic with three weeks of dyspnea, cough,
weakness,
and chills.
She was directed to the ED from clinic and eventually admitted
to
the FICU due to hypoxia and hypotension requiring levophed. CT
chest was consistent with post-obstructive pneumonia. She was
started on vanc/zosyn. She required levophed for approximately
24
hours. On initial presentation she required ___ O2 and has
been
weaned to 3L NC during FICU stay. She does not use oxygen at
home. Her hypoxemia was thought to be secondary to pneumonia as
well as underlying lung cancer. She was seen by IP and on ___
underwent flex bronch/rigid bronchoscopy with
electrocautery destruction and removal of the LMS endobronchial
lesion and stent placement in LMS. Copious mucopurulent
secretions were removed from the left and right sides.
During FICU stay she was also started on a stress dose steroids
for possible adrenal insufficiency given hypotension in the
setting of adrenal metastases. FICU course also complicated by
mild hyponatremic, thought to be hypovolemic. In terms of her
metastatic lung cancer, her CT chest showed tumor necrosis and
increase in metastatic disease and lymphadenopathy. She was seen
by At___ oncology and had a long discussion regarding goals of
care. Decision was made to transition to DNR/DNI and to
discharge
on home hospice. She did wish to complete antibiotics for
pneumonia and steroids that were initiated in the FICU.
For complete past medical, social, and family history as well as
a list of home medications, please review FICU admission note.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hypercholesterolemia
Pelvic relaxation due to cystocele
Urinary, incontinence, stress female
Osteopenia
Osteoarthritis
Hypercholesterolemia
LBP (low back pain)
Rotator cuff tear
Aortic stenosis
Macular degeneration, dry
Foot deformity, bilateral
Closed patellar sleeve fracture of left knee
Essential hypertension
History of nonmelanoma skin cancer
Social History:
___
Family History:
Noncontributory to this case
Physical Exam:
DISCHARGE EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: 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
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
===============
___ 06:13PM BLOOD WBC-31.0* RBC-3.46* Hgb-10.2* Hct-30.9*
MCV-89 MCH-29.5 MCHC-33.0 RDW-13.2 RDWSD-42.9 Plt ___
___ 06:13PM BLOOD Neuts-88* Bands-9* Lymphs-3* Monos-0
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-30.07*
AbsLymp-0.93* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 06:13PM BLOOD Plt Smr-NORMAL Plt ___
___ 06:13PM BLOOD Glucose-98 UreaN-16 Creat-0.5 Na-125*
K-4.2 Cl-87* HCO3-22 AnGap-16
___ 09:26AM BLOOD Calcium-7.9* Phos-4.1 Mg-1.7
___ 06:13PM BLOOD Albumin-3.0*
DISCHARGE LABS:
===============
___ 06:55AM BLOOD WBC-7.9 RBC-2.94* Hgb-8.7* Hct-26.8*
MCV-91 MCH-29.6 MCHC-32.5 RDW-13.3 RDWSD-43.9 Plt ___
___ 04:38AM BLOOD Neuts-100* Bands-0 ___ Monos-0 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-12.10* AbsLymp-0.00*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 06:55AM BLOOD Glucose-124* UreaN-19 Creat-0.5 Na-135
K-4.3 Cl-96 HCO3-26 AnGap-13
___ 04:38AM BLOOD ALT-8 AST-12 LD(LDH)-411* AlkPhos-83
TotBili-0.5
___ 06:55AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.2
IMAGING:
========
TTE ___: Mild symmetric left ventricular hypertrophy with
small biventricular cavity sizes and hyperdynamic systolic
function. Very severe aortic stenosis. Mild aortic
regurgitation. Mild to moderate mitral and tricuspid
regurgitation. Moderate pulmonary hypertension.
CT chest with Contrast ___:
1. The known right middle lobe lung mass demonstrates new
superimposed
infection evidence by a new abscess within it. New right middle
and upper
lobe pneumonia.
2. Mild interval increase in size of adrenal metastases.
3. Right IJ central venous catheter terminates in the ___.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of newly
diagnosed stage IV non small cell lung cancer with metastases to
the adrenals, severe aortic stenosis (area 0.8cm2), HLD, and HTN
who presented from clinic with 3 weeks of shortness of breath,
cough, weakness and was initially admitted to the ICU with
hypoxemia and hypotension, now stable after IP stenting for
post-obstructive pna and subsequently tx'ed to the floor.
# SEPTIC SHOCK
# POST-OBSTRUCTIVE PNA
# LEFT BRONCHUS LESION
The patient presented with cough, shortness of breath, and
evidence of pneumonia on CXR. She was also hypotensive d/t
septic shock and required pressors briefly in the FICU. She was
started on Vancomycin and Zosyn for post-obstructive pneumonia.
CT scan revealed an enlarged left mainstem bronchus tumor. This
was removed by interventional pulmonology via rigid bronchoscopy
in the OR on ___. A pulmonary stent was placed to maintain the
patency of the airway. The patient was given BID mucomist and
saline treatments per pulmonology recommendations. Her
breathing and pna improved significantly post-procedure. Her
abx were narrowed to PO levaquin for completion of 5 day course
on discharge.
# HYPONATREMIA
The patient was noted to hyponatremic on arrival based on the
review of baseline Atrius records that revealed a sodium level
that varied between 129-131. Her current presentation was
thought to be likely SIADH in the setting of her lung cancer,
with possible component of hypovolemia. Na stable/improved at
135 on dischare.
# METASTATIC LUNG CANCER
# GOC
A CT chest on admission showed likely tumor necrosis and slight
increase in size of suprarenal metastases, unchanged mediastinal
lymphadenopathy, and an unchanged 4mm pulmonary nodule. It also
revealed an occlusive left main stem bronchus tumor that was
removed with subsequent placement of a pulmonary stent on ___
by interventional pulmonology. On ___, the patient expressed a
desire to go home with hospice care. After goals of care
conversation with family, HCP, and Atrius oncologist it was
decided not to pursue any further tests/treatments per patient's
wishes. Pt was discharged with home hospice services.
# ADRENAL ISUFFICEINCY
Pt was started on empiric stress dose steroids in the ICU due to
hypotension and known adrenal metastases as well as recent
dexamethasone use. She was discharged to complete 2-week
hydrocortisone taper
# AORTIC STENOSIS: Severe on ___ TTE. She appeared euvolemic
on discharge.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 300 mg PO QHS
2. Benzonatate 100 mg PO TID
3. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
4. FoLIC Acid 1 mg PO DAILY
5. Dexamethasone 4 mg PO Q12H
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Lisinopril 10 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Ferrous Sulfate 325 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
12. Cyanocobalamin 1000 mcg IM/SC 1X/WEEK (___)
Discharge Medications:
1. Hydrocortisone 30 mg PO Q8H
Taper to 20mg on ___ and 10mg on ___ and off on ___
RX *hydrocortisone 10 mg 3 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
2. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Benzonatate 100 mg PO TID
4. Ferrous Sulfate 325 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 300 mg PO QHS
7. Glucosamine (glucosamine sulfate) 500 mg oral DAILY
8. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
9. Lisinopril 10 mg PO DAILY
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Simvastatin 20 mg PO QPM
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non-small cell lung cancer
Adrenal Insufficiency
Post-obstructive pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with a pneumonia due to an obstruction of your
airways caused by the lung cancer. You had a stent placed and
this helped clear the obstruction.
We are sending you home with hospice services to make sure you
have the best quality of life moving forwards.
Please return if you have intractable pain or symptoms not
relieved by medications.
It was a pleasure taking care of you at ___ ___
___.
Followup Instructions:
___
|
10352278-DS-19 | 10,352,278 | 26,543,725 | DS | 19 | 2184-10-25 00:00:00 | 2184-11-07 16:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___
Attending: ___.
Chief Complaint:
Increased seizure frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M w PMHx of epilepsy, DM2,
Bipolar,
HTN, and HLD who presents to ___ ED from ___
with increased seizure frequency.
Mr. ___ history begins on ___ when he had an
event concerning for seizure at a convenience store near his
home. The event was only witnessed by a convenience store clerk,
though his daughter did video tape a surveillance camera footage
of the event (poor quality). In the video, Mr. ___ stands
still near the doorway for several minutes. He then does two
turns in place before abruptly falling to the ground. Per report
he hit his head on a counter and was taken to ___.
A head lac was stapled at ___ and a ___ on ___ revealed
a
small <2mm SDH (?location). He was then transferred to ___.
___
for possible neurosurgical intervention. No operative
intervention was recommended, but he was admitted to the
hospital. His daughter reports that Mr. ___ was "fully
aware" on ___ evening, but when she came to visit him on
___, he was "crazy town." She describes essentially
delirium, though there was also some difficulty producing
speech.
Per his daughter, Mr. ___ was evaluated by staff at that
point and there was no concern for CVA or seizure. On ___,
his daughter reports that Mr. ___ was "still crazy" though
perhaps improving. He was also "spacing out" intermittently, and
she wondered if this might be seizure activity. On ___
evening he had an MRI which was reportedly normal.
On ___, his daughter reports that Mr. ___ was
"completely
back to normal", alert and oriented x4, and at his mental
baseline. He was discharged that evening to ___ in
___.
On ___ (the day of presentation), Mr. ___ was
observed to have three events concerning for seizure and was
sent
back to ___. Rehab ___ nursing staff
witnessed
the events, and they report that the first event occurred at
roughly 11:50AM. Prior to that, they reported that Mr. ___
appeared confused (getting out of wheelchair despite chair alarm
and repeatedly being told not to, fixated on leaving to pick up
suits from dry cleaners, etc), and "tried to leave" several
times. It is difficult to say whether or not this represented a
change in behavior for him, given that he had only been admitted
the evening prior.
At 11:50AM, while sitting in his wheelchair, he had sudden onset
of bilateral "eye twitching" and "arm twitching." He was
non-verbal during the event for approximately 30 seconds,
without
clear jerking or stiffening movements, laterality, incontinence,
or tongue biting. He maintained his O2 sats and did not fall out
of his chair. After the event resolved, he appeared awake and
aware but was unable to speak for ~40 seconds. He then had a
second event that was essentially identical to the first. He was
taken to his bed with seizure pads in place.
In the ~10 minutes between his second and third seizure, he
reportedly returned to his prior baseline within ___ minutes and
was talking to staff and apologizing for the seizure. After 10
minutes, he had a third event that lasted ___ minutes and
progressed to include shaking of his legs and loss of his bottom
dentures. After this event, he "came to" within 2 minutes.
Mr. ___ was then taken to ___ for further
work-up and evaluation. On arrival, BP was 165/71, afebrile. Per
___ documentation, Mr. ___ arrived "at his baseline
mental status" but then had 2 seizures in quick succession,
lasting 2 minutes in total. His daughter describes them as
"mouth
open, looking like he's trying to talk" with BUE shaking.
Seizure
activity resolved after Ativan 2mg IV. A dose of Keppra 1000mg
IV
was given as well. Repeat NCHCT showed no acute process or
worsening of previously visualized SDH. BP dropped to ~80s after
Ativan, improved with fluids. Cr was also noted to be 1.5, also
treated with IV fluids. Neurology at ___ recommended
transfer to ___ ED for possible continuous EEG monitoring.
In our ED, Mr. ___ appears to be at his baseline mental
status - corroborated by his daughter/HCP who is at bedside. He
states that he remembers the events of today completely, but
also
states that he was able to talk during the events (which is
contradicted by witnesses). He reports that he does no recall
the
event that occurred on ___. He reports being in good health
prior to ___, though he did have ___ nights of extremely
poor
sleep, unclear why. He denies missing medication doses.
Of note, there is some mention in records of recent dose change
of Keppra. After extensive clarification, it appears that Mr.
___ was changed from 500mg tabs (2 tabs BID) to 1000mg tabs
(1 tab BID) on ___ at his latest neurology
appointment.
There does not appear to have been any reduction in dosage. He
was also previously on Depakote, though this was discontinued
before Mr. ___ was started on Keppra in ___. Mr.
___ follows as an outpatient with Dr. ___ at ___
___
Neurology.
With regards to his epilepsy history, his daughter states that
Mr. ___ first seizure was in ___, and the most recent
was
in ___. She is unaware of an underlying diagnosis for his
seizures, though she does note that the diagnosis was around the
same time that he was diagnosed with bipolar disorder and
wonders
if the two may be linked. He has seizures less than 1x per year.
Prior to ___, he had never fallen after a seizure. The
seizures are described as usually shaking of "whole body" with
no
clear lateralization. He also has mouth opening, looking as if
he
is trying to speak. There has been no reported head or eye
deviation. Mr. ___ reports that he remembers his seizures.
Past Medical History:
- epilepsy
- first seizure in ___
- most recent seizure prior to this event was ___
- seizure semiology: "whole body shaking", mouth open
- reports that he retains full memory of his events?
- seizure frequency: <1x per year
- aside from SDH, no significant TBI / no CNS infection
- DM2
- Bipolar I d/o
- previous EtOH abuse
- HTN
- HLD
Social History:
___
Family History:
Mother - deceased of complications from colorectal cancer
Father - deceased of brain cancer
No known family history of seizures
Physical Exam:
ADMISSION PHYSICAL EXAM
VS T98.6 HR93 BP115/75 RR18 Sat96%RA
GEN - elderly M, cooperative, NAD
HEENT - NC, healing lac to L scalp, dry mucous membranes
NECK - age appropriate restricted ROM
CV - RRR
RESP - normal WOB
ABD - soft, NT, ND
EXTR - warm and well perfused, atraumatic
NEUROLOGICAL EXAMINATION
MS - brightly awake, alert, and oriented x3. Attentive to
examiner, performs MOYB briskly and accurately. Speech is fluent
with normal prosody and no paraphasic errors. Naming,
repetition,
and comprehension are all intact. No R/L confusion. No apraxia.
CN - VFF to finger counting. EOMI. PERRL. Facial sensation
symmetric to LT and PP. At rest, mild ptosis of R eye - likely
redundant skin, though no readily available pictures for
comparison. Remainder of face is symmetric at rest and with
activation. Hearing intact to voice. Palate elevates
symmetrically. SCMs and traps full power. Tongue is midline with
full ROM.
MOTOR - Normal bulk, some difficulty relaxing for tone check vs
paratonia. Grossly full power throughout, though there is a
pronator drift of the LUE. There is 4+ weakness at the L delt
with orbiting about the LUE. Patient states he has an old L
shoulder injury. Otherwise, strength is grossly full with no
clearly lateralized weakness.
SENSORY - Intact to LT and PP throughout. Proprioception intact
at B/L great toes.
REFLEXES - Some difficulty relaxing, and patient "facilitates"
reflexes. Grossly, ___ in BUEs with pectoral jerks bilaterally.
2+ at knees, difficult to assess spread given volitional
movements. Absent ankle jerks. Toes are mute.
COORD - Postural and intention tremor in B/L UEs. No dysmetria
on
FNF. No truncal titubation when sitting up at bedside with eyes
closed.
GAIT - Moderately unsteady, attempted few steps with 1 assist.
Antalgic gait ("I'm stiff because I've been in bed).
.
====================================
DISCHARGE PHYSICAL EXAM
Tmax 98.9F, 124-160/68-84, HR 74-82, RR ___, 95-97%, Glu
101-167
Gen - NAD
Mental status - alert and oriented x3
Cranial Nerves - EOMI, face symmetric, no nystagmus.
Motor - ___ strength in Deltoids, IPs; Left greater than right
postural worsened on finger/nose/finger
Sensory - intact to light touch in all four extremities.
Pertinent Results:
================
ADMISSION LABS
================
___ 07:30PM BLOOD WBC-11.9* RBC-3.35* Hgb-10.7* Hct-32.1*
MCV-96 MCH-31.9 MCHC-33.3 RDW-13.3 RDWSD-47.0* Plt ___
___ 07:30PM BLOOD Neuts-62.3 ___ Monos-13.0
Eos-0.8* Baso-0.5 Im ___ AbsNeut-7.43* AbsLymp-2.76
AbsMono-1.55* AbsEos-0.10 AbsBaso-0.06
___ 07:30PM BLOOD Plt ___
___ 07:30PM BLOOD Glucose-101* UreaN-28* Creat-1.2 Na-131*
K-4.6 Cl-99 HCO3-18* AnGap-19
___ 07:40AM BLOOD ALT-14 AST-23 LD(LDH)-159 CK(CPK)-358*
AlkPhos-36* TotBili-0.6
___ 07:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:30PM BLOOD Calcium-8.5 Phos-3.2 Mg-1.6
___ 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:53PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:53PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:53PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:53PM URINE CastHy-1*
___ 05:53PM URINE Mucous-RARE
___ 05:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
.
==============
DISCHARGE LABS
===============
___ 12:40PM BLOOD WBC-9.4 RBC-3.31* Hgb-10.6* Hct-31.8*
MCV-96 MCH-32.0 MCHC-33.3 RDW-13.2 RDWSD-46.6* Plt ___
___ 12:40PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-132*
K-4.6 Cl-104 HCO3-18* AnGap-15
==============
IMAGING
==============
BRAIN MRI WITH CONTRAST - ___
1. Stable 6 mm left anterior frontal meningioma without mass
effect on the
brain parenchyma.
2. No pathologic leptomeningeal or pachymeningeal contrast
enhancement.
3. Progression of supratentorial white matter signal
abnormalities since ___,
nonspecific but likely sequela of chronic small vessel ischemic
disease, given
the patient's age and cardiovascular risk factors.
4. The temporal horn of the right lateral ventricle is slightly
larger than
the left, a chronic finding which may sometimes be related to
medial temporal
lobe epilepsy. Otherwise, global parenchymal volume loss has
not
significantly changed since ___.
RECOMMENDATION(S): If right medial temporal lobe epilepsy is
suspected
clinically, then a dedicated seizure protocol MRI could be
obtained for better
assessment of the right medial temporal lobe.
.
PORTABLE CXR
Only an AP upright view could be obtained due to patient
condition. The lungs
are clear.
There is no pneumothorax, effusion, consolidation or CHF.
Degenerative changes are present in the spine and in both
shoulders.
.
EEG OVER ___ - NO SEIZURES
.
Chest Xray ___
Compared to prior chest radiographs since ___, most
recently ___.
Lungs grossly clear. Heart size normal. No pleural
abnormality. Thoracic
aorta is heavily calcified, but CT scanning would be required to
detect
aneurysm.
.
CTA Chest ___
1. No pulmonary embolism or aortic dissection.
2. A 2 mm left apical nodule.
3. Mild centrilobular emphysema.
4. Moderate atherosclerosis.
Brief Hospital Course:
Mr. ___ is a ___ M w PMHx of epilepsy, DM2,
Bipolar, HTN, and HLD who presents to ___ ED from ___
___ with possible increased seizure frequency.
.
Etiology unclear - could be related to recent head injury - we
did not see any SDH or blood on our imaging. ___ MRI with and
without contrast showed stable meningioma and small vessel
disease - negative for stroke or any structural lesion or blood
that can explain increased seizure frequency. He had returned to
baseline on this admission. cvEEG negative for seizure for over
24 hrs.
.
During his admission, he many events (Around 5 on ___ and 3 on
___ lasting around 5 minutes at a time characterized by
breathlessness, stuttering, and problems with speech that were
caught on video EEG. These events were NOT seizure, were not
treated with Ativan, and do not need to be treated with Ativan
in the future. On review of prior records and discharge summary
from ___, they sound similar to events that were thought to be
possible seizure. There were some rhythmic midline discharges
over night on EEG not related to any clinical episodes. We
continued his home Keppra and started Lamictal with planned
uptitration as below as we thought this would be a much better
med for him in light of his psychiatric history.
.
A workup for medical cause of breathlessness was performed -
troponin was negative, CXR was normal, ddimer was elevated so
CTA chest was performed and was negative for pulmonary embolism.
EKG was normal.
.
As mentioned he was continued on Keppra 1000mg BID as well as
started on Lamictal 25mg daily to slowly increase as outpatient
following this schedule:
.
25mg daily - Started on ___
Start 25mg twice daily on ___
Start 25mg AM, 50mg ___ on ___ twice daily on ___ AM, 100mg ___ ___ twice daily ___
.
Given the low severity of these episodes and the possible
questionable nature of his epilepsy diagnosis, we feel that
outpatient tapering of his Keppra would be appropriate after his
Lamictal has reached goal dose. This can be addressed by his
outpatient neurologist.
.
Metformin was held for slight ___ which improved with fluids. Pt
also had hyponatremia that was stable.
.
___ evaluated the patient and thought he was benefit from rehab.
.
# Transitional Issues #
- Started Lamictal and titrate up as listed.
- Had non-epileptic events in the hospital described above.
Would not treat these episodes with Ativan.
- Needs follow up with outpatient neurologist within 4 weeks
after discharge. Hopefully to consider decreasing Keppra as
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 1000 mg PO BID
2. Lovastatin 80 mg oral QHS
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. LeVETiracetam 1000 mg PO BID
3. Lisinopril 40 mg PO DAILY
4. Lovastatin 80 mg oral QHS
5. Multivitamins 1 TAB PO DAILY
6. LaMOTrigine 25 mg PO BID
RX *lamotrigine [Lamictal] 25 mg 4 tablet(s) by mouth twice a
day Disp #*240 Tablet Refills:*0
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Lorazepam 0.5 mg IM DAILY:PRN Seizure
Please only give if patient has convulsive episode lasting 2
minutes or more.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1.) Seizure
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 with possible increased seizure frequency and
were admitted for monitoring to make sure that your seizures
were controlled and for workup for other causes of increased
seizure frequency.
Your infectious and metabolic workup was negative. You were
monitored on EEG with no seizure activity. You had an MRI that
was negative for stroke, mass, or any other acute cause of
increased seizure frequency.
You had several events with breathlessness, stuttering, and
problems with your speech that were caught on video EEG. These
events were NOT seizure and do not need to be treated with
Ativan. In fact, it is possible that these episodes are the
events that were initially diagnosed as seizures. We will
continue your Keppra for now and the decision to decrease this
will come from your neurologist.
We started a new medication called Lamictal (Lamotrigine) which
is much better than Keppra for mood stabilization in addition to
seizures. This medication is started and uptitrated slowly
following this schedule:
25mg daily - Started on ___
Start 25mg twice daily on ___
Start 25mg AM, 50mg ___ on ___ twice daily on ___ AM, 100mg ___ ___ twice daily ___
Stay at this dose until following up with epilepsy as an
outpatient.
Followup Instructions:
___
|
10352433-DS-18 | 10,352,433 | 26,343,394 | DS | 18 | 2141-11-06 00:00:00 | 2141-11-06 19:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
convulsion
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
HPI: The patient is a ___ with hx of recent stroke
(discharged from stroke service on ___, on a background of
dementia, htn, hlp, dm, and prostate cancer, who presents today
after a convulsion. He was doing well since discharge, with
good
activity level and appetite, no new symptoms. Known deficits
from
recently identified right posterior frontal and parietal
infarcts
(inferior MCA territory) include a mild left facial droop and
dysarthria with occasional drooling on left.
This morning in his usual state of health, went to church this
morning. Was sitting down, waiting to be prayed on. Then stood
up
and as he was having the pastor lay his hands on him, started
having a convulsion. This happened approx. ___ minutes after
standing up.
Per his grandaughter, who was present and observing, his eyes
rolled back and he started drooling and his whole upper body
started shaking. He kept hold off his cane throughout. He was
gently lowered down to the floor by bystander and quickly
stopped
shaking. He was unresponsive initially while standing. Once they
laid him down and he stopped shaking, he appeared drowsy, was
not
following commands until EMS arrived ___ minutes later. Per
granddaughter, he looked pale. At that point, he still was not
talking. EMS brought him to ED, and at that point his mental
status had returned to his previous baseline with normal speech.
He was called a code stroke for concern of a question of a
visual
field deficit.
Pt recalls being in church and people standing around him but is
sparse on details.
On review of symptoms, currently denies headache, fevers,
chills,
chest pain, dyspnea, cough, abdominal pain, nausea, vomiting,
weakness.
Past Medical History:
Dementia
HTN
HMD
Diabetes -insulin controlled
Cataracts and glaucoma
Ablation therapy for Prostate
Stent placement
Right toe amputation ( ___ gangrene ___ diabetic ulcers)
Social History:
___
Family History:
HTN, DM, several family members with ___ CA, no known
neurological disease
Physical Exam:
ED vitals:
Time Pain Temp HR BP RR Pox
12:36 97.5 67 142/88 16 99% 4L Nasal Cannula
13:24 0 67 166/73 18 100%
13:51 68 163/87 18 100%
15:00 98.1 68 159/78 18 100%
16:15 64 144/71 18 98%
Orthostatics on floor:
lying 170/98, HR 64
standing 156/81 HR 72
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions,
mucosae dry, breath smells ketotic
Neck: Supple, no nuchal rigidity
Cardiovascular: Carotids w/o bruits and w/ nl volume & upstroke,
no JVD, RRR w/physiologic S2 splitting, no M/R/G
Pulmonary: Respirations nonlabored; equal air entry bilaterally,
no crackles or wheezes
Abdomen: Obese but not distended above baseline per
granddaughter, Soft, ___, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions
___ Stroke Scale: Total [3]
1a. Level of Consciousness:
1b. LOC Questions:
1c. LOC Commands:
2. Best Gaze:
3. Visual Fields:
4. Facial Palsy: 1
5a. Motor arm, ___:
5b. Motor arm, right:
6a. Motor leg, ___:
6b. Motor leg, right:
7. Limb Ataxia:
8. Sensory:
9. Language:
10. Dysarthria:
11. Extinction and Neglect: 2
Neurologic Examination:
- Mental Status: Awake, alert, oriented to BI and ___.
Very delayed response-time latency. Recalls fragments of
history.
Effort maintained but very slow and aborted by examiner.
Language
fluent without dysarthria and with intact repetition and verbal
comprehension. No paraphasic errors. Follows simple commands.
Misses high-frequency but correctly names ___ objects
on stroke card. Normal reading and writing. Normal prosody. No
dysarthria. Registration of 4 words required several attempts,
and recall ___, improving to ___ with list cueing. No apraxia
but
does appear to have motor neglect of left side (e.g., performs
actions with right when asked to perform with left). Occasional
motor perseveration observed.
- Cranial Nerves: [II] PERRL 3->2 brisk. VF full to number
counting but neglects left field to double simultaneous
stimulation. Fundoscopy unsuccesful due to small pupils and
likely cataracts. [III, IV, VI] EOM intact, no nystagmus. [V]
V1-V3 without deficits to pinprick bilaterally. Pterygoids
contract normally. [VII] Mild left lower facial droop [VIII]
Hearing grossly intact. [IX, X] Palate elevation symmetric. [XI]
SCM strength ___ bilaterally. [XII] Tongue midline.
- Motor: Normal bulk and tone. No pronation or drift. No tremor
or asterixis.
[Delt] [Bic] [Tri] [ECR] [FE] [FF] [IP] [Quad] [Ham] [TA] [Gas]
[___] [EDB]
L ___ 5
R ___ ___ 5
- Sensory: No deficits to pinprick, or proprioception
bilaterally
except for inconsistent responses to DSS.
- Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L ___ 2 0
R ___ 2 0
Plantar response mute on left, amputated toes on right.
- Coordination: No dysmetria on finger-to-nose
- Gait: deferred
Pertinent Results:
___ 09:25PM CK(CPK)-160
___ 09:25PM CK-MB-3 cTropnT-<0.01
___ 03:05PM K+-4.1
___ 03:00PM WBC-5.6 RBC-4.20* HGB-12.9* HCT-37.8* MCV-90
MCH-30.7 MCHC-34.1 RDW-14.0
___ 03:00PM NEUTS-70.7* ___ MONOS-5.0 EOS-1.9
BASOS-0.2
___ 03:00PM PLT COUNT-160
___ 03:00PM ___ PTT-34.6 ___
___ 01:50PM GLUCOSE-197* UREA N-26* CREAT-1.8* SODIUM-137
POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-22 ANION GAP-18
___ 01:50PM estGFR-Using this
___ 01:50PM ALT(SGPT)-46* AST(SGOT)-36 ALK PHOS-77 TOT
BILI-0.3
___ 01:50PM ALBUMIN-4.6
___ 01:50PM WBC-UNABLE TO RBC-UNABLE TO HGB-UNABLE TO
HCT-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO
___ 01:50PM NEUTS-UNABLE TO LYMPHS-UNABLE TO
MONOS-UNABLE TO EOS-UNABLE TO BASOS-UNABLE TO
___ 01:50PM PLT COUNT-UNABLE TO
___ 01:50PM ___ TO PTT-UNABLE TO ___
TO
___ 01:04PM COMMENTS-GREEN TOP
___ 01:04PM GLUCOSE-203* NA+-137 K+-5.1 CL--107 TCO2-22
___ 01:00PM UREA N-27*
___ 01:00PM WBC-UNABLE TO RBC-UNABLE TO HGB-UNABLE TO
HCT-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO
___ 01:00PM PLT COUNT-UNABLE TO
___ 01:00PM ___ TO PTT-UNABLE TO ___
TO
Brief Hospital Course:
This is an ___ year old man with a history of poorly controlled
diabetes, CKD, HTN and recent right MCA embolic appearing
infarcts with discharge on ___ presenting with an episode of
loss of consciousness with convulsion.
The patient was admitted to the stroke service overnight. His
orthostatics were positive on admission and he was given 1 liter
of fluid. On recheck he was no longer orthostatic. His exam was
unchanged from the time of discharge. While the circumstances
and description of the event point very strongly to orthostatic
syncope, he did have an EEG. The results of this are currently
pending. No medications were changed. The patient will follow up
with neurology and his PCP as previously arranged.
Transition of Care Issues: follow ups as below.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atenolol 100 mg PO DAILY
in AM
4. Atenolol 50 mg PO DAILY18
5. Atorvastatin 40 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Gabapentin 100 mg PO DAILY
8. Gabapentin 300 mg PO HS
9. HydrALAzine 10 mg PO BID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
11. Nitroglycerin SL 0.3 mg SL PRN chest pain
12. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atenolol 100 mg PO DAILY
in AM
4. Atenolol 50 mg PO DAILY18
5. Atorvastatin 40 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Gabapentin 100 mg PO DAILY
8. Gabapentin 300 mg PO HS
9. HydrALAzine 10 mg PO BID
10. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
12. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
orthostatic Syncope
Discharge Condition:
alert and oriented x3. Somewhat slow to respond and gives a
vague history. Some L/R confusion. Naming and repetition intact.
Slow elevation of left lower face, EOMI. Left delt 5, bi 4+ tri
4+. Right delt 5, bic 5- tri 4+. Lower ext ___. left toe
upgoing.
Discharge Instructions:
You came to the hospital because of an episode of convulsion
upon standing. Your neurologic exam is unchanged from your
recent admission so a new stroke is very unlikely. There is a
diffence between your standing and lying down blood pressures
which supports our belief that this may have been a syncopal
episode (fainting).
We have not changed your medications. You should be sure to stay
well hydrated, take regular meals and stand very slowly from a
seated position.
Followup Instructions:
___
|
10352433-DS-20 | 10,352,433 | 21,370,390 | DS | 20 | 2144-02-19 00:00:00 | 2144-02-19 18:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old male with history of HTN, HLD, CAD, CHF
(EF 55-60% in ___, Diabetes on insulin, hx of CVA, recently
diagnosed pericardial effusion, p/w acute-onset altered mental
status, unsteadiness, urinary incontinence today.
Patient's son is the one who provided the history. Patient's
son states that patient was sleeping in this morning, and much
less responsive. He reports that patient woke up with a blank
stare. Patient was also acutely noted to be incontinent of
urine once. His son reports that he was unable to walk around
steadily, and was having difficulty hold onto the walls/walker
to get around. Since then, he has been much less verbal with
difficulty with speech. At home, he was also endorsing some
L-sided abdominal and back pain. Son denies any falls or
headstrike. Son denies any fevers/chills; He does endorse some
wheezing but no chest pain, no
nausea/vomiting/diarrhea/constipation, no new swelling or focal
weakness anywhere aside from today's episode of generalized
weakness and unsteadiness on his feet. Of note, patient is on
Plavix.
In the ED, initial vitals: 99.4 102 186/90 15 98%
Labs were signficant for potassium of 5.3, but sample was
hemolyzed. Creatinine was 3.7 from baseline 1.8. pO2 from venous
O2 sats were 25. Patient triggered for shortness of breath. At
the time he was shaking, tachycardic to 100s; 94% on RA; placed
on NRB with improvement to 100%; rhonchi on L > R. Portable CXR
showing increased fluid overload. Patient was given Vancomycin
1g, Cefepime 1g, albuterol/ipratropium nebs, furosemide 40mg,
tylenol ___, 1L NS.
On transfer, vitals were: 101.8 105 161/87 33 100% bipap
On arrival to the MICU, patient was on BiPap. Patient's son
reports that his mental status is back to baseline. He also
reports that his grandson had a URI in the last week. Patient's
lasix dose was also decreased by half to 20mg last month.
Past Medical History:
- Stroke in ___
- Hypertension, medication changes as above. His blood pressure
at home at been 150-180 systolic in ___, but not
recently measuring. Had been ~ 153/82 on ___ before
hydralazine increased.
- Hypercholesterolemia, on Statin
- Diabetes, on insulin (Lantus and Humalog SS)
- Orthostasis and possible convulsive syncope, as above
- Toes amputated on right owing to diabetes
- Cataracts - no surgery
- Diabetic neuropathy, on gabapentin 100/300
Social History:
___
Family History:
Possible stroke in parents, one definitely diabetic.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T:100.8 BP:185/78 P:92 R: 18 O2: 100 on 2L NC
GENERAL: Alert, oriented to name and place. No acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Bilateral crackles
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, distended c/w obesity, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
EXT: Amputated toes
NEURO: Power ___ bilaterally in both lower and upper
extremities. Dyspraxic when trying to follow commands with left
upper extremity. Cn II-XII grossly intact.
DISCHARGE PHYSICAL EXAM:
VS - 98.0 157/70 70 18 100% on RA
GENERAL: Alert, oriented to name and place. No acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, swelling of the
eye noted
NECK: supple, JVP not elevated, no LAD
LUNGS: Crackles appreciated occasionally in bilateral lung
fields, good air movement, breathing comfortably without use of
accessory muscles
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, distended c/w obesity, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
EXT: Amputated toes, patient has an erythematous rash on the
back which is not pruritic, not spreading
NEURO: Power ___ bilaterally in both lower and upper
extremities. Dyspraxic when trying to follow commands with left
upper extremity. Cn II-XII grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 03:25PM PLT COUNT-105*
___ 03:25PM NEUTS-81.3* LYMPHS-10.7* MONOS-7.3 EOS-0.5
BASOS-0.1
___ 03:25PM WBC-8.7 RBC-3.25* HGB-9.8* HCT-28.1* MCV-87
MCH-30.2 MCHC-34.9 RDW-15.2
___ 03:25PM ALBUMIN-3.5 CALCIUM-9.2 PHOSPHATE-3.0
MAGNESIUM-2.1
___ 03:25PM CK-MB-1 cTropnT-<0.01 ___
___ 03:25PM LIPASE-22
___ 03:25PM ALT(SGPT)-16 AST(SGOT)-34 ALK PHOS-52 TOT
BILI-0.5
___ 03:25PM estGFR-Using this
___ 03:25PM GLUCOSE-147* UREA N-47* CREAT-3.7*#
SODIUM-139 POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
___ 03:38PM ___ TO PTT-UNABLE TO ___
TO
___ 03:40PM LACTATE-1.2
___ 04:45PM ___ PTT-29.9 ___
___ 05:25PM URINE RBC-4* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 05:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:25PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:25PM URINE UHOLD-HOLD
___ 05:25PM URINE HOURS-RANDOM UREA N-692 CREAT-121
SODIUM-57 POTASSIUM-37 CHLORIDE-49
___ 07:35PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 08:04PM O2 SAT-31
___ 08:04PM ___ PO2-25* PCO2-51* PH-7.30* TOTAL
CO2-26 BASE XS--2
___ CXR:
Mild pulmonary edema, without pleural effusions
.
___ CXR:
Cardiomegaly with pulmonary edema, progressed since prior study
dated ___ CT head:
No acute intracranial abnormality
___ CT abdomen:
1. Small bilateral layering at nonhemorrhagic pleural effusions,
right greater than left.
2. Moderate diverticular disease of the sigmoid colon without
evidence of diverticulitis.
EKG: rate 97, sinus, 1st degree A-V block (PR 226ms) otherwise
normal intervals, normal axis; ___ ST-T wave changes,
non-specific; TWI in I and avL no longer noted (since comparison
___
___: Renal U/S:
IMPRESSION:
5 mm nonobstructing left lower pole renal stone and a sub cm
left lower pole simple renal cyst. Otherwise, normal renal
ultrasound.
Brief Hospital Course:
This is a ___ year old male with history of HTN, HLD, CAD, dCHF
(EF 55-60% in ___, Diabetes on insulin, hx of CVA, recently
diagnosed pericardial effusion, p/w acute-onset altered mental
status, unsteadiness, urinary incontinence found to also be in
respiratory distress.
#RESPIRATORY DISTRESS: Likely ___ flash pulmonary edema. Patient
being resuscitated with fluid and was also very hypertensive in
the ED to 180s systolic. From at___ notes, diuretics were also
decreased to 20mg which could have predisposed him to having an
episode of flash pulmonary edema. BNP on arrival was in the
11000s favoring acute diastolic CHF exacerbation. Patient was
placed on fluid restriction and diuresed with 40mg IV lasix.
However patient was also febrile to 101 in the ED and has had hx
of prior stroke, so there was some concern for aspiration. He
was therefore covered broadly with vanc/cefepime/flagyl (flagyl
added given concern for aspiration) but these antibiotics were
discontinued after a few days given lack of clinical evidence of
pneumonia. The patient's shortness of breath improved with
diuresis alone and he never complained of cough, had an elevated
WBC count, or was febrile after being admitted. An echo was
performed which compared favorably with his prior echo in ___
with no changes in ejection fraction.
#ALTERED MENTAL STATUS: Unclear etiology. Patient does have hx
of stroke but CT head was negative for acute intracranial
process. Given urinary incontinence, gait instability, normal
pressure hydrocephalus is also on differential but no prominence
of ventricles on CT head. Infectious etiology also on
differential given fevers in setting of AMS. Patient could have
also suffered a seizure given urinary incontinence although no
prior hx of seizures. Infectious work up sent off which came
back negative. Patient was back to baseline upon arrival to the
ICU and his mental status was stable and at his baseline
throughout admission. The most likely etiology of his acute
mental status decompensation is pulmonary edema and resulting
respiratory distress.
#Acute on chronic kidney disease: Patient had an increase from
his baseline creatinine of 3.3 to 4.1 which trended back down to
3.7. CKD thought to be due to worsening DM. Most likely etiology
is pre-renal due to to infection/dehydration. His creatinine was
trended daily and a renal ultrasound was negative for
obstruction or hydronephrosis.
#CHF: Patient has hx of dCHF. Echo on this admission reveals
preserved EF without new regional wall motion abnormalities when
compared with that from ___. Fluid restriction to 1.5L and
2g Na diet were employed with daily weights and strict ins and
outs recorded. His metoprolol 100 qdaily was increased to 150
qdaily for improved BP control.
#CAD: Patient's last cath was in ___ which was negative. ___
cath showed moderate single vessel disease and was advised to be
medically managed. His home aspirin, statin, and metprolol were
continued while he was hospitalized.
#HX OF STROKE: Patient has suffered stroke in the past and has
been on dual antiplatelet therapy since then. His home plavix
and aspirin were continued.
#HYPERTENSION: Hypertensive to 180s systolic on admission. Goal
BP for this elderly gentleman is 160s systolic, will attempt to
control BP in light of flash pulmonary edema on admission. His
home hydralazine and metoprolol were continued, and his
metporolol dose was increased to provide better control of his
blood pressures at home.
#DM - Stable, patient's home lantus regimen was continued with
additional insulin sliding scale while hospitalized.
TRANSITIONAL ISSUES:
-The patient had a mild erythematous rash on his back which he
did not find bothersome and is most likely due to a heat rash vs
mild allergic reaction. He was treated with ceterizine and was
asymptomatic. Please ensure this rash clears.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 100 mg PO DAILY
6. Gabapentin 300 mg PO HS
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Metoprolol Succinate XL 100 mg PO DAILY
9. HydrALAzine 25 mg PO TID
10. Glargine 20 Units Breakfast
11. Calcitriol 0.25 mcg PO EVERY OTHER DAY 3x/weekly
12. Furosemide 20 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Acetaminophen 650 mg PO Q12H:PRN pain, fever
Discharge Medications:
1. Acetaminophen 650 mg PO Q12H:PRN pain, fever
2. Amlodipine 10 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Calcitriol 0.25 mcg PO EVERY OTHER DAY 3x/weekly
6. Clopidogrel 75 mg PO DAILY
7. Gabapentin 100 mg PO DAILY
8. Gabapentin 300 mg PO HS
9. HydrALAzine 25 mg PO TID
10. Glargine 20 Units Breakfast
11. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth qdaily Disp
#*90 Tablet Refills:*0
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute diastolic congestive heart failure
exacerbation
Secondary Diagnosis: Diabetes mellitus, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___. You were admitted because you were having
shortness of breath and fevers. We determined that your
shortness of breath was likely due to an acute exacerbation of
your heart failure and haveing too much fluid in your lungs. We
gave you a medication to help you remove the fluid from your
lungs. Your kidney function was also slightly worse than usual
while you were admitted. We closely followed it while you were
hospitalized and it returned to what is normal for you. We also
noticed that your blood pressure was somewhat high while you
were here, so we increased one of your blood pressure
medications (metoprolol). This is noted on the medication list
you will be given at discharge.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10352433-DS-22 | 10,352,433 | 20,993,863 | DS | 22 | 2145-11-23 00:00:00 | 2145-11-27 17:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fall, unsteadiness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year old man with a history of HTN, CKD
(awaiting HD planning), ___ and dementia who presents with
increased confusion after unwitnessed fall in the setting of
recent productive cough.
Patient unable to recall history. Does not know why he is in the
hospital. History obtained from granddaughter ___ (also ___)
who is his primary care giver. He has been in his usual state of
health until the last ___ days when he developed a cough. No
evidence of chills or fevers. Of note, patient lives in a
multigenerational household and a lot of his family members
recently developed a cold (started from a young child). On day
of presentation, he was found at the side of his bed. Told his
grandaughter that he fell towards the bed. Unclear of whether he
had a headstrike. Received flu shot this year. Did not complain
of abdominal pain, nausea, vomiting, diarrhea.
Of note, baseline mental status is oriented to family members
and location, but not date. Ambulates with walker, but over past
day has had instability even with walker. After the fall, his
knees kept buckling when trying to walk.
Of note, patient has CKD and is in the planning phase of
initiating dialysis. He has an appointment with renal this week.
He has met with transplant surgery, but does not have HD access
yet.
In the ED, initial vitals:
103 to 100.8 rectally 88 181/81 16 97% RA
Exam was notable for: T 100.8 (rectal), tender RLQ, bilateral
upper wheezes, dry mucous membranes, bilat ___ edema L>R.
Labs were significant for bland UA. Chem 7 with bicarb of 21,
CR of 5.0 (baseline). No leukocytosis. Anemia to hgb og 8.1
(recent baseline) and platelets of 106 (down from baseline of
120s). Flu negative. Lactate 1.5. Rapid viral panel is pending.
Imaging showed
CXR: w/o acute abnormality
CTH w/:
1. No evidence for acute intracranial abnormality.
2. Chronic complete opacification of the left frontal sinus and
multiple
contiguous left anterior ethmoid air cells.
CT abd and pelvis w/o contrast showed:
No abnormality to explain the patient's right lower quadrant
pain. Normal appendix. No free fluid.
Unilateral ___ on left showed: No evidence of deep venous
thrombosis in the left lower extremity veins.
In the ED, he received:
___ 12:23 IVF LR White,Roxane P Started 250
___ 12:24 IV CefePIME 2 g White,Roxane P
___ 12:26 PO Acetaminophen 650 mg White,Roxane P
___ 12:37 IH Albuterol 0.083% Neb Soln 1 NEB White,Roxane
P
___ 13:18 IV Vancomycin White,Roxane P Started
___ 15:14 IV Azithromycin White,Roxane P Started
___ 15:15 IV Vancomycin 1 mg White,Roxane P Stopped (1h
___
___ 16:25 IVF LR White,Roxane P Stopped (4h ___
___ 16:26 IV Azithromycin 500 mg White,Roxane P Stopped
(1h ___
Vitals prior to transfer: 99.1 89 151/68 17 100% RA
Currently, he had no complaints. Does not know why he is in the
hospital. Denies SOB. No CP. Not feeling chills. Denies sore
throat.
Past Medical History:
- Chronic systolic/diastolic heart failure
- Atrial fibrilation
- Coronary artery disease
- Diabetes complicated by retinopathy, nephropathy, peripheral
neuropathy, and vascular disease
- CKD (chronic kidney disease) stage 4, GFR ___ ml/min
- Hyperparathyroidism due to renal insufficiency
- Stroke
- Peripheral arterial disease
- Hypertension, essential
- Hypercholesterolemia
- COPD (chronic obstructive pulmonary disease)
- Dermatitis, atopic
- Cancer of prostate
- Esophageal reflux
- Thrombocytopenia
- Anemia in chronic renal disease
- Neuropathy, peripheral
- Colon adenoma
- Dementia
- Glaucoma
- Vitamin D deficiency
- Cataracts, bilateral
- s/p transmetatarsal amputation of right foot
Social History:
___
Family History:
Positive for CAD and hypertension in mother and CAD in brother.
Physical Exam:
ADMISSION PHYSICAL EXAM
==================
VS: 100.4 PO 155 / 87 96 28 96 RA
GEN: Alert, oriented to self and granddaughter. lying in bed, no
acute distress
HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI
NECK: Supple without LAD, no JVD
PULM: Prominent upper respiratory sounds. Diffuse end
inspiratory wheezes. Otherwise no rhonchi, crackles
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, +BS, no HSM
EXTREM: Warm, well-perfused, stasis changes with
hyperpigmentation but no discernible ___ edema.
NEURO: CN II-XII grossly intact, resting tremor. motor function
grossly normal, sensation intact
DISCHARGE PHYSICAL EXAM
==================
Physical exam: Temp 97.7 BP 118/57 HR 72 RR 18 100% RA
GEN: Lying in bed, no acute distress. Alert and oriented as
above
HEENT: Soft tissue swelling over eyelids and preseptal skin but
much improved from yesterday. Non-tender to plapation. Dry
crusting over skin. No conjunctival erythema. EOMI intact, no
change in visual acuity per patient. PERRL. Moist MM, oropharynx
clear.
PULM: Bronchial breath sounds, diffuse wheeze without stridor.
No rhonchi. Resonant to percussion.
HEART: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, +BS, no HSM
EXTREM: Warm, well-perfused, stasis changes with
hyperpigmentation but no discernible ___ edema.
NEURO: CN2-12 grossly intact, motor ___, marked response
latency, rigidity
Pertinent Results:
ADMISSION LABS
===========
___ 11:11AM BLOOD WBC-7.3 RBC-2.75* Hgb-8.1* Hct-23.9*
MCV-87 MCH-29.5 MCHC-33.9 RDW-15.6* RDWSD-49.0* Plt ___
___ 11:11AM BLOOD Neuts-79.1* Lymphs-8.7* Monos-9.5 Eos-1.9
Baso-0.4 Im ___ AbsNeut-5.74 AbsLymp-0.63* AbsMono-0.69
AbsEos-0.14 AbsBaso-0.03
___ 11:11AM BLOOD Glucose-116* UreaN-77* Creat-5.0* Na-139
K-4.7 Cl-101 HCO3-21* AnGap-22*
___ 11:25AM BLOOD Lactate-1.5
___ 04:20PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 04:20PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:20PM URINE Color-Straw Appear-Clear Sp ___
NOTABLE LABS
=========
___ 12:08PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 02:08PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 04:20PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 04:20PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:20PM URINE Color-Straw Appear-Clear Sp ___
___ 11:20PM URINE RBC-2 WBC-14* Bacteri-FEW Yeast-NONE
Epi-0
___ 11:20PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 11:20PM URINE Color-Straw Appear-Clear Sp ___
___ 04:32PM URINE Streptococcus pneumoniae Antigen
Detection-Test
___ 06:21AM BLOOD WBC-10.0 RBC-2.55* Hgb-7.5* Hct-22.7*
MCV-89 MCH-29.4 MCHC-33.0 RDW-15.5 RDWSD-50.7* Plt Ct-83*
___ 01:30AM BLOOD Plt Ct-74*
___ 06:21AM BLOOD Plt Ct-83*
___ 11:11AM BLOOD Glucose-116* UreaN-77* Creat-5.0* Na-139
K-4.7 Cl-101 HCO3-21* AnGap-22*
___ 01:30AM BLOOD Glucose-130* UreaN-83* Creat-5.8* Na-138
K-3.9 Cl-101 HCO3-20* AnGap-21*
___ 11:11AM BLOOD ALT-13 AST-22 AlkPhos-60 TotBili-0.5
___ 10:00PM BLOOD LD(___)-283*
___ 07:02AM BLOOD ALT-45* AST-51* LD(___)-297* AlkPhos-99
TotBili-0.5
___ 07:25AM BLOOD ALT-34 AST-28 LD(___)-305* AlkPhos-87
TotBili-0.5
___ 11:11AM BLOOD proBNP-6078*
___ 01:16AM BLOOD calTIBC-138* Ferritn-534* TRF-106*
___ 10:00PM BLOOD calTIBC-137* Hapto-242* Ferritn-726*
TRF-105*
___ 01:16AM BLOOD WBC-7.9 RBC-2.36* Hgb-7.1* Hct-20.7*
MCV-88 MCH-30.1 MCHC-34.3 RDW-15.7* RDWSD-50.6* Plt Ct-75*
___ 08:44AM BLOOD WBC-7.1 RBC-2.23* Hgb-6.5* Hct-19.9*
MCV-89 MCH-29.1 MCHC-32.7 RDW-15.8* RDWSD-51.8* Plt Ct-92*
___ 10:00PM BLOOD WBC-6.6 RBC-2.74* Hgb-8.0* Hct-24.4*
MCV-89 MCH-29.2 MCHC-32.8 RDW-15.2 RDWSD-48.8* Plt ___
___ 04:49PM BLOOD Lactate-2.1*
___ 06:48AM BLOOD Lactate-1.5
LABS ON DISCHARGE
==============
___ 06:50AM BLOOD WBC-9.2 RBC-2.86* Hgb-8.2* Hct-25.9*
MCV-91 MCH-28.7 MCHC-31.7* RDW-15.0 RDWSD-49.5* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-151* UreaN-100* Creat-5.4*
Na-148* K-4.3 Cl-107 HCO3-24 AnGap-21*
___ 06:50AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.6
MICROBIOLOGY
==========
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 12:04 pm
SEROLOGY/BLOOD TAKEN FROM CHEM # ___.
RAPID PLASMA REAGIN TEST (Pending):
__________________________________________________________
___ 11:20 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 12:08 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Refer to respiratory viral antigen screen and respiratory
virus
identification test results for further information.
Respiratory Viral Antigen Screen (Final ___:
Reported to and read back by ___ ___ (___) ON
___ @
11:28AM.
Positive for Respiratory viral antigens.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to Respiratory Virus Identification for further
information.
Respiratory Virus Identification (Final ___:
Reported to and read back by ___ ___ (___) ON
___ @
11:28AM.
POSITIVE FOR RESPIRATORY SYNCYTIAL VIRUS (RSV).
Viral antigen identified by immunofluorescence.
__________________________________________________________
___ 8:44 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:32 pm URINE CHEM ___ ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 5:20 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 12:24 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:11 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
======
CXR Dobhoff placement ___
Advancement of a Dobhoff feeding tube into the proximal stomach.
Continued advancement is recommended.
Decreased density and extent of the airspace consolidations in
both lungs.
TTE ___
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with basal and
mid-inferior hypokinesis. The remaining segments contract
normally (LVEF = 50%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CXR ___
Advancement of a Dobhoff feeding tube into the proximal stomach.
Continued
advancement is recommended.
Decreased density and extent of the airspace consolidations in
both lungs.
CXR ___
Comparison to ___. Stable bilateral
consolidations. Stable mild
pulmonary edema. Moderate cardiomegaly persists. No larger
pleural
effusions.
CXR ___
NG tube tip is in the stomach. Heart size and mediastinum are
stable. Right
basal consolidation appears to be progressing as well as left
basal
consolidation, concerning for progression of infectious process.
There is no
pneumothorax.
___ ___
IMPRESSION:
1. No evidence for acute intracranial abnormality.
2. Chronic complete opacification of the left frontal sinus and
multiple
contiguous left anterior ethmoid air cells.
CT abd/pelvis w/o:
No abnormality to explain the patient's right lower quadrant
pain. Normal
appendix. No free fluid.
CXR ___
FINDINGS:
AP upright and lateral views of the chest provided.
There appears to be mild pulmonary edema given subtle
ground-glass opacities
within both lungs. Trace visual fluid on the right noted. No
convincing
evidence for pneumonia. Cardiomediastinal silhouette appears
unchanged. Bony
structures are intact
IMPRESSION:
Findings concerning for mild pulmonary edema.
CXR ___ during trigger:
Bilateral pulmonary opacities are new since earlier today,
consider pulmonary edema, aspiration, or pulmonary hemorrhage.
Brief Hospital Course:
Mr. ___ is an ___ year old man with a history of HTN, CKD,
sCHF and dementia who presented to ___ with increased
confusion after unwitnessed fall in the setting of recent
productive cough, found to have RSV infection. During the
course of Mr. ___ hospital stay, the following issues were
addressed:
#fever
#RSV
#Hypoxia: Patient was initially admitted to the medical floor
and was transferred to ICU due to hypoxia. CXR showed bilateral
opacities as well as new RLL consolidation concerning for
pneumonia. He was initially started on ceftriaxone and
azithromycin due to concern for community acquired pneumonia.
Workup revealed positive RSV and antibiotics were discontinued.
Patient was also diuresed with IV Lasix with improvement in his
hypoxia. He was weaned to room air, restarted on his home
torsemide and transferred to the medicine floor. Patient's fever
curve improved and he remained afebrile prior to discharge. Of
note, as part of fever workup, he underwent CT A/P without focus
of infection.
# Falls: Patient walks with a walker at baseline. Increased
falls likely in the setting of URI. Patient was unable to recall
moment to give history of prodrome. He denied palpiations, CP,
or lightheadedness. In the ED CT head, abdomen, pelvis negative
for traumatic injury or source of infection. TTE showed no
change from previous, no arrhythmogenic events were witnessed on
telemetry. Mr. ___ is on ___ medications that could
predispose to falls (vasodilators, gabapentin). ___ was consulted
who recommended rehab.
# Chronic lacrimal duct obstruction and Primary Open Angle
Glaucoma. Patient with cyclic swelling in eyes bilaterally
second to lacrimal duct obstruction. Follows with an Atrius
Ophthamologist and reported to him that he had been taking
latanoprost nightly for POAG (has not filled Rx in our system
since ___. Also with history of preseptal cellulitis,
treated with systemic antibiotics (Bactrim 1 tab BID and
cefpodoxime 200 mg daily for 10 days in ___. On ___, Mr,
___ was noted to swelling around preseptal epithelium in
right eye with no conjunctival involvement concerning for
preseptal cellulitis vs known chronic ophthalmologic issues. He
received one day of clindamycin 300 mg PO/NG Q8H before
discontinuation this morning due to low suspicion for preseptal
cellulitis. Restarted Latanoprost 0.005% Ophth. Soln. 1 DROP
BOTH EYES QHS and artificial tears.
# sCHF
# CAD
# Hypertension. Patient had episodes of hypertension with SBP in
the 170s-180s. His imdur was increased from 30mg daily to 60mg
daily and he had improved blood pressure with SBP 110-150s. He
was continued on ASA, atorvastatin, amlodipine and clopidogrel.
TTE on ___ showed similar findings to previous ___ LVH with
regional left ventricular systolic dysfunction, EF 50%. 1+ MR,
mid PA hypertension.
#Anemia: Hgb 6.5 AM ___. Corrected to 8.3 after 1 uPRBCs. No
evidence of active bleeding during hospital stay. Had been
slowly downtrending since admission. Iron studies consistent
with iron deficiency. Gets EPO at home for anemia of chronic
renal disease, but recently had been held. To be restarted at
rehab. Iron studies consistent with iron deficiency. MCV
normocytic. TSH, B12, Folate, normal.
# DM2: Had previously been on lantus ___ at home, but stopped
for controlled fasting FSBG. However, inpatient, his FSBG
elevated to 200-400. Started on lantus 8U QHS with ISS. Will
need to be titrated.
Chronic issues:
===========
# Afib: Not on AC. Continued carvedilol, aspirin 81 mg.
# CKD: Per outpatient records, considering HD though decision as
not been made. Cr at baseline.
# GERD: Continued home omeprazole
TRANSITIONAL
============
- Please check CHEM 10 in 2 days (___) and weekly to
monitor for hypernatremia. Please ensure that patient drinks
750cc free water.
- F/U Chest X-ray 1 month after discharge to follow-up on
consolidations noted on prior Chest X-ray.
- Previously on Procrit, but stopped when Hgb 11, so placed on
hold. Hgb on discharge at 8.2. Spoke with ___ nephrology who
recommended restarting Procrit at 5000 q7 days. Should check CBC
every week prior to Procrit dose. Once Hgb reaches 10, dose
should be decreased. If Hgb 11, should be placed on hold. If
blood pressures consistently 180/100s, should hold Procrit. For
any questions on titration of Procrit dose, please call
___.
- Per recent Atrius Opthamology note, Mr. ___ takes
Latanoprost eye drops for primary open angle glaucoma and he
reported that he is taking the medication every night, but in
our system he has not filled Rx since ___. Restarted while
in hospital. Needs close ophthalmology follow up.
- Please obtain neuropsych evaluation as an outpatient for
dementia evaluation
- should check orthostatics and titrate down isosorbide
mononitrate extended release to 30mg (from 60mg).
- Torsemide dose: 20mg BID on discharge
- Please check weights weekly for help with daily titration
- Patient and family still deciding about whether to initiate
HD. Will continue to have discussions with family regarding HD
initiation.
- restarted lantus for elevated FSBG, please continue to
titrate.
Communication/HCP:
Name of health care proxy: ___
___: daughter in law
Phone number: ___
# Code: DNR but OK to intubate
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. HydrALAZINE 100 mg PO Q8H
5. Torsemide 30 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Carvedilol 12.5 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Gabapentin 100 mg PO QAM
10. Gabapentin 400 mg PO QHS
11. Aspirin 81 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry, irritated eyes
2. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
3. Docusate Sodium 100 mg PO BID
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Glucose Gel 15 g PO PRN hypoglycemia protocol
6. Heparin 5000 UNIT SC BID
7. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 17.2 mg PO QHS:PRN consitpation
11. Tamsulosin 0.4 mg PO QHS
12. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
13. Torsemide 20 mg PO DAILY
14. amLODIPine 10 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Atorvastatin 40 mg PO QPM
17. Carvedilol 12.5 mg PO BID
Hold for SBP <100, HR <60
18. Clopidogrel 75 mg PO DAILY
19. Gabapentin 100 mg PO QAM
20. HydrALAZINE 100 mg PO Q8H
Hold for SBP <100
21. Omeprazole 20 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
====
Hypoxic Respiratory Failure
respiratory syncytial virus
Acute on chronic systolic heart failure
Secondary
=======
Hypertension
Atrial Fibrillation
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you at ___
___. You came to us after falling in your home and
with complaints of shortness of breath and fever. You were found
to have a respiratory viral infection (Respiratory syncytial
virus or RSV) and were treated supportively. You were also found
to have fluid in your lungs due to your heart failure. We used
IV diuretics (lasix) to help remove the fluid and then
transitioned you back to your home torsemide.
There was some concern that you were having an infection in your
right eye, but it improved. You should follow up with your
ophthalmologist.
Please take all of your medications as detailed in this
discharge summary. Please weigh yourself every morning and call
your MD if weight goes up more than 3 lbs. If you experience any
of the danger signs listed below please call your primary care
doctor or come to the emergency department immediately.
Best Wishes,
Your ___ Care Team
Followup Instructions:
___
|
10352471-DS-9 | 10,352,471 | 24,731,434 | DS | 9 | 2142-02-02 00:00:00 | 2142-02-02 19:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
L femur fracture
Major Surgical or Invasive Procedure:
___ - Left femur IMN + ORIF Left femoral neck fx
History of Present Illness:
___ who is otherwise healthy s/p MVC with immediate left leg
pain and deformity. +HS/+LOC. Brought in by ambulance only
complaining of left thigh pain. Patient denies fevers, chills,
sweats, numbness, paresthesias and pain in other extremities.
Past Medical History:
Denies
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD
LLE: incision c/d/i w/o erythema or induration, SILT
s/s/sp/dp/t, Fires ___, FHL, G/S, TA, foot wwp
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L midshaft femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___. Intraoperatively she was noted to
have a L femoral neck fracture that was not seen on prior
imaging. She had a Left femur IMN + ORIF Left FNF, 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
with services 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
TDWB on the LLE, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC QPM Disp #*28 Syringe
Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Senna 8.6 mg PO BID
6. Vitamin D 400 UNIT PO DAILY
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left midshaft femur fracture, left femoral neck fracture
Discharge Condition:
Stable
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Touch down 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 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.
Physical Therapy:
TDWB LLE
Treatments Frequency:
Wound monitoring and care, DSD q1-2 days to wounds
___- TDWB LLE
Followup Instructions:
___
|
10352490-DS-14 | 10,352,490 | 29,094,070 | DS | 14 | 2124-08-24 00:00:00 | 2124-09-03 19:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Niacin / Remeron
Attending: ___
Chief Complaint:
fall, confusion, agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ yo right handed woman with a h/o EtOH abuse and
bipolar disorder who presents after falling down.
Per the patient, the fall happened in the setting of feeling
emotionally overwhelmed in the convenient store. Patient states
that she felt hot and that her legs were weak when she fell. She
denies dizziness, head trauma or LOC. Patient's husband states
that she has been more agitated for the past couple of weeks
with the largest decline in functioning the past few days
including increased depression, confusion and difficulty
ambulating. Denies CP, SOB, or HA.
In the ED, initial vital signs were: 0 98.1 88 91/61 16 93% RA
- Exam notable for: appears somewhat paranoid, perseverative
and inattentive, noted to have aphasia and asterixis
- Labs were notable for WBC 10.6 H/H 12.5/38.9 (last hemoglobin
___ 14.5) UA with large leukesterace, + nitrites, small blood,
> 182 WBC, 1 epi, glocose on chem 7 97, tox screen negative
- Studies performed include CT head which showed No acute
intracranial pathology, Age indeterminate right internal capsule
lacunar infarct. Mild, chronic microangiopathic ischemic
changes. Generalized volume loss and CXR with No acute
cardiopulmonary process
- Patient was given 100mg of thiamine and 1g of ceftriaxone
- Vitals on transfer: 97.9 65 100/62 18 100% RA
Past Medical History:
- bipolar
- EtOH abuse
- depression
- anxiety
- psychotic depression/schizoaffective disorder
- hypercholesterolemia
- intermittent transaminitis
- osteopenia
- s/p appendectomy
- s/p tonsillectomy
- ___
Social History:
___
Family History:
- alcoholism in father
- mother with dementia
Physical Exam:
ADMISSION PHYSICAL:
Vitals- Tm 98.7 BP 148-163/46-56 HR ___ RR 20 ___
General: WDWN female laying in bed NAD, husband at bedside
___: NCAT, EOMI, PERLA, MMM
Neck: Supple, no LAD
CV: RRR, normal S1 and S2 no murmurs, rubs, or gallops
Lungs: CTAB no wheezes
Abdomen: Non, distended, non-tender, no organomegaly, + BS
GU: Deferred
Ext: Warm well perfused, 2+ pedal pulses bilaterally, no edema,
cyanosis or clubbing
Neuro: CN2-12 Grossly intact, Alert, does not appear confused,
strength grossly ___ in bilateral upper and lower extremities,
sensation grossly in tact to light touch. No asterixis or
tremor. Mood depressed, affect appropriate, No SI or HI. Hearing
chanting/singing constantly for ~3 weeks.
Skin: No rashes noted
DISCHARGE PHYSICAL:
Vitals- Tm 99 BP 140-110/46-74 HR ___ RR 18 ___
General: ___ female laying in bed NAD
___: NCAT, EOMI, MMM
Neck: Supple, no LAD
CV: RRR, normal S1 and S2 no murmurs, rubs, or gallops
Lungs: CTAB no wheezes
Abdomen: Non, distended, non-tender, no organomegaly, + BS
GU: Deferred
Ext: Warm well perfused, 2+ pedal pulses bilaterally, no edema,
cyanosis or clubbing
Neuro: Alert and oriented X2, strength grossly ___ in bilateral
upper and lower extremities, sensation grossly in tact to light
touch. No asterixis or tremor. Mood depressed, affect
appropriate, No SI or HI. No current auditory hallucinations
Skin: No rashes noted
Pertinent Results:
ADMISSION LABS
___ 07:50PM BLOOD WBC-10.6* RBC-3.80* Hgb-12.5 Hct-38.9
MCV-102* MCH-32.9* MCHC-32.1 RDW-13.8 RDWSD-52.4* Plt ___
___ 07:50PM BLOOD Neuts-75.2* Lymphs-13.4* Monos-7.7
Eos-2.3 Baso-0.9 Im ___ AbsNeut-7.95* AbsLymp-1.42
AbsMono-0.81* AbsEos-0.24 AbsBaso-0.09*
___ 07:50PM BLOOD Plt ___
___ 07:50PM BLOOD Glucose-97 UreaN-30* Creat-1.0 Na-139
K-4.1 Cl-108 HCO3-19* AnGap-16
___ 07:50PM BLOOD ALT-63* AST-55* AlkPhos-55 TotBili-0.5
___ 07:50PM BLOOD Albumin-4.4
___ 07:50PM BLOOD TSH-0.81
___ 06:00AM BLOOD VitB12-528
___ 07:50PM BLOOD Lithium-1.6*
___ 07:34PM BLOOD Lithium-1.0
___ 06:30AM BLOOD Lithium-0.7
___ 07:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:01PM BLOOD Lactate-1.1
DISCHARGE LABS
___ 06:30AM BLOOD Lithium-0.7
___ 06:30AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9
___ 06:30AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-143
K-3.3 Cl-109* HCO3-23 AnGap-14
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD WBC-6.3 RBC-3.83* Hgb-12.4 Hct-38.8
MCV-101* MCH-32.4* MCHC-32.0 RDW-13.3 RDWSD-49.6* Plt ___
IMAGING:
Cardiovascular Report ECG Study Date of ___ 5:29:21 ___
Sinus rhythm. Non-specific ST-T wave changes. There is a late
transition that is probably normal. No previous tracing
available for comparison.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
69 ___ ___ 35 26 35
___ HEAD CT
There is no intra or extra-axial hemorrhage, mass effect, or
shift of normally
midline structures. Small focus of low attenuation in the right
anterior limb
of internal capsule likely represents an age-indeterminate
lacunar infarct or
prominent perivascular space. This could be further evaluated
with MRI.
There is a background of mild periventricular low attenuation,
nonspecific,
but likely related to chronic microangiopathic ischemia. There
is no CT
evidence for acute, major vascular territorial infarction. Mild
prominence of
the ventricles, sulci, and cisterns appears proportional.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial pathology.
2. Age indeterminate right internal capsule lacunar infarct.
Mild, chronic
microangiopathic ischemic changes. Generalized volume loss.
___ CHEST X-RAY
The lungs are well expanded and clear. There is no pleural
effusion or
pneumothorax. The heart demonstrates left ventricular
configuration. The
aorta is noted to be tortuous.
IMPRESSION:
No acute cardiopulmonary process.
___ MRI Brain:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or acute infarction. There is a chronic lacunar infarct in the
anterior limb
of the right internal capsule. There are scattered foci of T2
FLAIR
hyperintense signal in the supratentorial white matter, which
are nonspecific
and may be related to chronic small vessel ischemic disease.
The ventricles
and sulci are normal in caliber and configuration.
MRA brain: The intracranial vertebral and internal carotid
arteries and their
major branches appear normal without evidence of stenosis,
occlusion, or
aneurysm formation.
MRA neck: The common, internal and external carotid arteries
appear normal.
There is no evidence of internal carotid artery stenosis by
NASCET criteria.
The origins of the great vessels, subclavian and vertebral
arteries appear
normal bilaterally.
IMPRESSION:
1. No acute infarction.
2. Normal MRA of the head and neck.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Mrs ___ is a ___ yo female with history of Bipolar disease on
lithium recurrent cystitis presenting after fall and evidence of
AMS found to have a UTI which we felt was a likely cause or
contributing to AMS. She was started on CeftriaXONE 1 gm IV Q24H
and then changed to oral Bactrim at discharge. Her AMS may have
also been in part due to lithium toxicty which was found to be
1.6 on admission. Lithium was held and then restarted when
normalized. Prior to discharge her psychiatric medication regime
was clarified and follow up was recommended with both her PCP
who is very involved and aware as well as her psychiatrist. She
was offered inpatient admission to a geriatric psychiatric unit
but declined. She was given thiamine folate, B12 and
Multivitamin. She was placed on CIWA and did not score highly at
any point during her stay. A lacunar infarct of undeterminate
age was seen on CT the significance of which is unclear. For her
dyslipidemia simvistatin was continued.
TRANSITIONAL ISSUES:
Consider adding aspirin
Full Code
Emergency contact ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO TID anxiety
2. OLANZapine 5 mg PO QHS
3. Lithium Carbonate 150 mg PO TID
4. Mirtazapine 15 mg PO QHS
5. QUEtiapine Fumarate 50 mg PO QHS
6. Simvastatin 40 mg PO QPM
Discharge Medications:
1. ClonazePAM 0.5 mg PO TID:PRN anxiety
2. Lithium Carbonate 150 mg PO TID
3. OLANZapine 5 mg PO QHS
4. QUEtiapine Fumarate 50 mg PO QHS
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 0.8 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Simvastatin 40 mg PO QPM
9. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth every 12 hours Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
UTI
Altered Mental Status
Lithium toxicity
Secondary:
Alcohol abuse
Anemia
Dyslipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Dear ___ were admitted to ___ on ___ after ___ fell. We took
imaging of your head and neck and did not find any fractures or
bleeding. ___ reported that ___ had had several weeks of
decreased need for sleep, poor memory, hearing chanting/singing,
and decreased balance. We found that ___ had a urinary tract
infection and that ___ were unclear about your home psychiatric
medicine schedule. We treated ___ with antibiotics and clarified
your medications and your symptoms improved somewhat. Please
follow up immediately with your outpatient psychiatrist and
primary care physician
___ care and be well.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10352490-DS-15 | 10,352,490 | 22,879,837 | DS | 15 | 2125-04-11 00:00:00 | 2125-04-12 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ / ___
Attending: ___.
Chief Complaint:
Diarrhea, Confusion, Tremor
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of bipolar disorder,
alcohol use disorder (last drink ___, unspecified cognitive
disorder, and hyperlipidemia, who presented with two weeks of
increased confusion, tremors and diarrhea, which have worsened
over the last week. According to her husband, it began with mild
shaking in her legs and then began to increase daily to the
point where her gait has been limited and she has been unable to
hold a glass. She has reportedly had intermittent tremors for
years as well as confusion with word-finding difficulty. Denies
fevers. No melena or hematochezia, nausea, vomiting, abdominal
pain. She notes increased thirst recently and that she has been
drinking a lot of diet Coke, although this has diminished
because of her tremor. Notes no polyuria. No sick contacts.
Reports mild headache with no vision changes.
She reports that her psychiatric medications have been changed
frequently over the past several months. Her husband manages her
medications, although he says that sometimes she does take them
without his knowledge. She reports that she has been "lax" with
her medicine and sometimes taking them "when [she] feels like
it." No coingestants. No trauma. No depression or manic
symptoms currently. No SI, No HI.
In the ED, initial vitals were: T 95.2F BP 138/62 mmHg P 56 RR
18 O2 98% RA
Labs notable for CBC w/ WBC 10.1, H/H 12.7/40.6, PLT 336. Diff
w/ 68% N, 17.1%L, 8.5% M, 5.3% E. Lithium level 2.2. Chemistries
with Na 140, K 5.1, Cl 110, HCO3 22, BUN 16, Cr 0.9, Gluc 118.
LFTs w/ ALT 26, AST 46, Alk phos 59, Lipase 34, Tbili 0.4, Alb
3.9. Lactate 1.7. UA with trace protein, hematuria, and hyaline
casts. Negative WBCs, bacteria, leuks, or nitrites. Urine and
serum toxicology screens negative.
Exam notable for: Tremulous, greatest in legs, AAOx2, CN II-XII
intact, moves all extremities, DTRs 2+ ___, mild lower extremity
rigidity, no clonus, no asterixis, CV, pulm, abd benign
CT head was performed, showing no acute intracranial process,
age related parenchymal atrophy and chronic small vessel
ischemic disease. CXR negative.
Her presentation was thought less likely to be neuroleptic,
malignant syndrome or serotonin syndrome given absence of fever
and rigidity and more likely to represent lithium toxicity.
She was given 2L IV NS and admitted to the floor.
Review of systems:
- as above, otherwise, denied fevers, chills, chest pain,
shortness of breath.
Past Medical History:
- bipolar disorder
- alcohol use disorder
- depression
- anxiety
- psychotic depression/schizoaffective disorder
- hyperlipidemia
- intermittent transaminitis
- osteopenia
- s/p appendectomy
- s/p tonsillectomy
Social History:
___
Family History:
- alcohol use disorder in mother, father, and brother
- mother with dementia
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
Weight: 123.5 lbs
VS: T 97.9F BP 153-90 mmHg P 73 RR 18 O2 96% RA
General: Pleasant woman, alert, but with slowed and stuttering
speech, with thick, taped glasses, in NAD.
HEENT: PERRL; anicteric sclerae. EOMs intact. No nystagmus.
Neck: Supple, no JVD.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended, NABS.
Ext: Warm and well-perfused. No edema.
Neuro: Alert, oriented to person, place, and year. Halting
speech, conversant, but unable to provide days of week backward.
CNs II-XII grossly intact. Distal sensation intact to light
touch. Positive clonus. Coarse postural tremor noted.
Finger-nose-finger normal. Gait deferred.
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: T 97.6F BP 125/81 mmHg P 72 RR 18 O2 94% RA
General: Pleasant woman, alert and interactive, with stuttering
speech, with thick, taped glasses, in NAD.
HEENT: PERRL; anicteric sclerae. EOMs intact. No nystagmus.
Neck: Supple, no JVD.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended, NABS.
Ext: Warm and well-perfused. No edema.
Neuro: A&Ox3. Stuttering speech, conversant. CNs II-XII grossly
intact. Distal sensation intact to light touch. No clonus. No
tremor. Finger-nose-finger normal. Bilateral symmetric ankle
jerk reflexes. Narrow-based, steady gait.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 10:09AM BLOOD WBC-10.1*# RBC-3.96 Hgb-12.7 Hct-40.6
MCV-103* MCH-32.1* MCHC-31.3* RDW-12.7 RDWSD-47.8* Plt ___
___ 10:09AM BLOOD Neuts-68.0 Lymphs-17.1* Monos-8.5 Eos-5.3
Baso-0.7 Im ___ AbsNeut-6.86* AbsLymp-1.73 AbsMono-0.86*
AbsEos-0.54 AbsBaso-0.07
___ 10:09AM BLOOD Glucose-118* UreaN-16 Creat-0.9 Na-140
K-5.1 Cl-110* HCO3-22 AnGap-13
___ 10:09AM BLOOD ALT-26 AST-46* AlkPhos-59 TotBili-0.4
___ 10:09AM BLOOD Lipase-34
___ 10:09AM BLOOD Albumin-3.9 Calcium-10.0 Phos-3.8 Mg-2.1
___ 10:09AM BLOOD TSH-4.3*
___ 10:09AM BLOOD Lithium-2.2*#
___ 10:09AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:22AM BLOOD Lactate-1.7 K-3.5
___ 11:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 11:45AM URINE RBC-27* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-1
___ 11:45AM URINE CastHy-12*
___ 11:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
============
INTERIM LABS
============
___ 09:40PM BLOOD Lithium-1.3
___ 07:25AM BLOOD Lithium-0.8
___ 06:42AM BLOOD Lithium-0.6
___ 07:16AM BLOOD Lithium-0.4*
___ 06:47AM BLOOD Lithium-0.3*
___ 06:44AM BLOOD Lithium-0.2
==============
DISCHARGE LABS
==============
___ 06:44AM BLOOD WBC-9.7 RBC-4.14 Hgb-13.3 Hct-41.9
MCV-101* MCH-32.1* MCHC-31.7* RDW-12.8 RDWSD-47.8* Plt ___
___ 06:44AM BLOOD Glucose-97 UreaN-23* Creat-0.6 Na-142
K-4.2 Cl-108 HCO3-24 AnGap-14
___ 06:44AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.9
___ 06:44AM BLOOD Lithium-0.2*
============
MICROBIOLOGY
============
__________________________________________________________
___ 10:16 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 7:16 am SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
===============
IMAGING/STUDIES
===============
CT HEAD W/O CONTRAST (___):
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are prominent, suggesting cortical
volume loss, more significant in the frontal convexity, grossly
unchanged since the prior examination dated ___.
Periventricular and subcortical white matter hypodensities are
nonspecific, but likely reflect sequelae of chronic small vessel
ischemic disease.
There is no evidence of fracture. There is aerosolized
secretions within the right sphenoid sinus. The remaining
visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of
the orbits are unremarkable. Atherosclerotic calcifications of
the carotid siphons are noted bilaterally.
IMPRESSION:
1. No acute intracranial process.
2. Cortical volume loss, and chronic small vessel ischemic
disease appears
unchanged since the prior study.
3. Aerosolized secretions within the right sphenoid sinus.
CHEST (PA & LAT) (___):
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal
cardiomediastinal silhouette and well-aerated lungs without
focal consolidation, pleural effusion, or pneumothorax. The
visualized upper abdomen is unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
MR HEAD W & W/O CONTRAST (___)
FINDINGS:
There periventricular and subcortical white matter, central
pons, and basal ganglia FLAIR hyperintensity, probably within
the frontal cortices, likely reflecting sequela of chronic
microangiopathy. Otherwise parenchymal signal is unremarkable
without acute infarct, hemorrhage, mass, or mass effect. There
is no abnormal postcontrast enhancement. The vascular flow
voids are preserved. The extra-axial spaces are unremarkable.
There is prominence of ventricles and cortical sulci consistent
with mild to moderate degree of volume loss without lobar
prominence.
The orbits, calvarium, and soft tissues are unremarkable. There
is no fluid signal within paranasal sinuses. There is a partial
right mastoid air cell effusion.
IMPRESSION:
1. No acute intracranial abnormality without infarct,
hemorrhage, mass, or mass effect.
2. Unchanged periventricular and subcortical white matter, basal
ganglia, and central pontine FLAIR hyperintensity, likely
reflecting sequela of chronic microangiopathy.
3. Unchanged mild-to-moderate diffuse volume loss, without lobar
prominence.
CHEST (PA & LAT) (___):
FINDINGS:
Cardiomediastinal silhouette is within normal limits. Lungs are
clear. There is no pleural effusion or pneumothorax.
IMPRESSION:
No evidence of pneumonia
Brief Hospital Course:
___ is a ___ y/o woman with a PMH of bipolar
disorder, unspecified cognitive disorder, depression, anxiety,
alcohol use disorder in sustained remission, and hyperlipidemia
who presented with diarrhea, tremor and confusion.
.
# Chronic lithium toxicity. She was found to have a lithium
level of 2.2 mEq/L, which was thought to be most likely related
to recent changes in medication and confusion about her
appropriate dosing. There was no decline in renal function, and
no evidence to suggest intentional overdose. She developed no
hypernatremia. She was treated with IV fluids, and her lithium
levels normalized. TSH was normal. Lithium, clonazepam, and
fluoxetine were initially held. Psychiatry was consulted, who
recommended maintaining her off of lithium and fluoxetine owing
to concerns about her safely managing these medications. She was
restarted on clonazepam as below.
.
# Acute encephalopathy, hypoactive delirium. In the setting of
stopping her clonazepam, she developed hallucination and
formication. She was initially somnolent and confused, but this
improved over the course of her hospitalization. Her clonazepam
was judiciously restarted at her home dose. Infectious work-up
was otherwise negative. Head CT and MRI were performed, which
demonstrated no acute intracranial abnormality, without infarct,
hemorrhage, mass or mass effect. There was unchanged
periventricular and subcortical white matter, basal ganglia, and
central pontine FLAIR hyperintensity, likely reflecting sequela
of chronic microangiopathy, as well as unchanged
mild-to-moderate diffuse volume loss, without lobar prominence.
Neurology was also consulted, and it was felt that her clinical
syndrome was explained by her lithium toxicity and
benzodiazepine withdrawal, with a plan for outpatient cognitive
neurology work-up.
.
# Generalized anxiety disorder. As above, initially stopped
clonazepam because of concern for somnolence and QT
prolongation. This was restarted prior to discharge.
.
# QTc prolongation. QTc on admission was prolonged to 594 ms,
and all QT prolonging medications initially held, including her
benzodiazepine. QTc of 441 ms upon discharge. Will require
regular monitoring as outpatient.
.
==============
CHRONIC ISSUES
==============
# Hyperlipidemia. She was continued on her home simvastatin for
hyperlipidemia.
.
===================
TRANSITIONAL ISSUES
===================
# Outpatient management plan. Because of concerns about
medication safety, lithium and fluoxetine were stopped. She will
need very close primary care and psychiatric follow-up to
determine a safe medication regimen for her as well as to taper
her clonazepam. Her primary care follow-up has been arranged for
very soon after her discharge, however she will require a PCP
referral to establish care with a new psychiatrist (she has not
seen her previous psychiatrist in several years). She will also
require outpatient cognitive neurology work-up (this has also
been arranged).
# Medication changes. As above, lithium and fluoxetine were
stopped.
# QTc prolongation. QTc of 441 ms. ___ continue regular EKG
monitoring with QT prolonging medications.
# CODE: FULL
# CONTACT: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO TID anxiety
2. Lithium Carbonate 300 mg PO BID
3. Simvastatin 40 mg PO QPM
4. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
5. Fluoxetine 20 mg PO DAILY
Discharge Medications:
1. ClonazePAM 0.5 mg PO TID anxiety
RX *clonazepam 0.5 mg 1 tablet(s) by mouth TID (Three times per
day) Disp #*18 Tablet Refills:*0
2. Simvastatin 40 mg PO QPM
3. TraMADOL (Ultram) 50 mg PO DAILY:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
=================
PRIMARY DIAGNOSES
=================
- chronic lithium toxicity
- acute, hypoactive delirium
- bipolar disorder, NOS
- cognitive disorder, NOS
- generalized anxiety disorder
===================
SECONDARY DIAGNOSES
===================
- hyperlipidemia
- alcohol use disorder, in sustained remission
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 caring for you at ___
___. You were admitted because you were having
tremors, confusion, and diarrhea. We think that this was
primarily caused by taking too much of your lithium. For the
time being, we have therefore stopped your lithium and
fluoxetine. You will be continuing on your clonazepam. We have
set you up with a primary care doctor in our system, who will
see you and refer you to a psychiatrist to help with your
medications going forward. You will also be seeing a neurologist
to help with your memory.
Please continue to take all medications as prescribed. Your
discharge follow-up appointments are outlined below.
It is important that you continue to have someone with you at
all times at home while your mental status improves.
We wish you the very best!
Warmly,
Your ___ Team
Followup Instructions:
___
|
10352490-DS-16 | 10,352,490 | 21,234,405 | DS | 16 | 2128-08-24 00:00:00 | 2128-08-24 12:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ / ___
Attending: ___.
Chief Complaint:
Confusion and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMH of HTN, tobacco use, anxiety, depression who
presents after feeling ill for a few days and falling at home.
History gathered from the patient, notes, and husband. Per
the husband the patient has been not feeling well for 3 days
(malaise, fevers 100-102 at home, measured), sleeping more,
decreased appetite. Malaise is getting worse. She does not
report cough, dysuria, abdominal pain, or weakness. On the
morning of admission, husband heard a thud and went to the
bedroom to find Ms. ___ on the floor. She fell, did not hit
her head, did not lose consciousness. He couldn't get her up so
they called ___. At that time she said she could not get up due
to leg weakness.
In ED:
Vitals: T98.3-100.6, HR 102-->73, BP 106/69, 97% on 3L,
Code stroke called for RUE and RLE weakness- noticed by the ED
team.
CTA head and neck: atherosclerosis, no acute abnormality.
MRI: no acute abnormality, diffuse periventricular and
subcortical white matter hyperintensities (could be chronic
microangiopathy)
Chest xray: RLL opacities concerning for pneumonia.
Labs: WBC 19, Hgb 12, plts 257, Na 141, Cl 108, bicarb 16, BUN
29, Cr 0.9.
LP: no PMNs or bacteria
Blood cultures drawn
MEDS: CTX, Vancomycin, acyclovir, ampicillin. NS 2L.
On re-evaluation by neurology and ED--- determined that weakness
and pain only started after fall. exam more consistent with
generalized weakness (maybe slight right hemiparesis, ?chronic),
and most likely symptoms due to PNA.
On hospital floor, patient is having chills. She has no pain or
weakness. she is ambulating independently. she does not
remember the ED course (does not recall having a lumbar puncture
or MRI). she has SOB on exertion. no chest pain, leg pain,
numbness, vision problems.
ROS: 10 point review of systems negative unless otherwise listed
in HPI.
Past Medical History:
S/P TUBAL LIGATION
s/p appendectomy
s/p tonsillectomy
HYPERCHOLESTEROLEMIA
OSTEOPENIA
TOBACCO USE
ANXIETY
DEPRESSION
HYPERTENSION
Social History:
___
Family History:
- alcohol use disorder in mother, father, and brother
- mother with dementia
Physical Exam:
On Admission
Vitals: T98.3-100.6, HR 102-->73, BP 106/69, 97% on 3L,
GENERAL: Alert. fine resting hand tremor.
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
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
moves all limbs, sensation to light touch grossly intact
throughout. ___ strength and sensation in upper and lower
extremities. FINE tremor in hands bilaterally. tremulous
speech,
however it is intact. no recall problems.
Oriented to person and place. Year is ___.
PSYCH: pleasant, appropriate affect
On discharge
VS WNL, SpO2 > 94% on RA
GENERAL: Alert, NAD, sitting comfortably in chair.
EYES: Anicteric, PERRL
ENT: Ears and nose without visible erythema, masses, or trauma.
MMM
CV: RRR, +S1, +S2, no murmurs
RESP: RLL rhonchi without clearing s/p cough
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic TTP (improvement from ___. No flank TTP
MSK: Neck supple, moves all extremities, ___ LLE strength distal
to hip, 4+ RLE strength distal to RLE. ___ strength throughout
B/L UE.
SKIN: No rashes or ulcerations noted
NEURO: Alert+oriented x 3, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 09:16PM URINE HOURS-RANDOM
___ 09:16PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:16PM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 09:16PM URINE BLOOD-MOD* NITRITE-POS* PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG*
___ 09:16PM URINE RBC-79* WBC->182* BACTERIA-FEW*
YEAST-NONE EPI-0
___ 05:11PM ASA-NEG ETHANOL-NEG ACETMNPHN-14
tricyclic-NEG
___ 08:45AM ___ PTT-29.4 ___
___ 08:37AM %HbA1c-5.3 eAG-105
___ 08:10AM CEREBROSPINAL FLUID (CSF) PROTEIN-47*
GLUCOSE-81
___ 08:10AM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-3 POLYS-3
___ ___ 06:47AM ___ COMMENTS-GREEN TOP
___ 06:47AM LACTATE-1.3
___ 06:40AM GLUCOSE-148* UREA N-29* CREAT-0.9 SODIUM-141
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-16* ANION GAP-17
___ 06:40AM estGFR-Using this
___ 06:40AM ALT(SGPT)-29 AST(SGOT)-29 ALK PHOS-102 TOT
BILI-0.2
___ 06:40AM cTropnT-<0.01
___ 06:40AM ALBUMIN-3.4* CALCIUM-8.7 PHOSPHATE-1.8*#
MAGNESIUM-2.0 CHOLEST-90
___ 06:40AM TRIGLYCER-191* HDL CHOL-17* CHOL/HDL-5.3
LDL(CALC)-35
___ 06:40AM TSH-1.7
___ 06:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 06:40AM WBC-19.3* RBC-3.87* HGB-12.2 HCT-38.2 MCV-99*
MCH-31.5 MCHC-31.9* RDW-13.9 RDWSD-51.1*
___ 06:40AM NEUTS-84.0* LYMPHS-5.0* MONOS-9.3 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-16.26* AbsLymp-0.96*
AbsMono-1.80* AbsEos-0.07 AbsBaso-0.06
___ 06:40AM PLT COUNT-257
WBC: 10.2 <-- 13.5 <-- 19.3
Hb: 12.1 <-- 10.8 <-- 12.2 (B/L ___
Chem notable for K 3.3 (repleted) and Cl 110 (s/p 3L NS on ___
HCO3: 21 <-- 19 <-- 16
Cr: 0.5 <-- 0.9 (s/p 2L NS)
Serum/Utox: Neg
TSH: WNL
A1c: 5.3%
LP: 3PMNs and no bacteria
UA: >182 WBC, few bacteria, ___, +Nitrite
Urine Legionella Ag: Neg
Urine Strep: Neg
UCx (drawn after initiation of Abx, ___: NG
BCx (___): NGTD
CTA head and neck: atherosclerosis, no acute abnormality.
MRI C Spine: no acute abnormality, diffuse periventricular and
subcortical white matter hyperintensities (could be chronic
microangiopathy)
Chest xray: RLL opacities concerning for pneumonia.
Brief Hospital Course:
Ms. ___ is a ___ year old lady with a PMHx of
anxiety/depression, osteopenia, tobacco use disorder (1ppd) and
HTN who p/w fever, malaise and weakness, found to have UA c/w
UTI
She notes a subacute decline over the past few weeks with
worsening weakness and multiple falls from standing height due
to
"weakness". No LOC or head trauma. Denies worsening of vision or
peripheral neuropathy. Denies any symptoms of orthostasis.
Currently on clonazepam PRN for anxiety which is chronically
unchanged. No EtOH since ___ or recreational drug use.
3 days PTA she reported fatigue and fevers ___ measured at
home. Denies SOB, cough, URI sx, N/V/D, new rashes, dysuria.
Comments on increased urinary frequency without urgency. No neck
stiffness or photophobia. On day of admission, she gradually
fell
from her bed (-LOC, no head trauma) prompting her ER eval.
Upon admission, Tm 100.2 with SpO2 > 90% on RA (despite
application of 3L NC). ED team c/f for RLE/RUE weakness, called
stroke code, CTA H+N with no acute abnormality, MRI C spine w/
and w/o without any acute abnormalities. CXR with RLL opacity
initially c/f PNA. UA with e/o UTI. LP performed without e/o
infection. Patient initially stared on
Vanc/CTX/Acyclovir/Ampicillin then narrowed to CTX/Azithro.
Confusion improved to baseline ___ s/p 2L IVF and abx
ACUTE/ACTIVE PROBLEMS:
#Complicated cystitis
#RLL opacity c/f PNA
Presented with fever, malaise, and confusion with UA c/w
complicated UTI (given T > 99.9F and systemic symptoms, namely
AMS) and CXR c/f RLL CAP. Given lack of cough or SOB prior to
admission on this hospitalization, no clinical e/o PNA.
+Suprapubic TTP om ___ with UA c/w clinical UTI. Unfortunately
UCx not sent prior to initiation of ABx and understandably no
growth. Prior positive UCx with pan-sensitive E Coli.
- C/w Augmentin 875mg BID for 10 day course to treat
complicated
___ given Hx of pan-sensitive E. Coli
#Deconditioning with recurrent mechanical falls. No e/o worsened
vision, peripheral neuropathy, possible orthostasis given e/o
intravascular depletion on admission d/t poor PO intake, on
chronic klonopin but has remained unchanged, no EtOH use since
___, unassociated with new footwear. B/L ___ weakness (L>R) with
___ eval rec STR
#Renal: AGMA+NAGMA on admission, likely driven by starvation
ketosis. Improved with IVF but induced hyperchloremic NAGMA,
resolved with PO fluid intake.
- Encourage PO fluid
#HTN:
- C/w home amlodipine given SBP 100-130
#Nicotine use disorder: Actively smoking 1ppd, desires to quit
during this hospitalization without pharmacologic assistance.
Offered nicotine patch (14mg) + gum, but patient wants to quit
on
her own
- Continue to monitor need for pharmacologic assistance
#Toxic metabolic encephalopathy: Resolved. Likely ___ UTI with
component of dehydration. CTA H+N neg.CA/BS/TSH/Na WNL. No EtOH.
No Hx of Sz. Unlikely related to chronic klonopin. Hx of cog
impairment from prior Psych notes.
- Monitor
#Depression, Anxiety
Stable per patient and husband.
-continue fluoxetine, olanzapine, clonazepam 0.5mg AM, 0.25mg
qhs
prn.
#HLD:
Continue atorvastatin.
#Osteopenia
-continue alendronate
To Do:
[] Ongoing Physical therapy at ___
[] Increase PO fluid intake to goal > 1.5L as prophylaxis
against subsequent UTI
[] Augmentin 875mg BID for 10 day course to treat complicated
___
Greater than 40 mins were spent on discharge planning,
coordination of care and patient counseling/education
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Alendronate Sodium 5 mg PO Frequency is Unknown
4. ClonazePAM 0.5 mg PO 1 TAB IN AM AND HALF TAB QHS PRN anxiety
5. FLUoxetine 20 mg PO DAILY
6. OLANZapine 10 mg PO QHS
7. Aspirin 81 mg PO DAILY
8. Nicotine Lozenge 4 mg PO Q4H:PRN cravings.
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO BID Duration: 9 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*15 Tablet Refills:*0
2. Alendronate Sodium 70 mg PO QMON
RX *alendronate [Fosamax] 70 mg 1 tablet(s) by mouth ___
Disp #*4 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. ClonazePAM 0.5 mg PO 1 TAB IN AM AND HALF TAB QHS PRN
anxiety
7. FLUoxetine 20 mg PO DAILY
8. Nicotine Lozenge 4 mg PO Q4H:PRN cravings.
9. OLANZapine 10 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Complicated UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for confusion and weakness, and were found to
have a urinary tract infection. There was initial concern that
you may have had a stroke but fortunately you did not. We are
treating you with oral antibiotics for your urinary tract
infection which is the reason why your confusion has resolved.
The most important problem to focus on now is regaining your
strength so that you no longer have any falls, which is why we
think you will be best served at a short stay at a Rehab center.
It was a pleasure taking care of you,
Your BID Hospitalist Team
Followup Instructions:
___
|
10352688-DS-6 | 10,352,688 | 25,239,834 | DS | 6 | 2178-04-04 00:00:00 | 2178-04-05 19:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ gentleman with history of
migraine, hypertension, hyperlipidemia, CVA with left
hemiparesis (now with no residual) who presented as a transfer
from ___ with chest pain, left upper extremity
tingling and dizziness, for 2 days. Patient reports he currently
lives in a shelter and was in his usual state of health when he
noticed chest pain at rest.
Describes the pain as sharp localized to the left lower chest
without radiation to the jaw or the neck. The pain is associated
with left upper extremity tingling and numbness. No associated
dyspnea, palpitation, PND, orthopnea, presyncope, or syncope. He
has taken the taken to the ___, he went underwent
MRI brain without IV contrast which did not show any acute
intracranial process. He also had a CT angiography of the chest
with IV contrast which was negative for any thoracic aortic
dissection but did demonstrate a stenotic proximal celiac artery
with poststenotic dilation of the celiac trunk and small
intraluminal dissection which reportedly was similar compared to
prior studies.
He reports that his pain has improved since he has been in the
emergency room.
In the ED, initial vital signs were T 96.9 HR 50 BP 180/106 RR
18 O2 sat 97% RA
Exam notable for:
Exam with most recent vital signs blood pressure 153/87, heart
rate 45-50, respiratory rate 14, O2 sat 97% on room air.
Cardiovascular exam remarkable for soft systolic murmur best
heard over left upper sternal border, JVP ~8 cm H2O, lungs with
diffusely decreased breath sounds at but no wheezing, rales or
rhonchi, abdomen soft nontender/nondistended, no peripheral
edema.
Labs were notable for normal CBC with diff, normal chem7 and
LFTs, normal coags, trop negative x2, Utox positive for opiates,
UA with spec ___ >1.050.
ECG in ED: Serial EKG shows sinus bradycardia at 45-50 bpm, left
axis deviation, LVH with secondary repolarization abnormalities.
Studies performed include:
CT angiography chest
MRI brain with IV contrast (___)
Patient was given 1g acetaminophen, 10 mg IV prochlorperazine,
Consults:
Neurology: non-physiologic pattern of diffuse sensory loss.
Concern for cognitive impairment, recommended ___ and social work
cardiology: atypical chest pain, complete stress test if no
etiology of CT established. Continue labetalol and lisinopril
goal HR < 60 and BP < 120, can add alpha blocker.
vascular surgery: awaiting ___ scans for interval changes
Vitals on transfer:
T98, HR 75, BP 123/76, RR 16, 98% RA
Upon arrival to the floor, the patient reports this all began
yesterday night. He woke from sleep with a terrible headache. He
says he gets migraines but has not had one for a while. He says
he had "snowflakes" in front of his eyes. He also had a little
nausea, no vomiting. He denies photophobia or phonophobia.
He notes in this setting he also had new chest pain that he has
not had before. It is sharp in nature. Does not get worse with
movement. He says it does radiate to his left arm and is tingly.
It also radiates down his left leg. He denies orthopnea, PND, or
peripheral swelling. He denies diaphoresis.
He denies feeling any weaker than he has previously. He notes he
walks without assistive device. He says his left side is always
weaker than his right.
On ROS he denies lightheadedness, fever, chills, difficulty
breathing, cough, palpitations, vomiting, dysuria, frequency of
urination, constipation, or diarrhea.
Past Medical History:
- migraine
- L hemiparesis s/p CVA
- Hypertension
- Hyperlipidemia
- s/p robotic R partial nephrectomy
Social History:
___
Family History:
Pt does not know his family history.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- T97.7, BP 165/90, HR 61, RR 18, 94% O2
General: well appearing ___ male, sitting up in bed
HEENT: PERRLA 3->2 mm, MMM, no oral pharynx exudates/injection,
neck soft without anterior lymphadenopathy
Cards: normal S1, S2, RRR, no murmurs, rubs, gallops
Pulm: clear to auscultation bilaterally without wheezes/crackles
Abdominal: normal bowel sounds, soft, non-tender, non-distended
Extremities: warm, well perfused, no peripheral edema, 2+ DP
pulses
Neuro: CN II-XII in tact, ___ strength in upper extremities, ___
in LLE (including foot), ___ in RLE. normal sensation in all 4
extremities. Downgoing toes bilaterally.
DISCHARGE PHYSICAL EXAM
Vitals- 97.7 122 / 82 54 18 95 Ra
General: well appearing ___ male, sitting up in bed
HEENT: PERRLA, MMM, no oral pharynx exudates/injection, poor
dentition
Cards: normal S1, S2, RRR, no murmurs, rubs, gallops
Pulm: clear to auscultation bilaterally without wheezes/crackles
Abdominal: normal bowel sounds, soft, non-tender, non-distended
Extremities: warm, well perfused, no peripheral edema, 2+ DP
pulses
Neuro: CN II-XII in tact, ___ strength in upper extremities,
4+/5
in LLE (including foot), ___ in RLE. normal sensation in all 4
extremities.
Pertinent Results:
ADMISSION LABS:
___ 03:45AM BLOOD WBC-7.8 RBC-5.13 Hgb-14.8 Hct-44.6 MCV-87
MCH-28.8 MCHC-33.2 RDW-13.7 RDWSD-43.8 Plt ___
___ 03:45AM BLOOD Neuts-56.1 ___ Monos-11.3 Eos-2.7
Baso-0.4 Im ___ AbsNeut-4.35 AbsLymp-2.26 AbsMono-0.88*
AbsEos-0.21 AbsBaso-0.03
___ 06:26AM BLOOD ___ PTT-31.9 ___
___ 03:45AM BLOOD Glucose-105* UreaN-13 Creat-0.9 Na-140
K-3.8 Cl-103 HCO3-25 AnGap-12
___ 03:45AM BLOOD ALT-20 AST-19 AlkPhos-78 TotBili-0.3
___ 03:45AM BLOOD cTropnT-<0.01
___ 12:30PM BLOOD cTropnT-<0.01
___ 03:45AM BLOOD Albumin-3.9
PERTINENT LABS:
___ 07:20AM BLOOD VitB12-439 Folate-13
___ 07:20AM BLOOD TSH-0.47
DISCHARGE LABS:
___ 07:05AM BLOOD WBC-5.6 RBC-5.11 Hgb-14.5 Hct-44.9 MCV-88
MCH-28.4 MCHC-32.3 RDW-13.6 RDWSD-43.9 Plt ___
___ 07:05AM BLOOD Glucose-91 UreaN-10 Creat-0.9 Na-141
K-4.5 Cl-106 HCO3-24 AnGap-11
___ 07:05AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1
MICROBIOLOGY:
___ 4:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING/RESULTS:
CXR ___:
No acute cardiopulmonary process.
P-MIBI ___:
IMPRESSION:
1. Normal myocardial perfusion.
2. Increased left ventricular cavity size with normal systolic
function.
BILATERAL CAROTID DOPPLER US ___:
IMPRESSION:
No stenosis of the right carotid. Less than 40% stenosis of the
left carotid.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with history of
migraine, hypertension, hyperlipidemia, CVA with left
hemiparesis, renal cell carcinoma s/p nephrectomy in ___
who presented as a transfer from ___ with chest
pain, left upper extremity tingling and dizziness, for 2 days
found to have a chronic celiac artery aneurysm now admitted to
assist in coordination of care and disposition coordination.
ACUTE ISSUES:
=============
#Chest pain:
Patient presented with chest pain that had started a few days
prior to presentation. He notes that pain began while at rest
and has persisted. Unable to ascertain any exacerbating or
alleviating factors. Non-specific in nature with sudden onset,
non-exertional, no dyspnea, palpations, orthopnea. ACS work up
was negative. Trops remained flat and EKG was without signs of
ischemia. P-MIBI demonstrated normal myocardial perfusion and
increased left ventricular cavity size with normal systolic
function. He was started on Atorvastatin 80 mg PO/NG QPM and
continues on ASA 81 mg, labetalol 200 mg BID Etiology of his
chest discomfort likely related to celiac anyerseum and unlikely
cardiac in nature described as ___ and patient was started on
ranitidine and Maalox prior to discharge for pain relief of
GERD/hear burn symptoms.
#Weakness:
#Prior CVA with residual l sided hemiparesis
Patient with worsening of left sided weakness. Has prior history
of CVA with residual left hemiparesis. MRI at ___
reassuring for no acute infarct. Neurology consulted and felt
deficits were in a non-physiologic pattern. Work up with
electrolytes, folate, B12, TSH, and RPR negative. Carotid US
demonstrated no stenosis of the right carotid and less than 40%
stenosis of the left carotid. He remained on aspirin. His home
simvastatin was d/c and he was started on atorvastatin. ___
evaluated patient and determined that he should be discharged to
rehab. Weakness improved during his hospitalization
#Headache:
Patient has history of migraines. His typical migraines is
located mainly in posterior scalp and is accompanied by visual
aura of "snowflakes." He endorses a headache at time of
presentation that is different from typical migraine. Headache
is more frontal and he endorses flashing, colored lights.
Endorses mild nausea without emesis and denies
photo/phonophobia. Negative MRI w/o contrast in OSH. Patient was
treated with acetaminophen and Compazine PRN. He was started on
MVI/folate/thiamine given history of substance abuse. Headache
was improving at time of discharge, no aura and ___ headache.
#Hypertension:
Patient has hypertension and presented with poorly controlled
blood pressure in the ED, with SBPs in 180s. Cardiology
evaluated the patient in the ED and recommended SBP < 120 and HR
< 60 given celiac artery aneurysm and dissection. Patient was
kept on home amlodipine 10mg and lisinopril 40mg. His labetalol
was titrated based on HR and was kept on 200mg BID. He
intermittently received clonidine to control BP which was
discontinued secondary to low heart rate. Chlorthalidone was
considered but not started out of concerns about prior
compliance issues. His blood pressure should be checked daily
and SBP goal <140 ideally 120 and should not be greater than
160. If blood pressures >160, please start chlorthalidone 12.5
mg and check electrolytes 2 days after starting as the next
recommended
#Celiac artery aneurysm:
CT-A at ___ demonstrated a stenotic proximal
celiac artery with poststenotic dilation of the celiac trunk and
small intraluminal dissection which reportedly was similar
compared to prior studies. Vascular surgery was consulted and
felt that further evaluation could be done as an outpatient.
Plan to get a repeat CT scan in one month for further
evaluation.
#History of right renal cell carcinoma s/p partial nephrectomy
Patient recently underwent robotic assisted partial nephrectomy
at ___ for renal cell carcinoma. He complained of no
abdominal or back pain. His Cr remained stable at 0.9 and he had
___ UOP with no abdominal pain.
#History of substance abuse.
Patient with substance use history. Drug screen at presentation
was positive for opioids. Uncertain if this is related to
medications he received at ___. He was monitored for signs
of withdrawal and found not to be withdrawing.
TRANSITIONAL ISSUES:
[] Discharge Labs:
-- BUN 10 Cr 0.9
-- Hgb 14.6
-- TSH 0.47
-- RPR Non reactive
[] PMibi Stress was negative for inducible ischemic disease; on
primary prevention with ASA/Atorovstatin/Beta blocker
[] Add chlorthalidone 12.5mg if SBPs are persistently above 140s
and check electrolytes 2 days after initiation
[] Patient should follow up with vascular surgery and repeat
CT-A for evaluation of celiac artery aneurysm
in one month
[] Patient has neurology follow up in one week
[] Patient should ensure follow with urologist who performed his
nephrectomy
[] Monitor urine output if decreases or becomes dark yellow call
MD
Full code
___ Friend ___
I have seen and examined Mr. ___, reviewed the findings,
data, and discharge plan of care documented by Dr. ___, MD
dated ___ and agree, except for any additional comments
below.
Day of discharge management > 30 minutes
___, MD, PharmD
Section of ___ Medicine
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Labetalol 300 mg PO BID
3. Simvastatin 10 mg PO QPM
4. Lisinopril 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
reflux
2. Atorvastatin 80 mg PO QPM
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Ranitidine 150 mg PO BID
6. Labetalol 200 mg PO BID
7. amLODIPine 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Lisinopril 40 mg PO DAILY
10.Outpatient Lab Work
ICD 10 C64.9
Chem10: Na+/K+/Cl-/HCO3-/BUN/Cr
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Chest Pain
Headache
Hypertension
SECONDARY DIAGNOSES:
Celiac Artery Aneurysm
Prior CVA
History of substance abuse
S/P Nephrectomy ___ Renal Cell Carcinoma (performed at ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for choosing ___ for
your site of care!
Why was I admitted to the hospital?
- You were having chest pain
What was done for me while I was in the hospital?
- You had work up for your chest pain, including checking labs,
doing EKGs, and performing a stress test, which all came back
normal
- You had imaging which showed that one of the blood vessels in
your abdomen was enlarged but unchanged from previous images
- You were given medications to help with your headache.
- You had imaging of your neck done to determine if this was
contributing to your symptoms and it was determined to not be
contributing.
- You were given medications to improve your blood pressure.
What should I do when I leave the hospital?
-Please continue to take all of your medications as prescribed.
-Please follow up with the listed providers below.
We wish you the best!
Your ___ treatment team
Followup Instructions:
___
|
10352831-DS-20 | 10,352,831 | 24,459,937 | DS | 20 | 2128-11-09 00:00:00 | 2128-11-11 09:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Imipramine
Attending: ___
Chief Complaint:
complete heart block
Major Surgical or Invasive Procedure:
s/p single chamber pacemaker placement
History of Present Illness:
___ with h/o CAD s/p CABG in ___, depression, hypothyroidism,
HL presents with complete heart block. He was seen by his PCP
earlier this week for a routine appt where the patient
complained of SOB and fatigue - EKG showed complete heart block,
with ventricular escape at 40, RBBB, and QT of 0.6. He was asked
to come straight to the ER but waited until today when he
presented with his sister. In the ER, VS 97.9 40 122/49 20
97% on RA. He was taken directly to the cath lab where a single
chamber Ppm was implanted.
Currently, the patient is eating dinner. He denies pain and
feels ok. He notes slight improvement in his breathing since
placement of the Ppm.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: ___ (SV x3 to PDA, OM and LIMA to LAD)
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
CAD s/p CABG in ___
Severe major depression w/ history of catatonic features
Hypothyroidism after treatment for Grave's disease
HL
OSA
Social History:
___
Family History:
+ fam hx of CAD, HTN, Prostate CA.
Physical Exam:
On admission:
VS: AF 147/74 57 18 100% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: JVP not elevated
CARDIAC: RR, normal S1, S2. ___ systolic murmur at LUSB; L chest
is bandaged and in sling
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
Pertinent Results:
On admission:
___ 02:45PM BLOOD WBC-8.0 RBC-4.80 Hgb-14.2 Hct-43.4 MCV-90
MCH-29.5 MCHC-32.7 RDW-13.7 Plt ___
___ 02:45PM BLOOD ___ PTT-27.7 ___
___ 02:45PM BLOOD Glucose-87 UreaN-28* Creat-1.5* Na-137
K-5.4* Cl-100 HCO3-26 AnGap-16
___ 02:45PM BLOOD cTropnT-0.04*
___ 02:45PM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2
.
Device interrogation:
Quadripolar Single chamber ppm
Ventricular lead sensitivity: No intrinsic under 30 bpm
Proximal pole (atrial) sensitivity: 0.5-0.7 mV
Impedance: 627 ohms
Threshold: [email protected]
.
Brief Hospital Course:
Hospitalization Summary:
___ with h/o CAD s/p CABG in ___, depression, hypothyroidism,
HL presents with complete heart block. He underwent single
chamber pacemaker placement on ___, interrogation showed pacer
was functioning as intended.
# CHB s/p pacer: He presented to his PCP with complete heart
block - was in a junctional escape rhythm with rates in the ___
and Qtc ~ 600 ms. ___ included SOB and fatigue. He
presented to the ER on ___ and was sent directly to the EP lab
where single chamber Ppm placement was performed. Device was
interrogated on ___ prior to discharge by EP fellow and was
found to be functioning normal. CXR showed no pneumothorax and
leads in expected position. He was discharged with
recommendations to schedule a device clinic ___ in 1 week and
PCP ___ appt. He was also discharged on keflex to complete 72
hrs of therapy for prevention of infection.
# CAD s/p CABG: Continued plavix 75 mg qday, aspirin 81 mg qday,
crestor.
# Depression: Continued effexor, ritalin, remeron. These were
resumed at his usual home doses.
# Hypothyroidism: Continued levothyroxine 125 mcg qday.
DVT prophylaxis was with subQ heparin. Code status was Full
Code. Contact with sister ___ ___.
.
___ Issues
- device clinic ___ 1 week from Ppm placement
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Methylphenidate SR 10 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Venlafaxine XR 150 mg PO EVERY OTHER DAY
5. Venlafaxine XR 112.5 mg PO EVERY OTHER DAY
Alternate with 150 mg dose
6. Furosemide 20 mg PO 1X/WEEK (___)
7. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
8. Aspirin 81 mg PO DAILY
9. Mirtazapine 15 mg PO HS
10. Rosuvastatin Calcium 20 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Rosuvastatin Calcium 20 mg PO HS
5. Venlafaxine XR 112.5 mg PO EVERY OTHER DAY
Alternate with 150 mg dose
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Furosemide 20 mg PO 1X/WEEK (___)
8. Methylphenidate SR 10 mg PO DAILY
9. Mirtazapine 15 mg PO HS
10. Venlafaxine XR 150 mg PO EVERY OTHER DAY
11. Cephalexin 500 mg PO Q8H Duration: 8 Doses
Last dose on ___
RX *cephalexin 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*8 Tablet Refills:*0
12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
Duration: 2 Days
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every ___ hours as needed for pain related to the procedure Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Complete heart block
Secondary:
CAD s/p CABG
depression
hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the ___. You were admitted
for an arrhythmia called complete heart block, which is a
dangerous rhythm. You had a pacemaker placed and your device was
interrogated and found to be working normally. You will take
antibiotics to complete 3 days of therapy to prevent infection.
Please resume taking your antidepressants at their normal doses.
You will need to follow-up in the ___ device clinic in 1 week
to have your pacemaker again tested. The information to schedule
this appointment is below.
Followup Instructions:
___
|
10352831-DS-22 | 10,352,831 | 21,856,697 | DS | 22 | 2129-08-10 00:00:00 | 2129-08-12 21:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Imipramine
Attending: ___.
Chief Complaint:
left arm swelling
Major Surgical or Invasive Procedure:
___ - left upper extremity venogram with balloon
angioplasty
History of Present Illness:
___ yo M w/ PMHx CAD s/p CABG and complete heart block s/p
Quadripolar Single chamber PPM in ___ presents who p/w 4
days of left upper extremity swelling. It began in his hand and
progressed up his arm. He denies any trauma to his arm. No pain
in the arm. Does not feel it has been cooler than the other
extremity. He denies any pain or numbness or tingling, and any
decreased strength in his arm. He denies any shortness of
breath, chest pain, pleuritic pain, cough or hemoptysis. He has
never had a clot before and there is no family history of blood
clots in lungs or legs. Patient without any fevers.
He was admitted to the hospital and found to have a large,
extensive DVT in his LUE.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: ___ (SV x3 to PDA, OM and LIMA to LAD)
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
CAD s/p CABG in ___
Severe major depression w/ history of catatonic features
Hypothyroidism after treatment for Grave's disease
HL
OSA
Social History:
___
Family History:
No family history of blood clots
Physical Exam:
=================================
ADMISSION PHYSICAL
=================================
VS: 98.2 166/92 61-62 20 100%RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI, mild exophtholomous
Neck: supple, no JVD
CV: regular rhythm, ___ late peaking cresendo-decresendo murmur
heard best @ ___ right intercoastal space with radiation to
carotids
Lungs: CTAB, no rales
Abdomen: soft, NT/ND, BS+
Ext: LUE wrapped in ace wrap to upper arm, visibly more swollen
than RUE, +2 radial and brachial pulses bilaterally, no pitting
edema, strength and sensation intact, interosseous strength
intact, WWP, no edema of the lower extremities
Neuro: moving all extremities grossly
===================================
DISCHARGE PHYSICAL
===================================
VS 98.5 ___ 18 98% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI, mild exophtholomous
Neck: supple, no JVD
CV: regular rhythm, ___ late peaking cresendo-decresendo murmur
heard best @ ___ right intercoastal space with radiation to
carotids
Lungs: CTAB, no rales
Abdomen: soft, NT/ND, BS+
Ext: LUE wrapped in ace wrap to upper arm, visibly more swollen
than RUE but improved, +2 radial and brachial pulses
bilaterally, no pitting edema, strength and sensation intact,
interosseous strength intact, WWP, no edema of the lower
extremities
Neuro: moving all extremities grossly
Pertinent Results:
=====================================
ADMISSION LABS
=====================================
___ 06:50PM BLOOD WBC-8.7 RBC-4.38* Hgb-12.4* Hct-39.4*
MCV-90 MCH-28.4 MCHC-31.5 RDW-13.5 Plt ___
___ 06:50PM BLOOD ___ PTT-27.8 ___
___ 06:50PM BLOOD Glucose-70 UreaN-27* Creat-1.3* Na-135
K-7.1* Cl-93* HCO3-31 AnGap-18
___ 06:57PM BLOOD Lactate-1.6 K-5.2*
==========================================
PERTINENT RESULTS
==========================================
___ 01:00AM BLOOD calTIBC-296 Ferritn-151 TRF-228
___ 01:00AM BLOOD Albumin-3.3* Calcium-8.9 Phos-2.7 Mg-2.1
Iron-42*
___ 01:00AM BLOOD ALT-16 AST-23 LD(LDH)-184 AlkPhos-37*
TotBili-0.2
___ 02:56AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:25AM BLOOD CK-MB-3 cTropnT-<0.01
======================================
DISCHARGE LABS
======================================
___ 06:20AM BLOOD Glucose-94 UreaN-34* Creat-1.5* Na-141
K-4.6 Cl-104 HCO3-29 AnGap-13
___ 06:20AM BLOOD ___ PTT-33.3 ___
___ 06:20AM BLOOD WBC-8.0 RBC-4.42* Hgb-12.5* Hct-40.2
MCV-91 MCH-28.2 MCHC-31.0 RDW-13.6 Plt ___
=================================
IMAGING
=================================
___ CXR:
FINDINGS: Comparison is made to previous study from ___.
There is a single-lead left-sided pacemaker which is intact.
The heart size
is within normal limits. There are numerous rib fractures on
the left side,
which are partially healed. There is no focal consolidation,
pleural
effusions, or pneumothoraces. Old healed right mid clavicular
shaft fracture
is also seen.
___ ECG: Sinus rhythm with a ventricularly paced rhythm
___ CTA UE, CHEST
FINDINGS:
Chest: The lungs demonstrate dependent atelectasis, left
greater than right.
Left pleural thickening adjacent to prior rib fractures is again
seen. No
pleural or pericardial effusion is seen. Extensive arterial
atherosclerotic
calcifications includes the coronary arteries; the patient is
status post
CABG. Aortic valve calcification is severe. The pulmonary
arteries are again
noted to be enlarged, suggestive of pulmonary arterial
hypertension.
A transvenous pacemaker lead terminates in the right ventricle
with hardware
in the left chest subcutaneously and a left subclavian vein
approach. The
left brachiocephalic vein is completely collapsed around the
lead; this
suggests chronic venous scarring with a possible component of
decreased flow
due to the left subclavian vein clot. The superior vena cava is
patent.
Thrombus is seen surrounding the pacemaker lead in the left
subclavian vein,
better evaluated with ultrasound. No collateral venous
circulation is
opacified on this study.
No lymphadenopathy is detected in the chest. The thyroid gland
is small but
homogeneous in attenuation.
Left upper extremity: Extensive venous clot is better evaluated
with recent
prior ultrasound. Absence of contrast filling in the left
axillary,
subclavian, and jugular veins compared to the right is
consistent with known
clot. Hardware in the left chest slightly limits evaluation of
the axillary
and subclavian veins. Evaluation for focal venous stricture is
limited on
this study and would be better evaluated with conventional
venography.
Abdomen: The study is not optimized for evaluation of
intra-abdominal
structures, but no acute abnormalities are detected in the
visualized portions
of the liver, collapsed gallbladder, spleen, pancreas, adrenal
glands, or
intestine. A small hiatal hernia is again noted. A large
amount of stool is
seen in the visualized portions of the colon. Extensive
calcified and
noncalcified atherosclerotic plaque is seen along the abdominal
aorta which
demonstrates patent branch vessels with large amount of plaque
at their
origins. There is no free intraperitoneal air.
The kidneys demonstrate heterogeneous enhancement bilaterally in
a striated
pattern, which can be seen in the setting of pyelonephritis.
Neither kidney
demonatrates hydronephrosis.
Bones: Sternotomy wires appear intact. Prior left rib fractures
are again
noted.
IMPRESSION:
1. Extensive clot in the left subclavian, axillary, and jugular
veins, as seen
on ultrasound. Likely chronic narrowing of the left
brachiocephalic vein
around the existing pacemaker leads, incompletely evaluated on
this study.
These findings and further imaging options were discussed with
Dr. ___ by Dr. ___ in person at 3 p.m. on ___ at the
time of initial
review of the study in response to attending wet read request.
2. Bilateral striated nephrograms, which can be seen in the
setting of
pyelonephritis. Clinical correlation is recommended.
___ ECHO
The left atrium is mildly dilated. There is no left atrial
thrombus (better evaluated by ___). There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the basal to mid inferior wall. The remaining segments
contract normally (LVEF = 50 %). Overall left ventricular
systolic function is low normal. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg). No
left ventricular thrombus is seen. Right ventricular cavity size
and systolic function are normal. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: No intracardiac thrombus identified. Concentric left
ventricular hypertrophy with mild regional left ventricular
systolic dysfunction c/w CAD. Moderate aortic stenosis. Mild
aortic regurgitation. Mild mitral regurgitation. Pulmonary
artery systolic hypertension. Elevated PCWP.
Compared with the prior study (images reviewed) of ___,
regional dysfunction is better appreciated (may have been
present on prior study). Aortic stenosis has developed.
Pulmonary artery systolic pressure is higher. There is slightly
more mitral regurgitation.
___ CXR
FINDINGS:
The patient is status post median sternotomy and CABG. A
left-sided pacemaker
device is noted with single lead terminating in the right
ventricle. The
heart size is mildly enlarged. Mediastinal and hilar contours
are unchanged,
with enlargement of the pulmonary arteries re- demonstrated,
compatible with
pulmonary arterial hypertension. There is no pulmonary vascular
engorgement.
No new focal consolidation, pleural effusion or pneumothorax is
seen.
Multiple left-sided rib deformities are re- demonstrated with
minimal adjacent
scarring. Remote right mid clavicular fracture is also noted.
There are mild
degenerative changes in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
___ LUE US
LEFT UPPER EXTREMITY DOPPLER ULTRASOUND: Grayscale and Doppler
sonograms of
the bilateral subclavian, left internal jugular, left axillary,
left basilic,
left brachial, and left cephalic veins were obtained. There is
occlusive
thrombus involving all deep veins of the left upper extremity
mentioned above.
The cephalic vein remains patent. Soft tissue edema is
identified throughout
the left upper extremity.
IMPRESSION: Occlusive thrombus involving all deep veins of the
left upper
extremity.
==============================
___ LUE VENOGRAM
==============================
Assessment & Recommendations
1. Extensive thrombosis of the L upper extremity involving the
L basilic, brachial, axillart, SC and SVC.
2. Chronic occlusion around the PPM wire in the mid SCV ___
SVC.
3. Successful balloon angioplasty of the L axillary, SC and
SVC with good result.
4. Ace-wrap to the entire L arm.
5. Anticoagulation with Rivaroxaban long term
6. Follow up with me in vascular medicine clinic in ___ weeks.
Needs L UE venous duplex US on day of visit (please order
in ___ 7 Vascular medicine Lab.
7. L upper extremity sleeve going forward to augment venous
flow and prevent postphlebetic syndrome.
Brief Hospital Course:
___ yo M w/ PMHx of CHB s/p ICD in ___, CAD s/p CABG,
hypothyroidism, depression presents with asymptomatic LUE
swelling for four days.
# LUE DVT - likely related to underlying ICD that was place in
___. Underwent venogram during which there was successful
PTA of the L axillary, entire SC, as well as the SVC with 3.0,
4.0, 5.0, 6.0 and 8.0 balloons with good result. He was
continued on heparin and started on rivaroxaban. He will
continue anticoagulation for at least six months. He did not
undergo a hypercoagulability work-up as his clot was most likely
related to the ICD that was placed. His arm was ace wrapped and
elevated. He will wear a compression stocking on his arm to
prevent complications. He will f/u with Dr. ___. He will
have a follow up LUE ultrasound prior to his visit with Dr.
___.
# coronary artery disease - stable. Continued on rosuvastatin,
plavix, and aspirin.
# hypertension - hypertensive on admission and documented in
prior notes and not on any home medications. Goal
SBP<140/<90mmHg. Responded well to lisinopril but creatinine
rose so it was discontinued.
# aortic stenosis- ___ 1.0-1.2 indicating moderate disease.
currently asymptomatic.
# hyperlipidemia - LDL 77, HDL 72 in ___. At LDL goal of <100
# hypothyroidism - TSH 3.1 in ___. Continued on synthroid.
# depression - continued ritalin, venlafaxine, and mirtazapine.
# anemia - iron studies were WNL. needs to be addressed as
outpatient.
# thrombocytopenia - no reports of alcoholism, liver disease per
pt. Mild elevation in alk phos, normal LFTs.
=============================
TRANSITIONAL ISSUES
=============================
# anemia - f/u as outpatient
# thrombocytopenia - f/u as outpatient
# anticoagulation needs
# f/u LUE US
# f/u creatinine to ensure it is trending down
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Rosuvastatin Calcium 20 mg PO HS
6. Venlafaxine XR 150 mg PO DAILY
7. Methylphenidate SR 10 mg PO DAILY
8. Mirtazapine 15 mg PO HS
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Mirtazapine 15 mg PO HS
5. Rosuvastatin Calcium 20 mg PO HS
6. Venlafaxine XR 150 mg PO DAILY
7. Methylphenidate SR 10 mg PO DAILY
8. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*21 Tablet Refills:*0
9. left upper extremity ultrasound
ICD 9 code: ___
diagnosis: left upper extremity deep vein thrombosis
10. compression stocking for upper extremity
ICD 9: 45___
diagnosis: left upper extremity deep vein thrombosis
___ stocking
11. Outpatient Lab Work
diagnosis renal insufficiency
ICD diagnosis: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
1. left upper extremity deep vein thrombosis
2. hypertension
SECONDARY
3. complete heart block
4. coronary artery disease
5. diastolic congestive heart failure
6. depression
7. hyperlipidemia
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 came into the hospital because
your left arm was becoming progressively more swollen. When you
got here, we did an ultrasound of your left arm which showed a
clot, know as a deep vein thrombosis. You underwent a procedure
during which the clot was opened up via ballon angioplasty.
You will need to take a medicine called rivaroxaban, also known
as xarelto, to prevent the clot from coming back and to help
break the clot down. You should keep your arm wrapped to help
get rid of the swelling and prevent complications from having a
clot. Please wear the compression stocking on your arm to
prevent pain after having a clot in your arm. You will need to
get an ultrasound the same day you have an appointment with Dr.
___.
You were started on a new medication to treat your high blood
pressure. It controlled your blood pressure well but your kidney
function declined so we stopped the medication. You should have
your blood pressure and kidney function checked as an
outpatient.
Thank you for choosing ___.
Followup Instructions:
___
|
10352831-DS-23 | 10,352,831 | 25,430,132 | DS | 23 | 2131-12-21 00:00:00 | 2131-12-22 16:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Imipramine
Attending: ___.
Chief Complaint:
Dyspnea, L hand swelling, L eye redness
Major Surgical or Invasive Procedure:
___ ___
History of Present Illness:
Mr. ___ is an ___ y/o man with a PMH of CAD (s/p CABG in ___,
CHB (s/p PPM), moderate AS (area 1.0-1.2cm2), LUE DVT on
apixaban, who presented with 2 days of dyspnea on exertion, left
hand swelling, and left eye pruritis.
The patient reports about 2 days of shortness of breath, present
with exertion. He has no shortness of breath at rest. He notes
that this is sometimes associated with upper abdominal and chest
pain that resolves with rest. He denies any fever, chills,
nausea, vomiting, dysuria, bowel changes.
He also has had left hand and arm swelling. He thinks this has
been going on for a few days. He has a history of DVT in the
left upper extremity in ___ and is on apixiban for this. When
he had the DVT he notes his arm was much more swollen than this.
He has no pain, but notes that his hand has skin cracks from
dryness.
Finally he notes 2 days of redness, pruitis, and drainage from
his left eye. His vision is a little blurred but no
double-vision, no eye pain, no photopobia. He has not had any
fevers/chills. He does note some runny nose.
Past Medical History:
1. Coronary artery disease status post CABG in ___, LIMA-LAD,
SVG to OM, SVG to diagonal, SVG to PDA for exertional dyspnea.
2. Complete heart block status post permanent single-chamber
pacemaker.
3. Left upper extremity extensive DVT extending into the left IJ
nine months after implantation of the pacemaker in ___
status post venoplasty with Dr. ___, on long-term ___
for secondary prevention, now Eliquis.
4. Moderate calcific aortic stenosis.
5. Mixed dyslipidemia ___, TC 172, ___ 40, HDL 83, LDL
81).
6. CKD stage 2.
7. Depression
8. Hypothyroidism
Social History:
___
Family History:
- ___ parents had CABGs.
- Brother with "heart problems", unclear further details.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.0 132/79 65 18 100% on 2L NC
GEN: Alert, interactive. In no distress.
HEENT: PERRL. Conjunctiva injected bilaterally worse on right.
On the right there is also a small amount of purulent drainage.
MMM, no oral lesions.
NECK: No cervical or supraclavicular LAD.
CARDIO: Regular rhythm. Systolic murmur best at upper boarders.
LUNGS: Crackles at mid to bases bilaterally.
ABD: Soft, nondistended. Diffuse mild tenderness to palpation.
EXT: 2+ ___ edema bilaterally to the knees. The right hand is
mildly swollen and appears to extend to the forearm; no
tenderness or redness. There are several cuts in the right hand
that are not infected looking.
NEURO: AOx3. CN2-12 grossly intact. There is mild left sided
droop noted at the mouth. ___ strength throughout.
Finger-to-nose intact.
Discharge Physical Exam
VS: T 99.2, BP 97-127/47-70, HR ___ (paced) RR 18, 97-99% RA
I/O: -/inc x 1 WT: 57.9 <- 58.6 <- 60.1 <- 59.3 kg
GENERAL: Thin man. Breathing comfortably laying flat. Temporal
wasting. Oriented x3. Mood appropriate. Affect flat.
HEENT: Sclera anicteric. PERRL, EOMI. Exopthalmos present.
NECK: Supple with no JVD
CARDIAC: RR, normal S1, S2. faint systolic murmur best heard at
the RUSB. No thrills, lifts. No S3 or S4.
LUNGS: crackles at the bases. No wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no edema appreciated.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
Labs:
Admission Labs:
___ 05:30PM BLOOD WBC-4.8 RBC-3.79* Hgb-11.0* Hct-34.5*
MCV-91 MCH-29.0 MCHC-31.9* RDW-15.3 RDWSD-50.0* Plt ___
___ 05:30PM BLOOD Neuts-68.7 Lymphs-17.3* Monos-11.3
Eos-1.5 Baso-0.6 Im ___ AbsNeut-3.65 AbsLymp-0.92*
AbsMono-0.60 AbsEos-0.08 AbsBaso-0.03
___ 05:30PM BLOOD ___ PTT-30.5 ___
___ 05:30PM BLOOD Glucose-110* UreaN-54* Creat-1.9* Na-143
K-5.3* Cl-106 HCO3-28 AnGap-14
Initial cardiac markers:
___ 05:30PM BLOOD CK-MB-14* ___
___ 05:30PM BLOOD cTropnT-0.07*
___ 12:02AM BLOOD CK-MB-11* MB Indx-2.7 cTropnT-0.09*
___ 08:15AM BLOOD CK-MB-7 cTropnT-0.08*
Follow up BNP:
___ 03:10PM BLOOD proBNP-4676*
Other pertinent labs
___ 08:15AM BLOOD %HbA1c-6.3* eAG-134*
___ 05:30PM BLOOD TSH-13*
___ 08:15AM BLOOD Triglyc-54 HDL-78 CHOL/HD-1.9 LDLcalc-59
LDLmeas-69
Discharge labs:
___ 05:08AM BLOOD WBC-8.0 RBC-3.30* Hgb-9.4* Hct-29.8*
MCV-90 MCH-28.5 MCHC-31.5* RDW-14.6 RDWSD-47.0* Plt ___
___ 05:30PM BLOOD Neuts-68.7 Lymphs-17.3* Monos-11.3
Eos-1.5 Baso-0.6 Im ___ AbsNeut-3.65 AbsLymp-0.92*
AbsMono-0.60 AbsEos-0.08 AbsBaso-0.03
___ 05:08AM BLOOD Glucose-94 UreaN-30* Creat-1.1 Na-136
K-4.8 Cl-102 HCO3-31 AnGap-8
___ 05:08AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.2
___ 08:15AM BLOOD %HbA1c-6.3* eAG-134*
___ 08:15AM BLOOD Triglyc-54 HDL-78 CHOL/HD-1.9 LDLcalc-59
LDLmeas-69
___ 05:30PM BLOOD TSH-13*
___ 08:15AM BLOOD T4-6.0
Studies:
___ EKG:
Sinus rhythm with ventricular pacing. No significant change
compared to the
previous tracing of ___.
TRACING ___ CTH:
IMPRESSION:
1. No acute hemorrhage or acute large territorial infarct on
noncontrast head CT. Please note, however, that MR is more
sensitive in the detection of acute stroke.
2. Age-related involutional changes and likely sequela of
chronic small vessel ischemic disease.
___ upper extremity US:
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Chronic appearing recanalized thrombus in the left internal
jugular vein,
improved from ___.
___ TTE:
The left atrium is moderately dilated. The left atrial volume
index is severely increased. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is severely depressed (LVEF= 20%). There is overall
systolic dysfunction with focal akinesis of the inferior and
inferoseptal walls. There is visual left ventricular
dyssynchrony with the lateral wall contracting later than the
septum. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. Mild (1+) aortic
regurgitation is seen. Moderate to severe (3+) mitral
regurgitation is seen. The jet is posteriorly directed and
likely due to restricted motion of the posterior leaflet. There
is severe aortic stenosis ___ 0.6cm). There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypetrophy with
severely depressed left ventricular systolic function consistent
with multivessel coronary artery disease. Increased left
ventricular filling pressure. Severe aortic stenosis. Moderate
to severe mitral regurgitation. Moderate pulmonary artery
systolic hypertension.
Compared with the prior study (images reviewed) of ___, the
severity of aortic stenosis has increased. The severity of
mitral regurgitation has increased. The left ventricular
systolic function is worse globally and regionally (LVEF
previously 45% with inferior hypokinesis only).
___ pMIBI
IMPRESSION: Progressive fixed defects involving inferior wall
of the left ventricle as well as the apex with diminished
ejection fraction of 25%.
___ cardiac cath
Impressions:
1. Two vessel coronary artery disease
2. Patent LIMA to the LAD
3. Occluded SVG to Diagonal branch
4. Occluded SVG to PDA
Recommendations
1. Evaluation for ___
___ carotid US:
IMPRESSION:
Moderate plaque. Bilateral ___ ICA stenosis. Antegrade
vertebral flow
___ cardiac CT:
IMPRESSION:
Aortic valve stenosis without evidence of aortic aneurysm.
Patent subclavian and common femoral arteries bilaterally.
Mild pulmonary edema with moderate loculated pleural effusions.
Pulmonary artery enlargement, can be seen with pulmonary
hypertension.
Please refer to the separate CT report of the abdomen and
pelvis.
___ CTA torso:
IMPRESSION:
1. Heavily calcified and atheromatous abdominal aorta. 4 mm
length of
abdominal aorta penetrating ulcer. No evidence of abdominal
aneurysm or
dissection.
2. 40% stenosis of bilateral common femoral artery due to dense
calcification,
right worse than left.
3. Mildly tortuous common iliac artery bilaterally.
4. Patent bilateral subclavian arteries. Left subclavian artery
demonstrates
less calcium burden.
5. High-grade or complete occlusion of the celiac artery at the
origin with
reconstitution of the common hepatic and splenic artery.
6. Significant stenosis of the SMA at the origin due to
calcification.
Brief Hospital Course:
Mr. ___ is an ___ y/o man with a PMH of CAD (s/p CABG in ___,
CHB (s/p PPM), recently diagnosed severe AS, hx of LUE DVT on
apixaban, who presented with 2 days of dyspnea on exertion, left
hand swelling, and left eye pruritis. Found to have worsening
systolic function and severe AS now undergoing AVR workup.
# CORONARIES: CABG: LIMA-LAD patent, SVG to OM, SVG to diagonal
occluded, SVG to PDA occluded
# PUMP: LVEF 20%, severe AS, moderate MR, moderate PHTN
# RHYTHM: V-paced, LBBB
#) Severe AS, Acute, decompensated, systolic heart failure:
Mr. ___ presented with gross signs of volume overload, a new
oxygen requirement, dyspnea on exertion and orthopnea. On
presentation, his LUE was particularly edematous and assymetric
with he right. For this reason he underwent a LUE venous US,
which did not show any new DVT. He was diuresed with IV
furosemide with quick improvement in his right sided symptoms.
However, his hypoxia and pulmonary edema persisisted for days
after the right sided symptoms resolved, suggesting a primarily
left sided pathology. He underwent a TTE, which showed severe AS
and moderate MR as well as significantly reduced systolic
function from his prior (EF of 20% from 45%). Because of his
severe and symptomatic AS he underwent valve replacement workup.
He was seen by the cardiac surgery team, who deemed that he was
not a good candidate for surgical replacement. He underwent an
evaluation for ___ and underwent the procedure on ___. The
procedure was uncomplicated and he arrived to the CCU extubated
and off pressors. Because he did not necessitate ___ s/p ___,
and his post ___ echo showed: improved systolic function, EF
from 20 to 40%. He was not initiated on BB or ACEI. The
initiation of these medications can be done in the outpatient
setting and determined by his cardiologist. He should continue
aspirin 81 daily and apixaban (in place of plavix ___ to LUE DVT
treatment) s/p ___.
#) ___ on CKD: Mr. ___ presented with ___ 1.8 on admission
from a baseline of 1.3-1.5. Downtrended with diuresis and was
1.1 after leaving the CCU.
#) Hypoxia: Resolved. Pt had persistant oxygen requirement
despite effective diuresis. Most likely, his heart failure had
prominent left sided component with bad combination of AS and
MR. ___ improved with ___ and ___ echo as above. He did
not necesittate further diuresis after ___.
#) Left facial droop: On arrival to the floor, pt has a subtle
left-sided facial droop noted. No other focal neurologic
deficits. He had a CT head without acute finding. His facial
droop spontaneously resolved within 24 hours. He has no history
of CVA. DDx includes TIA vs. recrudescence of old stroke. Pt is
vasculopath and has evidence of vascular damage on head CT.
#) Left upper extremity swelling: Pt presented with asymmetric
swelling of his LUE. Pt with known history of DVT. Doppler
imaging of LUE is reassuring. Possible that there is who body
edema and increased baseline venous pressures in the LUE ___
reduced caliber veins from DVT leading to the asymmetric edema.
#) CAD: s/p CABG in ___ with LIMA-LAD, SVG to OM, SVG to
diagonal, SVG to PDA. HbA1c of 5.8% in ___. Lipid panel in
___ with Tc 172, Trig 40, HDL 83, LDL 75. pMIBI with fixed
defects and a cardiac cath with multivessel disease that was not
intervenable.
#) Conjunctivitis: Pt presented with evidence of injected
conjunctiva on exam (L>R), with watery, itchy eyes and
periorbital edema on presentation. Likely viral. He completed
course of erythromycin ointment QID with improvement in his
symptoms.
#) Hx of LUE DVT: In ___ had occlusive thrombus involving all
deep veins of the left upper extremity. Has no evidence of new
acute thrombosis on ultrasound. He was continued on apixaban.
#) Normocytic anemia: Appears to be near baseline of ___. CKD
likely contributing. MCV of 91. Iron studies within normal
limits in ___.
#) Complete heart block, s/p PPM: Currently V-paced in ___. No
symptoms of lightheadedness or dizziness at this time.
#) Depression: continue on home methylphenidate 10 mg daily,
mirtazapine 15 mg qhs, continue home venlafaxine 150 mg BID
#) Hypothyroidism
- TSH elevated in setting of acute illness, normal thyroxine,
continued on home dose of levothyroxine. would recommend
rechecking as an outpatient.
Transitional Issues
-based on post ___ echo: outpt cardiologist can decide whether
pt needs to be started on ACEI/ BB or standing diuretic
-TSH was elevated at 13 but thyroxine normal at 6.0, Goal TSH
___ (based on age). Levothyroxine dose not adjusted in setting
of acute illness, would recommend repeat TSH in outpatient
setting
-Discharge weight 57.9kg
# CODE: FULL
# CONTACT: ___, Sister, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
3. Mirtazapine 15 mg PO QHS
4. Apixaban 2.5 mg PO BID
5. Rosuvastatin Calcium 20 mg PO QPM
6. Venlafaxine XR 150 mg PO BID
7. Methylphenidate SR 10 mg PO QAM
8. Multivitamins 1 TAB PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Levothyroxine Sodium 125 mcg PO DAILY
3. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
4. Mirtazapine 15 mg PO QHS
5. Rosuvastatin Calcium 20 mg PO QPM
6. Venlafaxine XR 150 mg PO BID
7. Fish Oil (Omega 3) 1000 mg PO DAILY
8. Methylphenidate SR 10 mg PO QAM
9. Multivitamins 1 TAB PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis
severe AS s/p ___ ___
systolic heart failure
secondary diagnosis
CAD s/p CABG
CHB s/p PPM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Dear ___
___ was a pleasure caring for you at ___
___. You were admitted with worsening heart failure.
While you were here, we gave you diuretics, which are
medications to help you urinate. First, we did this through your
IV and then we switched you to an oral regimen.
You also had severe narrowing of one of your heart valves
(aortic valve) for which you underwent replacement of that valve
(transcatheter aortic valve repair or ___.
At discharge, you weighed 57.9kg. Weigh yourself daily and
notify your cardiology team if your weight increases more than 3
lbs in one day.
We will discharge you to rehab where you can become stronger.
Please follow up with the appointments listed below.
We wish you all the best,
Your ___ Cardiology team
Followup Instructions:
___
|
10353061-DS-13 | 10,353,061 | 21,977,750 | DS | 13 | 2171-05-16 00:00:00 | 2171-05-16 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
T6 lytic lesion
Major Surgical or Invasive Procedure:
___: ___ biopsy of T6 lesion
___: T6 posterior vertebral/tumor resection, T4-T8 fusion
History of Present Illness:
___ year old male with two weeks of back pain. He reports
gradual in onset, and worse with coughing. Denies trauma. Denies
loss of bladder or bowel control. Had previously presented to
___
ED for evaluation, no spine imaging performed at that time.
Past Medical History:
Heart Murmur
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Temp: 98 °F, Pulse: 70, RR: 16, BP: 117/74, O2 sat: 100 RA
Gen: WD/WN, uncomfortable
HEENT:
Pupils: PERRL
EOMs: Intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
Deltoid BicepTricepGrip
Right 5 5 5 5
Left 5 5 5 5
IPQuadHamATEHLGast
Right3 5 5 5 5 5
Left 3 5 5 5 5 5
Sensation: Intact to light touch
Toes downgoing bilaterally
PHYSCIAL EXAMINATION ON DISCHARGE:
Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Follows Commands: [ ]Simple [x]Complex [ ]None
Speech Fluent: [x]Yes [ ]No
Comprehension Intact: [x]Yes [ ]No
Motor:
Trapezius Deltoid Biceps Triceps Grip
Right5 5 5 5 5
Left5 5 5 5 5
IP Quadriceps Hamstring AT ___ Gastrocnemius
Right4+ 5 5 5 5 5
Left4+ 5 5 5 5 5
*Weakness appears pain limited
[x]Sensation intact to light touch - Decreased BLE, improved
from
pre-op
Wound:
[x]Clean, dry, intact
[x]Staples
Pertinent Results:
Please see OMR for pertinent lab or imaging results.
Brief Hospital Course:
#T6 Lytic Lesion
The patient was admitted to the Neurosurgery service on ___
and underwent an ___ biopsy of the T6 lytic lesion. CT
torso done, which was negative except for a small sclerotic
focus on the left iliac bone. His case was discussed at ___
___ Conference on ___. Patient was taken to the operating
room urgently on ___ for decreased bladder control. He
underwent a T6 posterior vertebral/tumor resection, T4-T8
fusion. The case was uncomplicated. For full details, please see
dictated operative report by Dr. ___. There was an
800mL blood loss intra-op. Frozen sample most resembled giant
cell tumor, sample sent for pathology. Patient was taken to the
PACU, where he pain was controlled with IV medications. His diet
was slowly advanced and he was transferred to the floor. After
surgery, he had full strength and sensation in his bilateral
lower extremities, limited only by pain. He endorsed
post-surgical back pain, which was treated with a multi-modal
regimen. A post-operative MRI T spine was obtained, which was
negative for hematoma and showed expected post-op changes.
Patient was fitted for ___ brace, which he was instructed
to wear for one month when HOB>30 degrees or when out of bed. He
had a post-op T-spine Xray on POD2, which showed stable
placement of hardware and expected post-op changes. His drain
was removed on POD3, with post removal x-rays which were all
stable. He remained neurologically stable and was discharged to
rehab on ___ per recommendation of ___ and OT.
#Tachycardia
Patient became tachycardic on POD1. He did not endorse chest
pain or shortness of breath. EKG revealed sinus tachycardia.
Patient was given IV fluids and pain medications, which did not
help. STAT CTA chest was done, which was negative for PE. CBC
was sent, which revealed a drop in Hgb and Hct. He received 2
units of PRBC and his H&H up-trended. H/H continued to be
monitored closely through the remainder of his admission.
#Fever & leukocytosis
The patient had a fever, Tm of 102.3, on ___ with an elevated
WBC. Fever workup was sent. LENIs were negative. Urine analysis
was negative, urine cultures negative, and blood cultures which
were negative. He received Tylenol and the fever resolved.
Patient remained afebrile afterwards. WBC continued to be
elevated, therefore repeat urine cultures, blood cultures and
chest xray were obtained on ___. CXR and UA were negative.
Medicine was consulted for further recommendations. WBC down
trended and cultures were negative.
#Urine retention
Foley was placed intraop and removed on POD2. He failed void
trial and was bladder scanned with >999cc, requiring straight
catheterization x2. A foley was placed and patient was scheduled
for urology follow up after discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Do not exceed 4g/day
2. Bisacodyl 10 mg PO/PR DAILY
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Diazepam 5 mg PO Q8H:PRN pain
5. Docusate Sodium 200 mg PO BID
6. Gabapentin 400 mg PO Q8H
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
8. Polyethylene Glycol 17 g PO BID
9. Senna 8.6 mg PO BID
10. Tamsulosin 0.4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T6 lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Surgery
Your incision is closed with staples. You will need staple
removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your staples.
Please avoid swimming for two weeks after staple removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
You must wear your brace at all times when out of bed. You may
apply your brace sitting at the edge of the bed. You do not need
to sleep with it on.
You must wear your brace while showering.
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10353094-DS-19 | 10,353,094 | 25,612,717 | DS | 19 | 2183-01-06 00:00:00 | 2183-01-08 10:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Plavix
Attending: ___
Chief Complaint:
Subdural Hemorrage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with a history of CAD s/p 3 vessel
CABG and ___ aortic valve replacement on warfarin who
presents from OSH after MRI/MRA showed a 3mm collection c/w
subdural hemorrage. He was in his usual state of health until
the day prior to admission when he had an episode where he had
difficulty recalling family member names as well as a like he
was "talking with novacaine" that lasted 3 hours. He also said
that around this time he felt some "pressure" over the front of
his head but denies headache. He was aware of his symptoms
during this episode and talked to his daughter over the phone
who told him to call EMS when he was unable to recall the name
of her pets, kids and other loved ones. He was aware of his
symptoms during this episode and denies any weakness. He says
that he's had some transient episodes of forgetfulness like this
before for the past few years (eg forgetting where he is when
entering a supermarket) but these have always lasted form only
minutes at a time. Mr. ___ called his ___ office on the
morning of admission to describe these symptoms that he had the
previous night and was told to come to the ED for workup.
.
Of note he denies any recent falls but says that about a month
ago he got a large bruise on his chest when a tree branch hit
him while he was doing yardwork. He also reports some
lightheadeness for the past few months but has attributed this
to his flomax. He denies any weakness, numbeness, tinging,
vision changes, headaches, history of seizures or known stroke.
.
At OSH, MRI/MRA showing 3 mm collection c/w SDH along R cerebral
hemisphere. His INR was 3.6. He got Vitamin K 10 mg and Factor
IX complex human 2,000 units PTA and was transfered to ___ for
neurosurgical evaluation.
.
In the ___ ED, initial vitals: Temp: 97.4 HR: 62 BP: 129/69
Resp: 16 O(2)Sat: 94.
His neurological exam was reported to be nonfocal. He received
2u FFP. Neurosurgery was consulted and said that his imaging
showed very small chronic R frontal SDH for which neurosurgical
intervention was not indicated and the should restart
anticoagulation on ___. He was initially started on a heparin
drip and transfered to the floor. He was admitted to the
medicine floor for managment of his anticoagulation.
Vitals prior to transfer: 97.6 °F (36.4 °C), Pulse: 54, RR: 14,
BP: 115/67, O2Sat: 93 RA
.
Currently, he feels well and has no complaints. Denies any
current weakness, dizzyness, headache or changes in sensation.
Past Medical History:
-CAD - s/p CABG in ___ for 3 vessel diease and s/p ___
aortic valve during this admission for calcified aortic valve.
INR goal 2.5-3.5
-Bladder cancer - s/p intravesical therapy in ___ (___)
-Hyperlipidemia
-Anxiety
-s/p appendectomy
-s/p inguinal hernia repair
-s/p lumbar spin surgery - many years ago
Social History:
___
Family History:
- Mother died of PE.
- Father died at young age in WWII.
- Significant family history of alzeimers disease on mother's
side of his family.
- No family history of seizure disorders other neurologic
problems.
Physical Exam:
On Admission:
VS - Temp 97.6F, BP 136/60 , HR 58, RR 18, O2-sat 93% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA (4->3mm bilaterally), EOMI, sclerae
anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - RRR, loud S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition
"No ifs ands or buts".
Naming intact. No dysarthria or paraphasic errors.
Memory: Registers ___ objects and recall ___ objects at 5 mins.
CN:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3mm
bilaterally. III, IV, VI: Extraocular movements intact
bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength ___ in shoulder, biceps, triceps, finger
abductors. No pronator drift.
Sensation: Intact to light touch in all extremities distally.
Reflexes: reflexes 3+ at knees bilaterally, 2+ brachial
bilaterally. 2 beats of clonus in feet bilaterally. Downgoing
does bilaterally.
Cerebellar: Finger-nose-finger intact bilaterally, normal rapid
ulternating hand movements, normal heal-shin.
Clock Draw: normal.
On Discharge:
VS: 98.4/97.7, 105/63(98-132/40-60), 53 (53-60), 18, 93% on RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA (4->3mm bilaterally), EOMI, sclerae
anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - RRR, loud S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO: AO3x. Speech fluent with good comprehension. CN II-XII
intact. Full strenth in arms and legs bilatearlly. Reflexes 3+
knees bilaterally. ___ beats of clonus. Sensation to light touch
intact in all extremities. No tremors.
Pertinent Results:
___ 06:10AM BLOOD WBC-6.6 RBC-4.99 Hgb-13.1* Hct-40.1
MCV-80* MCH-26.2* MCHC-32.6 RDW-14.5 Plt ___
___ 11:30AM BLOOD WBC-7.3 RBC-5.44 Hgb-14.4 Hct-43.4
MCV-80* MCH-26.4* MCHC-33.2 RDW-14.5 Plt ___
___ 11:30AM BLOOD Neuts-64.6 ___ Monos-6.7 Eos-2.8
Baso-0.9
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-30.1 ___
___ 11:30AM BLOOD Plt ___
___ 11:30AM BLOOD ___ PTT-34.3 ___
___ 06:10AM BLOOD Glucose-100 UreaN-26* Creat-1.1 Na-137
K-4.4 Cl-105 HCO3-26 AnGap-10
___ 11:30AM BLOOD Glucose-106* UreaN-29* Creat-1.1 Na-137
K-4.7 Cl-105 HCO3-24 AnGap-13
___ 06:10AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.3
___ 11:30AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.4
CT head w/o Contrast
COMPARISONS: Outside hospital MR head ___ at 8:54
a.m.
TECHNIQUE: Contiguous axial MDCT images were obtained through
the brain
without administration of IV contrast. Axial images were
interpreted in
conjunction with coronal, sagittal, and thin slice bone
algorithm reformats.
FINDINGS: A subtle right cerebral subdural hematoma is
suspected, up to
perhaps 3 mm in thickness (2:15) corresponding to the
abnormality seen on
reference MR. ___ small hyperdense structure in the right frontal
extraaxial space appears to correspond to a vein seen on MR.
___ is no evidence of new hemorrhage, edema, mass effect, or
large territorial infarction. There is no shift of the normally
midline structures. The ventricles and sulci are mildly
prominent, compatible with age-related volume loss. The basal
cisterns appear patent, and there is preservation of the
gray-white matter differentiation. No fracture is identified.
The visualized paranasal sinuses and middle ear cavities are
clear. There is opacification of right mastoid air cells with
adjacent bone thickening, suggesting chronic inflammation. No
bone destruction is seen. The left mastoid air cells are clear.
The visualized portions of the globes are unremarkable.
IMPRESSION:
1. Suspected tiny small right-sided subdural hematoma without
evidence for increase.
2. Chronic right mastoid inflammation.
Brief Hospital Course:
# Episode of forgetfulness: Reesolved prior to admission.
Neurologic exam mostly nonfocal. Likely bilatearal hyperreflexia
in legs is due to previous l-spine surgery. The cause of this
episode is not completely certain. Given his age a strong family
history of alzheimer's disease and mild recall difficulties ___
objects at 5 mins) it is possible that he might have some
underlying memory deficits at baseline. However, this recent
episode seems to be more acute and possibly associated with some
word finding difficulites and facial numbness which makes TIA a
likely possibility. It would be unusual for his subdural
hemorrage to cause symptoms such as these without causing a
potentially more sustained deficit with more motor findings but
this is also on the differential. Electrolyte abnormalities
including hypoglycemia, seizure or infection were considered but
deemed unlikely given his presentation and normal labs. MRI/MRA
from OSH without evidence of ischemic insult to explain his
symptoms. He was monitored with q4h neurochecks HD1->2 and did
not have any evidance of new neurologic symptoms. ___ was
discharged with plan to obtain outpatient neurology followup for
his forgetfullness.
.
# Subdural hemorrage: Found on OSH MRI/MRA. CT here consistant
with old small subdural. He does not recall any trauma related
to this but unrecalled minor trauma along with his high goal INR
make him susceptible to bleeds. His neurologic exam is nonfocal
and hypereflexia in the legs is likely due to lumbar surgery in
the past. He was seen by neurosurgery who did not think that
there was any need for surgical intervention. Heparin was
initially held overnight due to initially unclear risk for
rebleed but lovenox was restared on HD2 with plan to bridge to
warfarin as his INR had dropped to 1.2.
.
# CAD s/p CABG and ___ aortic valve: Cardiology was
consulted and is ok to hold coagulation for up to 5 days without
large risk for thrombosis. Further discussion with neurosurgery
revealed that risk for re-bleed was low given the chronic nature
of the subdural so he was started on lovenox with a bridge to
warfarin on HD2. Followup with his cardiologist was arranged on
discharge.
.
# BPH: stable. He was continued on home tamsulosin.
# Hyperlipidemia: Stable. He was continued on home rosuvastatin
# Anxiety: Stable. Continued on home escitalopram.
.
# Transition issues:
- repeat INR on ___
- outpatient cardiology followup
- consider echo w/ bubble study as an outpatient
- outpatient neurology followup
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Warfarin 10 mg PO DAILY16
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. Aspirin 81 mg PO DAILY
6. Rosuvastatin Calcium 20 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL 1 twice a day Disp #*30 Syringe
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Warfarin 10 mg PO DAILY16
8. Outpatient Lab Work
Please have your INR checked on ___. ICD 9
V43.3. Have this faxed to ___ ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Subdural Hemorrage, Possible Transient Ischemic Attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for word finding difficulties. Your head
imaging did not show a stroke, but did show a small and chronic
subdural hematoma. We held your coumadin to monitor you
overnight. Because you have an mechanical aortic valve, our
cardiolgists would like you to be bridged with enoxaperin until
your INR is therapeutic. We have discussed this with the
neurosurgeons. We have started you on lovenox. You can
continue the rest of your medications, including your coumadin
at your home dose.
You should take enoxaperin until your INR levels are between
2.5-3.5. Please have these checked ___. Dr.
___ will tell you when you can stop the enoxaperin. It is
important to take this because a mechanical valve is predisposed
to developing clots. This is a blood thinner, should you have
new neurologic symptoms or signs of bleeding, please tell your
cardiologist immediately.
Please follow up with your cardiologist as below who will
consider if you need to get an echocardiogram with a bubble
study.
Please follow up with neurology as below.
Followup Instructions:
___
|
10353397-DS-12 | 10,353,397 | 23,569,343 | DS | 12 | 2170-10-05 00:00:00 | 2170-10-06 10:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Pleural catheter placement ___
History of Present Illness:
Ms. ___ is a ___ female with recently
diagnosed metastatic RCC complicated by left malignant pleural
effusion who presents with shortness of breath and weakness.
Patient reports progressive shortness of breath over the past
week. She had trouble walking up the stairs to her bedroom due
to
her breathing. She also notes feeling more weak. She denies any
falls. She has spent most of her time in bed or on the couch.
Her
husband has needed to assist her with walking around the home.
She does not use a cane or walker. She also reports poor
appetite
and believes she has lost weight but unable to quantify. She has
occasional nausea with dry heaves as well as lightheadedness and
a persistent mild dry cough. Her niece who is an NP saw her
today
and found he O2 sats to be in the ___ with an irregular
heartbeat
so called her Oncologist and brought her to the ED.
On arrival to the ED, initial vitals were 97.7 95 130/80 20 96%
3L. Exam was notable for crackles at bilateral bases and
accessory respiratory muscle use. Labs were notable for WBC
10.9,
H/H 7.8/26.5, Plt 398, INR 1.3, Na 129, K 4.2, BUN/Cr ___,
trop
< 0.01, lactate 1.8, and UA negative. Blood and urine cultures
were sent. CXR showed large left pleural effusion. Patient was
given cefepime 2g IV. Prior to transfer vitals were 97.9 88
114/67 20 96% 3L.
On arrival to the floor, patient reports feeling her breathing
is
improved. She denies fevers/chills, night sweats, headache,
vision changes, hemoptysis, chest pain, palpitations, abdominal
pain, vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
-Hypertension
-Colonic polyps
-Hyperlipidemia
-Bradycardia (first-degree AV block, asymptomatic)
-Dermatofibroma, seborrheic keratoses, actinic keratosis
-Ovarian cystectomy
Social History:
___
Family History:
History of lung cancer in brother and sister (both smokers).
Colon cancer (father). History of gastric ulcers in siblings.
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
VS: Temp 97.9, BP 120/70, HR 92, RR 32, O2 sat 96 on 2.5L.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in mild respiratory distress, decreased breath
sounds on left halfway up lung field.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
========================
DISCHARGE PHYSICAL EXAM
========================
GENERAL: elderly woman lying in bed with HOB elevated, appears
comfortable, not dyspneic with conversation
HEENT: AT/NC, anicteric sclera, MMM
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: persistent crackles in the left lung field, no wheezes
ABD: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXT: wwp, no cyanosis or edema
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
=====================
ADMISSION LAB RESULTS
=====================
___ 03:03PM BLOOD WBC-10.9* RBC-3.06* Hgb-7.8* Hct-26.5*
MCV-87 MCH-25.5* MCHC-29.4* RDW-16.7* RDWSD-52.7* Plt ___
___ 03:03PM BLOOD Neuts-74.7* Lymphs-14.0* Monos-6.9
Eos-0.2* Baso-0.3 Im ___ AbsNeut-8.15* AbsLymp-1.53
AbsMono-0.75 AbsEos-0.02* AbsBaso-0.03
___ 03:03PM BLOOD ___ PTT-29.5 ___
___ 03:03PM BLOOD Glucose-128* UreaN-8 Creat-0.5 Na-129*
K-4.2 Cl-94* HCO3-22 AnGap-13
___ 03:03PM BLOOD ALT-15 AST-24 AlkPhos-293* TotBili-0.4
___ 03:03PM BLOOD cTropnT-<0.01
___ 03:03PM BLOOD proBNP-484
___ 03:03PM BLOOD Albumin-2.1* Calcium-7.0* Phos-2.1*
Mg-2.2
___ 03:14PM BLOOD ___ pO2-26* pCO2-35 pH-7.46*
calTCO2-26 Base XS-0
___ 03:14PM BLOOD Lactate-1.8
=====================
IMAGING AND REPORTS
=====================
CXR ___
IMPRESSION:
Substantial increase in now large left pleural effusion, with
subsequent
rightward shift of the cardiac silhouette. Small right pleural
effusion.
Evidence of pulmonary nodularity seen in the region of the right
mid to lower lung.
CXR ___
1. Interval placement of a left-sided chest tube with
substantial interval
decrease in size of a left pleural effusion, now trace in
appearance.
2. Minimal streaky opacities at the left lung base may represent
atelectasis,
however the possibility of slight re-expansion edema should also
be
considered.
3. Mild cardiomegaly and mild pulmonary vascular congestion.
======================
DISCHARGE LAB RESULTS
======================
___ 06:47AM BLOOD WBC-11.1* RBC-3.10* Hgb-8.0* Hct-26.4*
MCV-85 MCH-25.8* MCHC-30.3* RDW-16.9* RDWSD-52.2* Plt ___
___ 06:47AM BLOOD Plt ___
___ 06:47AM BLOOD Glucose-139* UreaN-8 Creat-0.5 Na-133*
K-4.5 Cl-96 HCO3-24 AnGap-13
___ 06:47AM BLOOD Calcium-7.1* Phos-2.5* Mg-2.5
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of hypertension,
anemia and metastatic renal cell carcinoma diagnosed in ___ by mediastinal lymph node biopsy with known metastases to
lung, bone, mediastinal/hilar and periaortic lymph nodes s/p
initiation of treatment with Nivolumab/Zometa (C1D1 ___ who
presents with dyspnea due to recurrent malignant pleural
effusion. She underwent placement of a PleurX catheter with IP
and was discharged to rehab.
ACUTE PROBLEMS:
===============
# Acute hypoxemic respiratory failure
# Recurrent malignant left pleural effusion
Patient developed respiratory symptoms a few months ago which
led to initial thoracentesis and subsequent diagnosis of renal
cell carcinoma. She was discharged and developed recurrent
dyspnea. She was admitted for hypoxemia and drainage due to
evidence of large left pleural effusion. She underwent placement
of PleurX catheter on ___ with interventional pulmonary team.
She drained about 2 liters of fluid and her dyspnea hypoxemia
improved. Plan is to open the catheter to drain every
___. She will follow up with IP in the next few weeks.
She was not treated with antibiotics due to low concern for
infection; pleural fluid culture was negative.
CHRONIC PROBLEMS:
=================
# Metastatic renal cell carcinoma
She was started on Nivolumab/Zometa on ___ by her oncologist Dr.
___. She was scheduled for outpatient bone scan but due to
hospitalization she missed this appointment. She will need to
reschedule upon discharge.
# Cough
Continue home benzonotate and guaifenesin
# Weakness and fatigue
___ recommends rehab for deconditioning.
# Hypertension
Continue home amlodipine.
# Anemia
Continue home iron supplement.
===========================
TRANSITIONAL ISSUES
===========================
[ ] Reschedule outpatient bone scan; patient missed her
appointment while hospitalized
[ ] Open pleural catheter to drain every ___
[ ] Follow up with IP for monitoring of drain
CODE: Full Code (presumed, day team to confirm in AM)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___. (husband)
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO QPM
2. Benzonatate 100 mg PO TID:PRN cough
3. Vitamin D ___ UNIT PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Ondansetron ODT 4 mg PO BID:PRN nausea/vomiting
6. guaiFENesin 200 mg oral Q4H:PRN cough
Discharge Medications:
1. amLODIPine 5 mg PO QPM
2. Benzonatate 100 mg PO TID:PRN cough
3. Ferrous Sulfate 325 mg PO DAILY
4. guaiFENesin 200 mg oral Q4H:PRN cough
5. Ondansetron ODT 4 mg PO BID:PRN nausea/vomiting
6. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
-Malignant pleural effusion
Secondary:
-Metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for worsening shortness of breath.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have fluid reaccumulating around your lung.
This is related to your cancer.
- The interventional pulmonary team placed a catheter into your
chest to drain the fluid around the lung.
- You were evaluated by physical therapy, who recommended rehab
to help you regain your strength.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10353397-DS-14 | 10,353,397 | 28,653,026 | DS | 14 | 2170-11-04 00:00:00 | 2170-11-04 13:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with recently
diagnosed metastatic RCC complicated by left malignant pleural
effusion who presents s/p TPC, PE/DVT on Xarelto, paroxysmal
atrial fibrillation, and hypertension who presents with weakness
and shortness of breath.
Patient was recently ___ to ___ with acute dyspnea and found
to
have PE/DVT started on Xarelto. Her dyspnea was thought to be
multifactorial to malignant pleural effusion, PE, lymphangitic
carcinomatosis, and pulmonary nodules. Plan was made to start
cabozantinib urgently. She was discharged to rehab.
She reports that she had been recovering slowly in rehab and
ambulating with a walker since her recent discharge. She reports
that she was having her baseline dyspnea on exertion until this
morning when she was taken to the restroom without her oxygen
(the tubing did not reach far enough). When returning she had
sudden onset of shortness of breath. She had O2 increased to 5L
from ___ at baseline. She was told that her heart rate was fast
and blood pressure was low. She denies any chest pain or
palpitations.
Her husband reports that her Cabozantinib will be delivered in
afternoon of ___ and then he will bring it into the hospital.
On arrival to the ED, initial vitals were 97.7 83 97/59 18 97%
RA. Exam was notable for tachycardia and peripheral edema. Labs
were notable for WBC 11.1, H/H 8.0/27.8, Plt 275, INR 2.5, Na
132, K 5.5 -> 4.7, BUN/Cr ___, tropT < 0.01, BNP 797, lactate
3.0 -> 1.9, and UA negative. Blood and urine cultures were sent.
CXR showed bilateral pleural effusions and persistent moderate
interstitial abnormality. Patient went into rapid afib with
hypotension and was cardioverted 200J x 2 (sedated with fentanyl
25mcg IV and versed 2mg IV) with return to sinus rhythm. She was
seen by IP and left TPC was attached to pleurovac and
recommended
to place to -20 wall suction. Patient was given zosyn 4.5g IV,
vancomycin 1g IV, and 500cc NS. Prior to transfer vitals were
98.1 97 101/54 27 94% 2L.
On arrival to the floor, patient reports her breathing is
improved and back to baseline. She notes some difficulty
urinating as well as some discharge from her right eye that is
not painful or itchy. She denies fevers/chills, night sweats,
headache, vision changes, dizziness/lightheadedness,
weakness/numbness, cough, hemoptysis, chest pain, palpitations,
abdominal pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
-Hypertension
-Colonic polyps
-Hyperlipidemia
-Bradycardia (first-degree AV block, asymptomatic)
-Dermatofibroma, seborrheic keratoses, actinic keratosis
-Ovarian cystectomy
-Recurrent malignant left pleural effusion s/p pleurX
-Metastatic RCC
Social History:
___
Family History:
History of lung cancer in brother and sister
(both smokers). Colon cancer (father). History of gastric ulcers
in siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.3, BP 104/67, HR 91, RR 22, O2 sat 92% 2L.
GENERAL: Pleasant fatigued-appearing woman, in no distress,
lying
in bed comfortably.
HEENT: Anicteric, yellow discharge from right eye without
conjunctive erythema, PERLL, OP clear.
CARDIAC: RRR, no murmurs.
LUNG: Appears in no respiratory distress, decreased sounds at
bilateral bases, left TPC in place.
ABD: Soft, non-tender, non-distended, positive bowel sounds.
EXT: Warm, well perfused, trace bilateral lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
==============================
Discharge physical exam:
GENERAL: sitting up in bed, NAD. appears comfortable
CV: regular rate, rhythm. no m/r/g
PULM: chest tube in place, capped. lung fields with bl crackles
at bases. no wheezing
ABD: soft, ND. +BS. no TTP
Extremities: WWP, no ___ edema
Pertinent Results:
ADMISSION LABS:
___ 10:38AM BLOOD WBC-11.1* RBC-3.09* Hgb-8.0* Hct-27.8*
MCV-90 MCH-25.9* MCHC-28.8* RDW-17.2* RDWSD-56.3* Plt ___
___ 10:38AM BLOOD Glucose-249* UreaN-19 Creat-0.7 Na-132*
K-5.5* Cl-97 HCO3-15* AnGap-20*
___ 10:38AM BLOOD ALT-32 AST-52* AlkPhos-411* TotBili-0.3
___ 03:48PM BLOOD Albumin-1.5* Calcium-7.3* Phos-3.6 Mg-1.9
___ 11:56AM BLOOD pO2-38* pCO2-46* pH-7.37 calTCO2-28 Base
XS-0 Comment-GREEN TOP
___ 11:56AM BLOOD Lactate-3.0* K-4.6
CXR:
Very similar appearance of the chest with persistent moderate
interstitial
abnormality in bilateral pleural effusions. Prior studies
suggested that at least for the most part the interstitial
abnormality is due to lymphangitic carcinomatosis.
Pelvic Ultrasound
TECHNIQUE: Grayscale ultrasound images of the pelvis were
obtained with transabdominal approach followed by transvaginal
approach for further delineation of uterine and ovarian anatomy.
FINDINGS:
The uterus is anteverted and measures 8.0 cm x 4.1 cm x 4.5 cm.
The endometrium is heterogenous and measures 26 mm. Equivocal
vascularity demonstrated in the thickened endometrium.
The ovaries are normal. There is minimal free fluid.
IMPRESSION: Heterogenous thickened endometrium with equivocal
internal vascularity. Correlation with endometrial biopsy
advised
DISCHARGE LABS
Hgb 9.0, wbc 6.9, plt 188
BMP: ___
Brief Hospital Course:
Ms. ___ was admitted to the hospital and immediately
transfused one unit of PRBCs. She was started on cabozanatib
that evening. Her course was complicated by worsening hypoxic
respiratory failure -- likely driven by enlarging left pleural
effusion, perhaps in the setting of starting cabozanatib, which
resolved with two doses of IV furosemide, as well as severe
constipation requiring manual disimpaction. Her carbozanatib
was increased on ___ to 40 mg daily and she was monitored for
side effects without any. Her course was complicated by vaginal
bleeding on ___. Workup with a pelvic ultrasound showed a
thickened endometrium. Gynecology was consulted and discussed
endometrial biopsy with patient. After discussion, pt decided to
not pursue biopsy as she does not wish to pursue hysterectomy in
the case that biopsy positive for endometrial cancer (no
chemotherapy options).
HOSPITAL COURSE BY PROBLEM:
# Chronic Hypoxic Respiratory Failure
# PE/DVT
# Left Malignant Pleural Effusion s/p TPC
# Lymphangitic carcinomatosis
Patient with multifactorial chronic hypoxemic respiratory
failure due to RCC with malignant pleural effusion, and
lymphangitic carcinomatosis as well as recently diagnosed PE.
Patient had one episode of acute worsening of her hypoxemia iso
A fib with RVR which responded to lasix 40 mg IV x2. She had an
extensive work up on recent hospitalization that showed that
interstitial infiltration on CXR was more c/w lymphangitic
spread of cancer as opposed to pulmonary edema. She was trialed
on PO diuretics at that time without good effect. For that
reason, further direusis was not pursued on this
hospitalization. Pt was continued on her DOAC and initially had
her pleurX catheter uncapped and draining due to increased
drainage iso chemotherapy initiation. Catheter was capped ___
and ___ drainage was resumed. She was continued on rivaroxaban
(15mg BID until ___ and then start 20mg QD on ___ and
supplemental O2. She has follow up with interventional
pulmonology on ___ for consideration chest tube discontinuing.
# Vaginal bleeding
Episode of dark red blood ___. No stool mixed in. Upon
exam, blood near vaginal canal. Pelvic US with thickened
endometrium. Gynecology consulted and discussed risk and
benefits of endometrial biopsy with patient. After discussion,
pt decided to not pursue biopsy as she does not wish to pursue
hysterectomy in the case that biopsy positive for endometrial
cancer (no chemotherapy options). Hemoglobin remained stable in
spite of anticoagulation, which was continued given recent PE
diagnosis.
# Paroxsymal Atrial Fibrillation:
Required cardioversion while in ED; she was in NSR throughout
the remainder of her hospitalization. She was started on
metoprolol succinate 12.5 mg daily with good effect and she was
cont on AC as above
# Metastatic RCC:
# Secondary Neoplasm of Bone:
# Secondary Neoplasm of Lung:
# Secondary Neoplasm of Lymph Node:
She was started cabozantinib ___ at 20 mg daily. Dose was
increased to 40 mg daily on ___. She was monitored after
increase in medication and will need close follow up with Dr.
___
# Anemia in Malignancy: There was no evidence of bleeding. She
received 1 unit PRBCs, and hemoglobin was stable thereafter.
# Hyponatremia. Resolved with blood and cabozantinib.
# Constipation
# Bleeding hemorrhoids. s/p manual disimpaction on ___. After
disimpaction pt with regular BMs without e/o bleeding
=========================================
Transitional Issues:
[ ] Continued on rivaroxaban 15mg BID for recent PE. Please
decrease to 20mg QD starting on ___
[ ] A fib with RVR on admission requiring cardioversion. Started
on metop succinate 12.5 daily with good effect
[ ] Continue with cabozantinib 40 mg daily. Will f/up with
oncologist, Dr ___ consideration of dose increase on ___
[ ] Follow up with interventional pulmonary on ___ for
consideration of chest tube discontinuation
[ ] Vaginal bleeding noted during hospitalization. Pt does not
wish to pursue biopsy as she is not interested in operative
management if it were to be positive for malignancy. H/H stable.
Continue to monitor and use pads for bleeding
[ ] Please continue ___ conversations iso non resectable
metastatic ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Ferrous Sulfate 325 mg PO DAILY
3. Milk of Magnesia 30 mL PO DAILY:PRN constipation
4. Ondansetron ODT 4 mg PO BID:PRN nausea/vomiting
5. Vitamin D ___ UNIT PO DAILY
6. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia
7. Mirtazapine 15 mg PO QHS
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Rivaroxaban 15 mg PO BID
10. Benzonatate 100 mg PO TID:PRN cough
11. guaiFENesin 200 mg oral Q4H:PRN cough
Discharge Medications:
1. cabozantinib 40 mg oral DAILY
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Polyethylene Glycol 17 g PO BID
5. Benzonatate 100 mg PO TID:PRN cough
6. Bisacodyl 10 mg PO DAILY:PRN constipation
7. Ferrous Sulfate 325 mg PO DAILY
8. guaiFENesin 200 mg oral Q4H:PRN cough
9. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety/insomnia
10. Milk of Magnesia 30 mL PO DAILY:PRN constipation
11. Mirtazapine 15 mg PO QHS
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Ondansetron ODT 4 mg PO BID:PRN nausea/vomiting
14. Rivaroxaban 15 mg PO BID 15mg BID until ___ and then start
20mg
QD on ___. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital feeling very weak and with low
blood counts (anemia) in the setting of your cancer. You also
had atrial fibrillation and required cardioversion. You were
started on a new medication called metoprolol. You received a
unit of blood and were started on cabozantinib with much
improvement in your symptoms. Otherwise, had some worsened
breathing which also got better, and you had constipation which
required manual disimpaction. You will follow up with Dr. ___
to track the progress of your chemotherapy. It has been a
pleasure taking care of you!
Followup Instructions:
___
|
10353722-DS-16 | 10,353,722 | 20,733,099 | DS | 16 | 2175-09-15 00:00:00 | 2175-08-30 13:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, dehydration s/p colostomy takedown
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a history of CAD, hypertension,
diabetes, hyperlipidemia, Lap transverse colectomy and colostomy
reversal by Dr. ___ presenting with weakness, fatigue, ___,
abdominal distention. Patient was discharged home after surgery
1
week ago. Reports for 3 days he has had abdominal distention,
decreased flatus. Having his same watery stools that he has had
for a month. No nausea or vomiting. No fever or chills. No chest
pain, shortness of breath, cough. Patient presented to an
outside
hospital where he appeared to be near syncopal, blood pressure
70/30 responsive to fluids. Patient was transferred for
continuity.
Past Medical History:
PMH:
MI s/p PCI x 3 on DAPT
HTN
NIDDM
COPD
PSH:
___ colostomy
Social History:
___
Family History:
No Family History of colon cancer
positive for prostate cancer in father
mother with possibly GYN malignancy.
Physical Exam:
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, No JVD
PULM: normal excursion, no respiratory distress
ABD: soft, ND, no mass, nontender throughout
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Brief Hospital Course:
___ h/o diverticulitis s/p ___ and subsequently discovered
transverse colon Ca s/p lap transverse colectomy & colostomy
reversal p/w weakness, dehydration. Patient was discharged home
after surgery 1 week before presenting to the ED. Patient
reported for 3 days he has had abdominal distention, decreased
flatus and continued watery stools for about a month. Patient
presented to an outside hospital where he appeared to be near
syncopal, blood pressure 70/30, responsive to fluids. Patient
was transferred for further management. C diff was sent and came
back positive. Patient was made NPO and Cipro/flagyl/PO vanco
was started. CT scan overnight showed no SBO but did show gas in
the mesentery posterior to the residual transverse colon
suggestive of microperforation. Since the patient's abd was
benign, he was just treated with antibiotics. On presentation,
the patient also had an ___, which slowly improved with IVF
(Creatinine 1.7 from 2.1 from 2.7). The patient's ___ continued
to improve, Cr 1.4 from 1.6. Hct 18.5, guiac stool positive,
negative stool heme. The patient also developed hyponatremia (Na
129 from 133) so fluids changed to normal saline for
resuscitative purposes. On ___, CT with rectal contrast was
done to assess questionable leak. The CT showed locules of gas
layering dependently posterior to the residual transverse colon.
Rectal contrast within this region appeared contained to an
area measuring approximately 7.4 x 3.5 cm. This suggested
perforation vs. stool ball vs. ulcerated lesion. There was no
evidence of leak at the anastomosis site in the mid pelvis.
There was interval decrease in size in the loculated fluid
collections along the left anterior mid pelvis. On ___, the ___
continued to be improving, Cr 1.0 from 1.4. Hct was stable.
Hyponatremia resolved. By this time, the patient was on full
liquids, abd was benign, but did continue to have watery stools.
On ___, the ___ again improved with Cretinine at 1.0. Hct
decreased to 18.4 and 2 units of PRBC were ordered. Hematology
consulted for anemia: diagnosed with thalassemia and Anemia of
chronic disease. Cardiology consulted
for ability to stop Plavix and additional anticoagulants in the
setting of anemia, and they said patient was able to stop it.
The patient continued on full liquids with supplements. By ___,
the Cr again improved to 0.8. Hct 25.9 . The patient was bolused
1L for multiple liquid BMs, given a regular diet. Cholestyramine
was added to slow down the bowel movements. On ___, cipro and
flayl were d/c'd. Vanc was continued. CT A/P shows no evidence
of leak or perforation. On ___, Crit dropped and 1 unit was
transfused. Vanc was stopped on ___. On ___ overnight, the
patient spiked a fever to 101. A fever work up was sent. UA was
negative. Blood cx and Urine cx were pending. The patient's
fever resolved, and he clinically complained of no symptoms, so
it was felt that the patient was ready for discharge with a
cholestyramine prescription.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Cyclobenzaprine 5 mg PO HS:PRN spasm
5. Atorvastatin 80 mg PO QPM
6. Ferrous Sulfate 325 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. meloxicam 7.5 mg oral DAILY
9. Cilostazol 100 mg PO BID
10. Clopidogrel 75 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. GlipiZIDE XL 5 mg PO DAILY
13. Hydrochlorothiazide 12.5 mg PO DAILY
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Cyanocobalamin 250 mcg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. Cholestyramine 4 gm PO BID
RX *cholestyramine (with sugar) 4 gram 1 powder(s) by mouth
twice a day Refills:*0
4. Psyllium Wafer 2 WAF PO TID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Cilostazol 100 mg PO BID
8. Cyanocobalamin 250 mcg PO DAILY
9. Cyclobenzaprine 5 mg PO HS:PRN spasm
10. Docusate Sodium 100 mg PO BID
11. Ferrous Sulfate 325 mg PO DAILY
12. GlipiZIDE XL 5 mg PO DAILY
13. Hydrochlorothiazide 12.5 mg PO DAILY
14. Levothyroxine Sodium 50 mcg PO DAILY
15. Losartan Potassium 100 mg PO DAILY
16. meloxicam 7.5 mg oral DAILY
17. Metoprolol Succinate XL 50 mg PO DAILY
18. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C. diff
Microperforation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Hello Mr. ___,
You were admitted here for dehydration and weakness and
treatment of C. difficile, causing loose stools. Since then, you
have done well, and are now ready for discharge. You are
tolerating a regular diet, your stools have improved and you
received treatment for the C difficile. You will need to follow
up with us in clinic, and these instructions will be provided
for you.
Sincerely,
Colorectal Surgery Team
Followup Instructions:
___
|
10353794-DS-18 | 10,353,794 | 26,216,293 | DS | 18 | 2174-05-15 00:00:00 | 2174-05-16 12:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
morphine / Toradol / nortriptyline
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w complicated history of choledocholithiasis, gallstone
pancreatitis and subsequent development of a large pancreatic
pseudocyst that was obstructing the duodenum requiring J tube
for feeding (which has subsequently been removed). He also has a
history of portal vein thrombosis and was being anticoagulated
with Coumadin until he was told he could discontinue this
medication recently. He reports chronic abdominal pain which has
worsened in the past week. He describes subjective chills at
home and vomiting X4. He is passing flatus and having normal
bowel movements, while taking creon with meals. He has not tried
any new foods recently. He denies sick contacts or recent travel
out of the country. He denies blood in his stool or vomit. He
has no difficulty urinating.
Past Medical History:
PMH Diabetes mellitus type 2, portal vein thrombosis, history
of chronic pancreatitis, ___ esophagus, HTN, vitamin D
deficiency, varicose veins
PSH: cholecystectomy, inguinal hernia repair, knee surgery,
Right elbow surgery
Social History:
___
Family History:
No family history of pancreas disorders. His mother died of C.
difficile at age ___. His father had dementia and diabetes and
died at age ___.
Physical Exam:
Admission Physical Exam:
Temp: 98.3 HR: 78 BP: 141/99 Resp: 18 O(2)Sat: 97 Normal
Constitutional: Comfortable, awake and alert
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits, mucous membranes moist
Chest: Clear to auscultation, normal effort
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: distended, diffusely TTP
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent, moving all extremities
Psych: Normal mood, Normal mentation
Discharge Physical Exam:
VS:98.0, 78, 108/57, 18, 95 RA
Gen: Awake, alert, interactive and appropriate
HEENT: PERRL, EOMI. no deformity, mucus membranes pink moist.
trachea midline, neck supple.
Chest: RRR
Lungs: Clear to auscultation bilaterally.
Abd: Soft, moderately tender to palpation diffusely > LLQ,
mildly distended.
Skin: Grossly intact. Warm and dry.
Ext: no edema. 2+ ___ pulses.
Neuro: A&Ox3. Follows commands, moves all extremities equal and
strong. Speech is clear and fluent.
Pertinent Results:
___ 05:40AM BLOOD WBC-6.3 RBC-4.76 Hgb-13.7 Hct-39.5*
MCV-83 MCH-28.8 MCHC-34.7 RDW-12.5 RDWSD-37.9 Plt ___
___ 01:50PM BLOOD WBC-8.1 RBC-5.64 Hgb-16.4 Hct-47.0 MCV-83
MCH-29.1 MCHC-34.9 RDW-13.1 RDWSD-39.0 Plt ___
___ 01:50PM BLOOD Neuts-73.7* ___ Monos-5.7
Eos-0.0* Baso-0.5 Im ___ AbsNeut-5.99 AbsLymp-1.60
AbsMono-0.46 AbsEos-0.00* AbsBaso-0.04
___ 05:40AM BLOOD Plt ___
___ 01:50PM BLOOD Plt ___
___ 01:50PM BLOOD ___ PTT-30.3 ___
___ 05:40AM BLOOD Glucose-103* UreaN-16 Creat-0.8 Na-138
K-4.3 Cl-104 HCO3-21* AnGap-17
___ 05:55AM BLOOD Glucose-106* UreaN-15 Creat-1.0 Na-143
K-4.1 Cl-107 HCO3-26 AnGap-14
___ 01:50PM BLOOD Glucose-183* UreaN-15 Creat-0.9 Na-138
K-5.3* Cl-103 HCO3-20* AnGap-20
___ 05:40AM BLOOD ALT-31 AST-22 AlkPhos-72 TotBili-1.0
___ 05:55AM BLOOD ALT-39 AST-28 AlkPhos-68
___ 01:50PM BLOOD ALT-48* AST-44* AlkPhos-74 TotBili-0.6
___ 05:40AM BLOOD Lipase-25
___ 05:55AM BLOOD Lipase-18
___ 01:50PM BLOOD Lipase-25
___ 05:40AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
___ 01:55PM BLOOD Lactate-1.7
___ CT Abd/Pelvis
1. Mild intrahepatic biliary ductal dilation is slightly worse
compared to
prior exam.
2. Multiple ovoid hypodensities in the spleen, the largest
measuring up to 8 mm, are indeterminate, but could represent
isolated microabscess, or new focal lesions.
3. Hepatic steatosis and splenomegaly are again seen. Focal
liver
hypodensities are again seen.
4. No pneumoperitoneum, necrotizing pancreatitis, fluid
collection, or bowel obstruction.
___ MRCP
1. Multiple rounded lesions in the spleen are unchanged compared
with CT
abdomen pelvis on ___, however are new compared with
MRI liver on ___. Differential diagnosis includes
progression of splenic
infarcts versus granulomas. Although these lesions do not have
typical
peripheral wedge shaped appearance of splenic infarct,
development of multiple granulomas since prior MRI would also be
unusual. There are no worrisome features for tumor or
abscesses. 3 month follow-up MRI is recommended to ensure
stability.
2. Multiple subcapsular hepatic lesions are stable from prior,
and likely
represent focal fat deposition in the background of mild hepatic
steatosis.
3. Unchanged appearance of the biliary tree status post
cholecystectomy, no evidence of stones, masses or cysts.
Brief Hospital Course:
Mr. ___ is a ___ yo M admitted to the Acute Care Surgery
service on ___ with increasing abdominal pain. He has a
complicated history of choledocolithiasis, gallstone panreatitis
and subsequent development of a large pancreatic pseudocyst in
___. He has chronic abdominal pain that worsened in the past
week. He had a CT scan and MRCP which were unremarkable. He was
admitted to the surgical floor for further evaluation and pain
control.
He was seen and evaluated by the ___ Surgery team who
agreed that there is no acute surgical need at this time and
recommended outpatient follow-up with Dr. ___ for
___ chronic pain.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV dilaudid
and then transitioned to oral oxycodone once tolerating a diet.
He is managed by a chronic pain specialist outpatient and
resumed on his home regimen.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with IV fluids.
On HD2 his diet was advanced to clear and subsequently to
regular on HD3 which he tolerated well. He abdomen remained
tender but reportedly at baseline. Patient's intake and output
were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. Follow up appointments were
scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
2. Glargine 30 Units Breakfast
Glargine 30 Units Dinner
Humalog Unknown Dose
3. Creon ___ CAP PO QIDWMHS
4. Omeprazole 40 mg PO DAILY
5. Pregabalin 25 mg PO DAILY
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp
#*15 Tablet Refills:*0
2. Omeprazole 40 mg PO DAILY
3. Glargine 30 Units Breakfast
Glargine 30 Units Dinner
4. Creon ___ CAP PO QIDWMHS
5. Pregabalin 25 mg PO DAILY
6. Vitamin D ___ UNIT PO 2X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic pancreatitis
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
with abdominal pain and inability to tolerate a regular diet.
You had a CT scan and MRCP that did not reveal any new acute
problems. Your pain was most likely related to chronic
pancreatitis. You were given IV fluids and pain medication. You
were gradually advanced to a regular diet. You are now
tolerating a regular diet, on your home medications, and are
ready to be discharged to home to continue your recovery.
Please follow up with your outpatient pain management provider
as needed.
We recommend that you follow up with your primary care provider
___ 30 days of discharge from the hospital. Please talk to
your provider about scheduling ___ repeat MRI in 3 months to
follow up on new lesions noted in your spleen.
We scheduled you and appointment with Dr. ___ as
listed below.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
___
|
10354217-DS-13 | 10,354,217 | 24,115,619 | DS | 13 | 2159-03-28 00:00:00 | 2159-03-28 17:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / adhesive tape / Cephalexin / Percocet
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o woman with PMHx EtOH cirrhosis c/b esophageal varicies
(last EGD ___ and ascites, HTN, HLD and AS s/p bioprosthetic
AVR in ___ (last TTE ___, mean AV gradient 24) presenting
with SOB. She states that she last felt in her USOH in ___.
At that time she was able to walk her dogs ___ mile, 8 times per
day. Since then, she has noted progressive DOE; currently she is
only able to walk 20 feet before needing to stop and rest. She
denies any recent CP or pedal edema. For the past 36 hours she
has noted orthopnea, which is new for her and some PND. She is
not sure if she has gained weight recently. She denies personal
history of CAD, CHF or MI, though she has a very strong family
history of early CAD. She denies syncope and states she has
never had exertional CP before.
.
Initial VS in the ED:
T 96.9 HR 61 BP 125/41 RR 18 O2 Sat 95% RA
Labs were notable for BNP 5230, trop <0.01, normal CBC, normal
lytes. CXR showed moderate pulmonary edema, b/l pleural
effusions L>R, and cardiomegaly, which is new compared to study
dated ___. She was given Lasix 80mg IV x1 and admitted to
medicine. She received Lasix 80mg IV in the ED at 01:15, to
which she had put out 400cc of urine on arrival to the floor at
02:45.
.
On the floor, initial VS were:
T 98 BP 115/57 HR 65 RR 18 O2 Sat 95% 2L (88% RA)
Past Medical History:
Aortic stenosis
Hypertension
Hypercholesterolemia
Asthma
Gastroesophageal Reflux Disease
s/p r. Total Hip Replacement ___
s/p Tonsillectomy
Social History:
___
Family History:
father died during CEA. Mom had RA. No FH of liver problems,
diabetes, emphysema.
Physical Exam:
ADMISSION Physical Exam:
T 98.2 BP 125-128/57-66 HR 56-65 RR 18 O2 Sat 94% 2L
General: Obese woman in NAD, RR increases with talking
HEENT: EOMI, NCAT, MMM
Neck: JVP to the ear at 45 degrees
CV: III/VI late peaking systolic murmur best heard at the RUSB
radiating to the bilateral carotids. Normal S2, no audible
S3/S4.
Lungs: Bibasilar crackles to midway up back, diminished BS, no
increased WOB, no wheezes or rhonchi.
Abdomen: Obese, NTND, NABS, no r/r/g
Ext: WWP, no c/c/e
Neuro: A/Ox3, CN II-XII intact, no asterexis, non focal
Skin: No impairments
DISCHARGE Physical Exam:
T 98.0 BP 90-135/34-54 52-67 20 95%RA I:O ___ Wt
189->186.4lbs
General: Pleasant woman in NAD, appears well
HEENT: EOMI, NCAT, MMM
Neck: No JVD
CV: III/VI late peaking systolic murmur best heard at the RUSB
radiating to the bilateral carotids. Normal S2, no audible
S3/S4.
Lungs: Good air movement, no increased WOB, no wheezes or
rhonchi.
Abdomen: Obese, NTND, NABS, no r/r/g
Ext: WWP, no c/c/e
Neuro: A/Ox3, CN II-XII intact, no asterexis, non focal
Pertinent Results:
ADMISSION:
___ 07:30PM BLOOD WBC-7.0 RBC-4.03* Hgb-12.5 Hct-38.3
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.9 Plt ___
___ 07:30PM BLOOD Neuts-67.5 ___ Monos-4.6 Eos-4.4*
Baso-0.8
___ 11:20AM BLOOD ___ PTT-34.0 ___
___ 07:30PM BLOOD Glucose-153* UreaN-13 Creat-0.9 Na-135
K-3.7 Cl-97 HCO3-28 AnGap-14
___ 07:30PM BLOOD cTropnT-<0.01 proBNP-5230*
___ 07:30PM BLOOD Calcium-9.2 Phos-3.6 Mg-1.9
DISCHARGE:
___ 06:16AM BLOOD WBC-5.6 RBC-3.77* Hgb-11.6* Hct-36.1
MCV-96 MCH-30.7 MCHC-32.1 RDW-13.7 Plt ___
___ 06:05AM BLOOD Glucose-119* UreaN-14 Creat-0.8 Na-138
K-3.6 Cl-96 HCO3-32 AnGap-14
___ 06:45AM BLOOD ALT-23 AST-32 LD(LDH)-214 AlkPhos-80
TotBili-0.6
___ 06:05AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1
___ 06:05AM BLOOD AFP-2.6
IMAGING:
TTE (___):
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. A bioprosthetic aortic valve
prosthesis is present. The aortic prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
TTE: ___
IMPRESSION: Suboptimal image quality. Well-seated bioprosthetic
aortic valve with markedly increased transaortic gradient in the
setting of only mild aortic regurgitation (may be underestimated
secondary to shadowing). Visually, the valve appears more
pliable than would be suggested by mean gradient, but no good
quality short axis images are available for review. Preserved
global biventricular systolic function. Increased left
ventricular filling pressure. At least mild mitral
regurgitation. Moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the transaortic mean gradient has markedly increased from 24
mmHg to 68 mmHg. The severity of aortic regurgitation has
increased. Moderate pulmonary artery systolic hypertension is
new. Hyperdynamic left ventricular systolic function is no
longer appreciated.
If clinically indicated, a transesophageal echocardiogram may be
considered to better assess the aortic valve bioprosthesis and
severity of aortic regurgitation.
TEE: ___
Mild spontaneous echo contrast but no thrombus is seen in the
left atrial appendage. No spontaneous echo contrast or thrombus
is seen in the body of the left atrium or the body of the right
atrium/right atrial appendage. Left atrial appendage ejection
velocity is borderline reduced (0.22 m/s). No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is mild elevation of pulmonary artery
pressures. Simple atheroma are seen in the aortic arch and
descending thoracic aorta. A well-seated bioprosthetic aortic
valve prosthesis is present with thickened/relatively immobile
leaflets. Moderate aortic regurgitation is seen. There is simple
atheroma in the aortic arch and descending aorta 33cm from the
incisors. No masses or vegetations are seen on the aortic valve.
Moderate (2+) aortic regurgitation is seen. The mitral leaflets
are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: Well-seated bioprosthetic aortic valve with
restricted leaflet motion. Moderate aortic regurgitation. Normal
left ventricular systolic function. Mild-moderate mitral
regurgitation. Moderate tricuspid regurgitation. Mild pulmonary
artery hypertension. Spontaneous echo contrast but no thrombus
in the ___.
.
CXR (___): Moderate pulmonary edema, b/l pleural effusions
L>R, and cardiomegaly, which is new compared to study dated
___.
RUQ U/S ___
IMPRESSION:
1. Nodular hepatic contour with a coarsened echotexture
consistent with
history of cirrhosis.
2. 8 mm hypoechoic nodule in segment ___ ___s poorly
defined larger
isoechoic lesion in segment 4A which are suspicious for ___.
Recommend
further evaluation with MRI or multiphasic liver CT.
3. Cholelithiasis.
Brief Hospital Course:
___ y/o woman with PMHx EtOH cirrhosis c/b esophageal varicies
and ascites, HTN, HLD and AS s/p bioprosthetic AVR in ___
(previous TTE ___, mean AV gradient 24) presenting with CHF
___ aortic stenosis.
.
Active Problems:
# Decompensated aortic stenosis with acute CHF: Pt s/p AVR in
___ for AS with bioprosthetic valve and has had good functional
capacity. Orthopnea, cardiomegaly, hypoxia and pulmonary edema
in the setting of progressive decline in functional capacity and
elevated BNP is consistent with acute decompensated CHF. TTE
showed normal EF with concern for increased gradient in aortic
valve, concerning for symptomatic AS with TEE confirming
non-working AVR. She denies CP or syncope. She was seen by
cardiology who recommended cardiac surgery eval for redo AVR.
Patient currently at or near dry weight. Functional capacity
increased from walking 10ft on presentation to 5 laps around the
nursing station on d/c. Low Na diet. Switched to PO Lasix 120mg
with strict instructions for patient to weight herself every
morning as critical AS is pre-load dependent and do not want to
dry her out too much. Patient will return to AS clinic on ___.
Hepatology deemed her low risk for surgery.
# EtOH Cirrhosis: Due to longstanding EtOH use. Currently well
compensated. ___ Class A. MELD 7. RUQ showed mass
suspicious for HCC, AFP 2.6. MRI read did not pick up any mass
and after speaking to radiologist confirmed that sometimes there
can be a "fake out" with U/s. Did recommend f/u ultrasound in 3
months. Continued home Spironolactone, Nadolol. EGD without any
significant changes from previous.
Chronic Problems:
# GERD: Patient reports heart burn for 2-days that lasts about
30min. Had not mentioned this previously because didn't think a
big deal. Not worse with exercising. Pt on Pantoprazole at home
for GERD. Likely non-cardiac. EKG no acute changes. Encourage
sitting upright after meals. Continue Protonix
.
# Anxiety: Continue home Alprazolam
TRANSITIONAL ISSUES:
- Patient will require repeat AVR. Appt with AS clinic on ___
- Needs left heart cath
- Panorex done, needs dental read
- F/u ultrasound in 3 months for ?finding
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO Q6H PRN anxiety
2. Citalopram 40 mg PO DAILY
3. Nadolol 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Spironolactone 100 mg PO DAILY
6. Furosemide 80 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Cetirizine *NF* 10 mg Oral daily
9. 20 mg Other daily
10. Vitamin D ___ UNIT PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
Discharge Medications:
1. ALPRAZolam 0.5 mg PO Q6H PRN anxiety
2. Cetirizine *NF* 10 mg Oral daily
3. Citalopram 20 mg PO DAILY
RX *citalopram 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Furosemide 120 mg PO DAILY
RX *furosemide 40 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
7. Nadolol 20 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Spironolactone 100 mg PO DAILY
10. Mupirocin Nasal Ointment 2% 1 Appl NU BID Duration: 5 Days
RX *mupirocin calcium [Bactroban Nasal] 2 % 1 application
topically twice a day Disp #*1 Unit Refills:*0
11. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
12. Multivitamins 1 TAB PO DAILY
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Critical Aortic Stenosis
Acute Congestive 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 to ___ with
shortness of breath due to your aortic valve replacement not
working. This caused fluid to build up in your lungs. We used a
water pill to remove this fluid, but you will require a aortic
valve replacement to prevent this in the future. You will meet
with cardiac surgeons on ___.
For your heart failure and fluid. You should weigh yourself
EVERY morning after going to the bathroom and before
eating/drinking. If this weight decreases or increases by more
then 2lbs, please call your doctor. You were started on a new
dose of Furosemide (Lasix) with a goal of keeping your weight
the same as currently. Your weight on discharge is 185.5lbs,
make sure to weigh yourself on your scale in case this differs.
Followup Instructions:
___
|
10354217-DS-15 | 10,354,217 | 27,926,162 | DS | 15 | 2159-05-23 00:00:00 | 2159-05-23 21:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / adhesive tape / Cephalexin / Percocet
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with history of CHF w/preserved
EF secondary to aortic stenosis s/p bioprosthetic replacement in
___ now requiring second replacement presents with 1 week of
10# increased weight, edema, dyspnea on exertion, and orthopnea.
She has also had a cough productive of clear sputum and
fatigue. Patient reports typically being very diet-compliant
but admits that this week she did eat some saltier foods than
usual. Patient does endorse some right-sided chest pain with
some radiation around her abdomen which is not exertional in
nature; she feels it worsens with coughing, and it is "fleeting"
in duration. ROS is negative for fever, chills, abdominal pain,
dysuria.
In the ED vitals were stable, CXR was unremarkable except for
mild cardiomegaly and mild atelectasis, and EKG was unchanged
from prior and without signs of ischemia.
Past Medical History:
PMHx:
AS s/p bioprosthetic valve replacement ___
CHF with preserved EF
HTN
Dyslipidemia
Cirrhosis ___ etOH with h/o variceal bleed ___ s/p banding
Asthma
GERD
PSHx:
AVR
Total hip replacement ___
Tonsillectomy
Cataract surgery
Social History:
___
Family History:
Brother died of an MI at age ___ father with CAD, multiple MIs,
CVA. Mom had RA. No FHx of liver problems or DM.
Physical Exam:
UPON ADMISSION:
VS: T 97.6 BP 98/43 P 58 R 19 SPO2 94% on RA
Weight 86.7 kg
General: Alert, NAD, comfortably reclining in bed
HEENT: Moist mucous membranes
Neck: Jugular venous pulse meniscus visualized at 5 cm above
the sternal notch with head of bed at 45 deg.
CV: RRR, ___ crescendo-decrescendo murmur loudest at the RUSB
with radiation to the carotids and attenuation of A2.
Lungs: Crackles present at the lower ___ of lungs bilaterally.
Abdomen: + BS, soft, nontender, obese.
Ext: 1+ pitting edema at the ankles, none appreciated in the
sacral region. Extremities are warm and well-perfused.
Neuro: WNL
UPON DISCHARGE:
VS: T 97.6 BP 93/48 P 72 R 18 SPO2 97% on RA
Weight 79 kg
General: Alert, NAD, comfortably reclining in bed
HEENT: Moist mucous membranes
Neck: No jugular venous distension
CV: RRR, ___ crescendo-decrescendo murmur loudest at the RUSB
with radiation to the carotids and attenuation of A2.
Lungs: Fine crackles present at the lower ___ of lungs
bilaterally.
Abdomen: + BS, soft, nontender, obese.
Ext: No edema. Extremities are warm and well-perfused.
Neuro: WNL
Pertinent Results:
ADMISSION LABS
___ 08:00PM GLUCOSE-190* UREA N-25* CREAT-1.3* SODIUM-134
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-26 ANION GAP-17
___ 08:00PM cTropnT-<0.01
___ 08:00PM ___
___ 08:00PM WBC-7.2 RBC-3.64* HGB-11.2* HCT-33.7* MCV-93
MCH-30.7 MCHC-33.2 RDW-15.2
___ 7:20AM TIBC 477 Ferritin 34 Serum iron 39
___ 5:00PM ALT 17 AST 34 AP 91 TBili 1.1
___ 6:00AM Albumin 4.4
___ 6:00AM Na 136 Cl 91 BUN 25 K 4.0 HCO3 34 Cr 1.2 Gluc
132
DISCHARGE LABS
___ 06:25AM BLOOD WBC-8.0 RBC-3.96* Hgb-12.4 Hct-35.6*
MCV-90 MCH-31.3 MCHC-34.8 RDW-14.7 Plt ___
___ 06:05AM BLOOD Glucose-132* UreaN-25* Creat-1.2* Na-136
K-4.0 Cl-91* HCO3-34* AnGap-15
REPORTS
___ Imaging CHEST (PA & LAT)
IMPRESSION: Mild cardiomegaly. Mild retrocardiac atelectasis.
Otherwise,
unremarkable.
___ Imaging UNILAT LOWER EXT VEINS
IMPRESSION:
No evidence of DVT in the left lower extremity.
Brief Hospital Course:
___ F w/ Aortic Stenosis s/p avr ___ which was restenosed
currently awaiting TAVR, EtOH cirrhosis c/b varices w/ hx
bleeding on ASA, CHF, who presents with shortness of breath
#CHF exacerbation felt most likely secondary to diet
noncompliance with possibility of worsening valvular function.
EKG unchanged and trop neg x 2 so ischemia felt unlikely. She
diuresed well on metolazone and furosemide drip. Creatinine
declined initially due to relief of venous congestion, but
increased with further diuresis presumably due to intravascular
depletion. Patient did develop some transient hypokalemia which
was treated with KCl po. She was continued on her
spironolactone throughout her hospitalization. Upon discharge,
weight was 79.0 kg from 86.7 kg on admission, and she was
clinically euvolemic. She is discharged with her torsemide dose
increased from 80 to 100 mg po qday, as well as her usual dose
of spironolactone. For her CHF nadolol was discontinued and pt
was started on metoprolol succinate 25 mg po qHS.
#Anemia - Iron studies returned suggestive of Fe deficiency with
low ferritin, low SI, and high TIBC. Patient was given iron
sulfate 325 mg po BID with senna. FOBT was negative.
Colonoscopy is suggested as an outpatient as she has never had
one.
#Pruritus - Pt developed pruritus on the hands bilaterally on
___ without associated rash. She reported that this had
occurred in the past with an antibiotic. Medications were
reviewed and it was deemed unlikely that furosemide or iron
sulfate, the medications started around that time, would cause
an allergic reaction. Bilirubin was normal. The etiology may
be intravascular depletion/dehydration. Hydroxyzine was started
prn to assist with the pruritus, and arrangements for a
dermatology appointment as an outpatient were made. The patient
is discharged with prn hydroxyzine with instructions not to take
it near the same time as taking her alprazolam to avoid
oversedation.
#Aortic stenosis - Thickening and reduced motion of
bioprosthetic valve leaflets according to ___ ___.
Patient will likely go for TAVR in ___.
#Cirrhosis - Stable throughout this admission. MRI in ___
shows no portal hypertension. Nadolol was held during this
admission to prevent hypotension in the setting of vigorous
diuresis. Later, metoprolol was started due to its cardiac
benefits. Her spironolactone was continued.
#CAD/HLD - Most recent cath in ___ showed 70% LAD stenosis
and 80% diagonal branch stenosis. LDL 201 in ___bove goal of 100 for CAD. Atorvastatin was
discontinued, and rosuvastatin 40 mg po qday and ezetimibe 10 mg
po qday were started. Patient was offered ___ clinic but she
declined due to living too far away.
TRANSITIONAL ISSUES
- patient will have followup in heart failure clinic as well as
dermatology
- patient is planning on undergoing TAVR in ___ for AVR
restenosis
- remained full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
2. ALPRAZolam 0.5 mg PO Q6H:PRN anxiety
please hold for sedation, RR<12
3. ZYRtec *NF* 10 mg Oral daily
4. Citalopram 20 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Nadolol 20 mg PO DAILY
please hold for HR<60, SBP<100
9. Pantoprazole 40 mg PO Q12H
10. Spironolactone 100 mg PO DAILY
please hold for SBP<100
11. Vitamin D ___ UNIT PO DAILY
12. Torsemide 40 mg PO BID
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 80 mg PO HS
Discharge Medications:
1. ALPRAZolam 0.5 mg PO Q6H:PRN anxiety
2. Aspirin 81 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Spironolactone 100 mg PO DAILY
9. Torsemide 100 mg PO DAILY
RX *torsemide 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Vitamin D ___ UNIT PO DAILY
11. ZYRtec *NF* 10 mg Oral daily
12. Ezetimibe 10 mg PO DAILY
RX *ezetimibe [Zetia] 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
13. Ferrous Sulfate 325 mg PO BID fe deficiency
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
14. HydrOXYzine 25 mg PO TID:PRN pruritus
Do not take if sedated, do not take with other sedating
medications, with alcohol, or while driving
RX *hydroxyzine HCl 25 mg 25 mg by mouth at bedtime Disp #*10
Tablet Refills:*0
15. Metoprolol Succinate XL 25 mg PO HS
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth at bedtime Disp #*30 Tablet Refills:*0
16. Rosuvastatin Calcium 40 mg PO QHS
RX *rosuvastatin [Crestor] 40 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute decompensation of valvular heart disease
Aortic stenosis
Secondary Diagnosis:
Alcoholic Cirrhosis
Hypertension
Hypercholesterolemia
Asthma
Gastroesophageal Reflux Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You came in with increasing shortness of breath.
We believe these symptoms were due to fluid in your lungs
resulting from your previously diagnosed aortic stenosis. You
were started on diuretics (water pills) with improvement of your
symptoms. Your home dose of torsemide has been increased.
Please see below for your appointments and medications.
Followup Instructions:
___
|
10354217-DS-18 | 10,354,217 | 26,254,039 | DS | 18 | 2164-03-08 00:00:00 | 2164-03-08 20:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / adhesive tape / Cephalexin / Percocet /
Zetia
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ EtOH cirrhosis c/b variceal bleed s/p banding,
bioprosthetic AVR in ___, s/p re-do AVR, CABG (LIMA-LAD,
SVG-diag), and pericardial patch aortic root enlargement in
___, hypertension, hyperlipidemia, asthma, Afib (started
Eliquis ___, and GERD who presented to OSH with SOB and
progressive DOE, likely due to mild CHF fluid overload,
transferred here for evaluation of possible GI bleed, found to
be stable.
Patient reports chronic SOB/DOE, but says over the last 2 weeks
these symptoms have worsened. She reports having a stable 3
pillow orthopnea and being able to walk only 6 steps before
becoming SOB (from a baseline of ___ blocks a few months ago).
Also reports worsening fatigue over the last few weeks. Per
patient, asthma relative under control, only using inhalers a
few times a week.
No ___ edema, taking her Lasix daily. Has not had emesis, dark or
black stools. Denies nausea, vomiting, hematemesis,
coffee-ground emesis, melena, and/or hematochezia. Denies chest
pain, fever, cough. Denies abdominal pain, diaphoresis,
headaches, wheezing.
**Transfer note from OSH says she received 1u RBC but she did
not.
In ED:
Hemoglobin 7.8 from baseline of around 10. BNP in the 3000s
though prior history in the 31,000. Troponin unremarkable. INR
1.9, Hb 7.8
CXR with mild pulmonary vascular congestion without overt edema.
No effusion. No pneumonia. Unchanged moderate to severe
cardiomegaly.
Hepatology consulted who felt no evidence of acute upper or
lower GI bleed. Recommended that we continue monitoring for
signs of GI bleeding, can start octreotide gtt, PPI IV BID, and
ceftriaxone for infectious ppx.
Initial vital signs were notable for: T 97.6 HR 60 BP 107/70 RR
18 O2 sat 97% RA
Exam notable for: Guaiac positive on eliquis
Notable Medications received:
- Lasix 40mg IV
Upon arrival to the floor, the patient was feeling better after
she received Lasix.
Past Medical History:
EtOH cirrhosis c/b EV
Bioprosthetic AVR with redo AVR
CABG
Pericardial patch aortic root enlargement
HTN
HLD
Asthma
Atrial fibrillation
GERD
L knee and R hip replacements
Social History:
___
Family History:
Brother died of an MI at age ___ father with CAD, multiple MIs,
CVA. Mom had RA. No FHx of liver problems or DM.
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
VITALS: 98.0 PO 119/58 R Sitting 81 20 93% RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: JVD 14cm at 45 degrees
CARDIAC: irregularly irregular. Prominent S2. Systolic ejection
murmur best heard in LUSB. No rubs/gallops.
LUNGS: Clear to auscultation bilaterally with mild crackles in
lung bases bilaterally. No wheezes, rhonchi. No increased work
of breathing.
ABDOMEN: Obese, soft, non-tender to deep palpation in all four
quadrants.
EXTREMITIES: No clubbing, cyanosis. Mild edema up to ankle.
Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. No rash.
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
T:98.5 BP:132/81 HR:76 RR:20 O2:96RA
GENERAL: Comfortable appearing woman lying flat in bed and
speaking to me in no apparent distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Oropharynx is clear.
NECK: JVP remains angle of jaw at 30 degrees.
CARDIAC: Irregular S1/S2. Systolic ejection murmur best heard in
LUSB. No rubs/gallops.
LUNGS: Clear to auscultation bilaterally, no longer any crackles
at bases. No wheezes, rhonchi. No increased work of breathing.
ABDOMEN: Soft, non-tender to deep palpation in all four
quadrants. Abdomen is less distended than prior. No significant
pitting edema in flanks.
EXTREMITIES: No clubbing, cyanosis. Trace mid shin edema
persists. Pulses DP/Radial 2+ bilaterally. Firm hematoma in R AC
with surrounding erythema has significantly improved over the
past 2 days. No swelling in distal arm. Normal radial pulses.
SKIN: Warm. Multiple 1cm hyperpigmented lesions with broken
skin, patient endorses picking at her skin.
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 05:00AM BLOOD WBC-4.0 RBC-2.92* Hgb-7.8* Hct-25.7*
MCV-88 MCH-26.7 MCHC-30.4* RDW-18.2* RDWSD-58.4* Plt ___
___ 05:00AM BLOOD Neuts-66.3 ___ Monos-8.8 Eos-3.5
Baso-0.5 Im ___ AbsNeut-2.64 AbsLymp-0.81* AbsMono-0.35
AbsEos-0.14 AbsBaso-0.02
___ 05:02AM BLOOD ___ PTT-32.5 ___
___ 05:00AM BLOOD Glucose-115* UreaN-30* Creat-1.1 Na-140
K-3.7 Cl-102 HCO3-27 AnGap-11
___ 05:00AM BLOOD LD(LDH)-154 DirBili-<0.2
___ 05:00AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9
___ 05:05AM BLOOD ___ pO2-59* pCO2-47* pH-7.38
calTCO2-29 Base XS-1 Comment-GREEN TOP
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 06:09AM BLOOD WBC-6.3 RBC-3.43* Hgb-9.4* Hct-30.1*
MCV-88 MCH-27.4 MCHC-31.2* RDW-17.8* RDWSD-56.3* Plt ___
___ 06:19AM BLOOD ___ PTT-34.0 ___
___ 06:09AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-138
K-4.2 Cl-95* HCO3-28 AnGap-15
___ 06:19AM BLOOD ALT-8 AST-16 AlkPhos-64 TotBili-0.5
___ 06:09AM BLOOD Calcium-9.6 Phos-3.0 Mg-2.3
___ 05:00AM BLOOD cTropnT-<0.01 proBNP-34___*
___ 10:32AM BLOOD calTIBC-490* Ferritn-16 TRF-377*
___ 07:11AM BLOOD IgA-155
___ 07:11AM BLOOD tTG-IgA-3
===========================
REPORTS AND IMAGING STUDIES
===========================
___ TRANSTHORACIC ECHOCARDIOGRAM
The left atrium is moderately dilated. The right atrium is
moderately enlarged. There is normal left ventricular wall
thickness with a normal cavity size. There is suboptimal image
quality to assess regional left ventricular function. Global
left ventricular systolic function is normal. There is
beat-to-beat variability in the left ventricular contractility
due to the irregular rhythm. The visually estimated left
ventricular ejection fraction is 55-60%. Diastolic function
could not be assessed. The right ventrlcle is not well seen.
There is a normal ascending aorta diameter. An aortic valve
bioprosthesis is present. The prosthesis is well seated. There
is trace aortic regurgitation. The mitral leaflets are mildly
thickened with no mitral valve prolapse. There is moderate
mitral annular calcification. There is mild to moderate [___]
mitral regurgitation. Due to acoustic shadowing, the severity of
mitral regurgitation could be UNDERestimated. The tricuspid
valve leaflets are mildly thickened. There is mild to moderate
[___] tricuspid regurgitation. Due to acoustic shadowing, the
severity of tricuspid regurgitation may be UNDERestimated. The
estimated pulmonary artery systolic pressure is moderately
elevated. There is no pericardial effusion.
IMPRESSION:
Suboptimal image quality. Normal global left ventricular
systolic function with beat to beat variability in EF. Right
ventricle poorly visualized. Well-seated AVR with trivial
regurgitation. Transvalvular gradients not obtained on current
study (full study done in ___. Mild/moderate mitral
regurgitation. At least moderate pulmonary hypertension.
Compared with the prior TTE ___ , the severity of mitral
and tricuspid regurgitation is now lower.
============
MICROBIOLOGY
============
None
Brief Hospital Course:
=================
SUMMARY STATEMENT
=================
Ms. ___ is a ___ year old woman with alcohol cirrhosis
complicated by prior variceal bleed with banding, a
bioprosthetic AVR in ___ with a AVR re-do, prior CABG,
pericardial patch aortic root enlargement in ___, HTN, HLD,
asthma, atrial fibrillation on Eliquis and GERD who presented to
an outside hospital with progressive dyspnea on exertion.
- Discharge weight: ___: 86.27kg (190.2 pounds)
====================
ACUTE MEDICAL ISSUES
====================
#Dyspnea on exertion:
Ms. ___ reports progressive dyspnea on exertion for the past
three months. Previously, she was able to walk up to an hour a
day with her dogs without difficulty. However, prior to
presentation she could barely walk a few steps without becoming
dyspneic. Presented with elevated weight (though unclear dry
weight), proBNP 3472 (highest 31,366; lowest 1,934), and
bibasilar crackles. She takes furosemide 40mg daily at home with
good adherence. Repeat TTE showed well seated aortic valve, and
improvement in MR ___ TR. ___ does have atrial fibrillation, not
anticoagulated, so chronic PE was on the differential.
She was diuresed with 40mg IV Lasix X2 for several days with
excellent urine output and vastly improved symptoms. By
discharge, she reported feeling close to, if not completely back
to her baseline level of function from several months ago. Her
weight was down over 10 pounds at discharge. It was therefore
presumed that her symptoms were being drive by an acute on
chronic heart failure exacerbation. She was discharged on
torsemide 60mg. She was continued on cetirizine and albuterol
PRN.
# Anemia:
Presented with a hemoglobin of 7.8 from a recent level of 10 in
the setting of having started apixaban on ___ in advanced of
her planned watchman device procedure (which requires 3 weeks of
anticoagulation prior to placement). Notably, a ___ colonoscopy
did not show any sources of bleed, and an EGD at that time
showed 1 cord of grade I varices. She did intermittently have
guaiac positive stools, though not consistently, and has known
hemorrhoids. After admission she had a stable anemia with a
hemoglobin around 8. She was found to be iron deficient and was
give 250mg IV ferric gluconate for four consecutive days.
#Afib:
Planning for watchman device on ___. It is unclear if this will
have to be postponed, as three consecutive doses of her apixaban
were held out of concern for GI bleed. She was continuously on
apixaban staring ___. Her atrial fibrillation was well rate
controlled during her hospitalization on her home nadolol.
======================
CHRONIC MEDICAL ISSUES
======================
# EtOH cirrhosis complicated by esophageal varices with prior
banding
As above, no evidence of GI bleed except for guaiac positive
stool that was thought to be related to hemorrhoids. Her
hemoglobin was stable. She had no signs of hepatic
encephalopathy. There was no clinical suspicion for SBP. She was
continued on spironolactone 100mg daily.
#GERD: Continued pantoprazole 40mg BID
#HLD
#CAD with CABG:
Continued ASA 81 and rosuvastatin 40mg
# Anxiety/insomnia:
Continued alprazolam, citalopram
===================
TRANSITIONAL ISSUES
===================
[ ] Will need continued titration of diuretics given that she
was discharged below any recent dry weight, and still does not
have a clear dry weight.
[ ] Will need clarification with her cardiologist if watchman
procedure needs to be delayed given that several doses of her
apixaban were held out of concern for GI bleed
[ ] Consider sleep study for possible OSA causing her AF
[ ] Follow-up of anemia and monitoring of iron levels. Received
250mg IV Ca gluconate x4d while hospitalized.
[ ] Please obtain chemistries at next appointment on ___.
- New Meds:
------> Torsemide 60mg daily (replacing furosemide 40mg daily)
- Stopped/Held Meds:
------>Furosemide 40mg daily STOPPED
- Discharge weight: ___: 86.27kg (190.2 pounds)
- Code Status: Full
- Contact Information: ___ (___)
Greater than ___ hour spent on care on day of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
2. Citalopram 20 mg PO DAILY
3. ALPRAZolam 0.5 mg PO Q6H:PRN anxiety
4. Albuterol Sulfate (Extended Release) 4 mg PO Q4H:PRN wheezing
5. Aspirin 81 mg PO DAILY
6. Cetirizine 10 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. melatonin 5 mg oral QHS:PRN
9. beclomethasone dipropionate 80 mcg/actuation inhalation BID
10. Multivitamins 1 TAB PO DAILY
11. Spironolactone 100 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. Rosuvastatin Calcium 40 mg PO QPM
14. Apixaban 5 mg PO BID
15. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
16. Nadolol 20 mg PO DAILY
17. Docusate Sodium 100 mg PO BID
18. Fish Oil (Omega 3) Dose is Unknown PO DAILY
Discharge Medications:
1. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
2. Fish Oil (Omega 3) unknown PO DAILY
3. Albuterol Sulfate (Extended Release) 4 mg PO Q4H:PRN
wheezing
4. ALPRAZolam 0.5 mg PO Q6H:PRN anxiety
5. Apixaban 5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. beclomethasone dipropionate 80 mcg/actuation inhalation BID
8. Cetirizine 10 mg PO DAILY
9. Citalopram 20 mg PO DAILY
10. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
11. Docusate Sodium 100 mg PO BID
12. melatonin 5 mg oral QHS:PRN
13. Multivitamins 1 TAB PO DAILY
14. Nadolol 20 mg PO DAILY
15. Pantoprazole 40 mg PO Q12H
16. Rosuvastatin Calcium 40 mg PO QPM
17. Spironolactone 100 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Acute on chronic heart failure with preserved ejection fraction
===================
SECONDARY DIAGNOSES
===================
Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you while you were admitted to ___
___.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having a lot more trouble breathing.
- We were worried you were bleeding from your intestines.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We kept a close eye on your blood counts, and we do not think
you were having serious bleeding.
- We gave you iron to help your blood count go up.
- We gave you diuretics to help you urinate more, and this made
your breathing get significantly better.
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Carefully review the attached medication list as we may have
made changes to your medications.
- Take your weight every morning. If your weight goes up by 3
pounds in a day or 5 pounds in two days, call your doctor right
away.
- Discharge weight: ___: 86.27kg (190.2 pounds)
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10354217-DS-21 | 10,354,217 | 22,804,533 | DS | 21 | 2165-04-01 00:00:00 | 2165-04-01 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / adhesive tape / Cephalexin / Percocet /
Zetia / torsemide
Attending: ___.
Chief Complaint:
Found down at home
Major Surgical or Invasive Procedure:
TEE
R hip joint aspiration
IJ Placement, then PICC placement
History of Present Illness:
___ w/ alcoholic cirrhosis, CAD s/p CABG, bioprosthetic AV with
redo-AVR using pericardial patch aortic root enlargement in
___, h/o GIB, persistent AF (s/p watchman), and HFpEF, brought
in after found on the ground by son and ___.
Patient reported that she slid to the ground ~4am and was on
ground for 7 hours. C/o right hip pain (present prior to fall)
and now unable to ambulate. Endorses shortness of breath. Denies
chest pain. Son reports she is more
confused than normal.
In the ED,
- Vitals: Tmax 104.8 HR 103, BP initially 132/68 then
increasingly hypotensive, RR 18, SpO2 96% 2L
- Exam: Tachypneic, speaking in ___ word sentences
- Labs: notable for WBC 12.3, Neuts 92.5%, Na 126, Cr 0.9, BNP
3681 (stable from recent discharge), lactate 2.7.
She was given vanc/Zosyn, started on a levophed gtt, and was
admitted to the MICU.
Upon arrival to the ICU, the patient remained on a small dose of
levophed. She was arousable to sternal rub/very loud voice but
almost immediately drifts back off to sleep; in the small gaps
in between was objectively AOx3.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Hypercholesterolemia
2. CARDIAC HISTORY
- CAD
- Bioprosthetic AVR in ___
- CABG (LIMA-LAD, SVG-diag) with redo-AVR using pericardial
patch
aortic root enlargement in ___
- AF s/p watchman implantation in ___
3. OTHER PAST MEDICAL HISTORY
- s/p right total hip replacement, ___
- s/p Tonsillectomy
- Child A cirrhosis with prior variceal bleeding s/p banding
Gastroesophageal Reflux Disease
Social History:
___
Family History:
There is a family history of hypertension, heart disease, and
strokes. Father deceased age ___, TB. Mother deceased age ___,
CAD. No siblings. Four children - son deceased age ___, ___.
Daughter deceased age ___, ___ disease. Two sons and a
daughter alive and well.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS: T 99.3 HR 123 BP 106/57 SpO2 97% 2LNC
Otherwise notable for obese elderly woman lying in bed, eyes
closed, responsive only briefly to sternal rub/shouting as
above.
A&Ox3, PERRL, JVP difficult to assess, soft crackles in b/l lung
fields although difficult to appreciate given lack of deep
inspirations, heart rhythm irreg w/o murmur, abd soft/NT/ND,
legs
warm without edema. Bedside US notable for lack of ascites, and
collapsing IVC with inspiration (PGY-1 interpretation)
DISCHARGE PHYSICAL EXAM
========================
VITALS: all vitals since arrival on the medical ward were
reviewed
CONSTITUTIONAL: obese woman in NAD
EYE: sclerae anicteric, EOMI
ENT: audition grossly intact, MMM, OP clear
LYMPHATIC: No LAD
CARDIAC: irregular, systolic murmur, JVP 8-9 cm
PULM: normal effort of breathing, LCAB
GI: soft, NT, ND, NABS
GU: no CVA tenderness, suprapubic region soft and nontender
MSK: no visible joint effusions or acute deformities.
DERM: no visible rash. No jaundice. Dusky area at tip of R third
toe.
NEURO: AAOx3. No facial droop. ___ strength in all muscle groups
of lower extremities. No saddle anesthesia. Good rectal tone.
PSYCH: Full range of affect
Pertinent Results:
MICRO:
===============
___ BLOOD CULTURE: STAPH AUREUS COAG +
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
Surveillance BCx persistently positive for the same though
___, then prelim negative starting ___.
ADMISSION LABS:
===============
___ 03:07PM BLOOD WBC-12.3* RBC-4.09 Hgb-12.5 Hct-38.7
MCV-95 MCH-30.6 MCHC-32.3 RDW-15.1 RDWSD-52.2* Plt ___
___ 07:52PM BLOOD ___ PTT-25.3 ___
___ 03:07PM BLOOD Glucose-229* UreaN-15 Creat-0.9 Na-126*
K-4.9 Cl-86* HCO3-24 AnGap-16
___ 03:07PM BLOOD ALT-22 AST-58* CK(CPK)-151 AlkPhos-92
TotBili-1.0
___ 03:07PM BLOOD proBNP-3681*
___ 03:07PM BLOOD cTropnT-<0.01
___ 03:07PM BLOOD Albumin-3.8
___ 01:39AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
___ 08:45PM BLOOD Osmolal-275
___ 01:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-13
Tricycl-NEG
___ 03:12PM BLOOD ___ pO2-33* pCO2-41 pH-7.46*
calTCO2-30 Base XS-4
___ 03:12PM BLOOD Lactate-2.7*
IMAGING RESULTS:
================
CXR ___
Bibasilar atelectasis and mild pulmonary vascular congestion.
HIP XR ___
Status post right hip arthroplasty without hardware
complications. No acute fracture or dislocation.
NCHCT ___
No acute intracranial abnormality.
CT A/P W/ CONTRAST ___
1. No acute abnormality identified to account for the patient's
symptoms.
2. Colonic diverticulosis without acute diverticulitis.
3. Cirrhotic liver morphology without focal hepatic lesion.
4. Cholelithiasis.
5. Redemonstration of left ovarian dermoid.
6. Prominent bilateral pelvic varices and dilated gonadal veins
could suggest pelvic congestion syndrome but clinical
correlation is needed.
TEE ___
IMPRESSION: No evidence of valvular vegetations or masses. Well
seated aortic valve prosthesis with thickened leaflets and mild
valvular regurgitation. Well seated ___ left atrial
appendage occlusion device without residual ___
communication. Moderate mitral regurgitation. Mild tricuspid
regurgitation.
MRI PELVIS ___
There is newly developed ascites when compared with prior study.
The ascites is seen extending even in the left inguinal hernia.
There is subcutaneous edema likely due to third spacing. There
is also nonspecific edema posteriorly to the muscles of the
proximal thighs, more prominent on the left than on the right.
The right hip cannot be assessed since there a creating
significant artifacts the left hip does not demonstrate
significant effusion. There is no evidence bone marrow edema
within limitation of the artifacts created by the right hip
prosthesis. The examination is significantly degraded by motion
artifacts, greatly limiting the muscle signal intensity. [A
psoas abscess was also questioned on this study, but that was
not seen on a higher-quality L-spine MRI the next day]
MRI L SPINE ___
1. Small ventral epidural abscess at the L5 level which in
combination with degenerative change results in at least
moderate spinal canal stenosis.
2. Findings concerning for septic arthritis of the bilateral
L4-L5 facet
joints with associated perispinal intramuscular edema and small
amount of
mildly rim enhancing fluid collection in the right perispinal
musculature,
suggestive of a phlegmon or early abscess formation.
3. Severe degenerative changes at the L4-L5 level with a disc
bulge, severe facet joint arthropathy, ligamentum flavum
thickening and epidural lipomatosis resulting in severe spinal
canal stenosis with crowding of the cauda equina nerve roots.
4. Questionable enhancement of the L5-S1 cauda equina nerve
roots which may be reactive in etiology.
5. Unchanged large L5 superior endplate Schmorl's node with
associated
degenerative endplate changes.
Brief Hospital Course:
___ w/ alcoholic cirrhosis, CAD s/p CABG, bioprosthetic AV with
redo-AVR using pericardial patch aortic root enlargement in
___, h/o GIB, persistent AF (s/p watchman), HFpEF, admitted w/
septic shock from high-grade MRSA bacteremia or unclear source.
On vancomycin. TEE neg for endocarditis.
# Sepsis due to MRSA BSI
# Small ventral epidural abscess at L5 level
# Paraspinal abscess/L4-L5 facet joint septic arthritis
Initially septic requiring pressors, but quickly
stabilized. Found to have high grade MRSA bloodstream infection,
based on multiple days of blood cultures positive for MRSA
despite appropriate antimicrobial therapy with vancomycin.
Gent/rifampin was briefly added and her cultures cleared, at
which point vancomycin monotherapy was resumed.
She has an infectious collection at the base of the spine
(small ventral epidural abscess at L5 level and also L4-L5 facet
joint septic arthritis with small associated paraspinal
abscess); this is probably hematogenously seeded originally, but
may have been the reason that the blood cultures were slow to
clear. She has RLE pain and muscle spasms that correlate with
the location of the collection, but no weakness or numbness.
Seen by neurosurgery who felt no intervention was needed other
than ongoing antibiotics.
TEE negative; the Watchman and the bioprosthetic AVR looked
fine. Arthrocentesis of R THA shows no e/o PJI.
Of note, it is unclear what the initial site of entry was.
No recent history of central access. No IVDU. No recent staph
infections. She has poor dentition, but Staph aureus would not
usually be from an oral source.
The patient will continue vancomycin 1250 mg q12h for ___
weeks. She will need a weekly vanco trough, BUN/Cr, CBC with
diff. She will follow with ___ infectious disease.
# Acute hypoxic respiratory failure: resolved
Briefly had a 2L O2 requirement. Possibly occult aspiration
event (not seen on portable CXR) vs. mild volume overload
related to fluid resuscitation in the ED. She has been on room
air for many days at time of discharge.
# Diabetes type 2
A1c is 7.3 and serum glucose was in the 200s on most checks
here. She is not on any diabetes meds, although A1c was 6.7 in
___ when last checked in our system, so she probably has
longstanding mild diabetes. ___ be acutely worse due to her
infection, so remains to be seen if she may be able to be
managed with diet alone in future.
We have started metformin (currently 1g extended release
daily), which should be increased if needed and as tolerated to
a goal dose of 1g BID. If her A1c remains elevated despite
metformin, she would need Victoza or Jardiance, given her known
comorbidity of CAD s/p CABG.
# Hyponatremia
Probably driven by ADH release related to septic hypotension
& her baseline cirrhosis. Improved.
#Chronic diastolic heart failure
She will resume her prior diuretic dose of Lasix 80 mg daily
and aldactone 100 mg daily. She will need daily weights and
should follow up with cardiology for ongoing diuretic
management.
# Alcoholic cirrhosis
Continues nadolol for h/o varices. Continue Lasix 80 mg daily
and aldactone 100 mg daily as above. She does not need lactulose
to have ___ BMs a day, but it was left on her med list as a PRN
and should be given if she ever goes a day without moving her
bowels.
# Anxiety
Resumed alprazolam, which she seems to tolerate reasonably
well. Continue citalopram.
# CAD, Peripheral vascular disease
Continued home aspirin, statin
=====================
TRANSITIONAL ISSUES
=====================
MRSA INFECTION:
- Vancomycin 1250 mg q12h for ___ weeks (earliest possible end
date is ___
- weekly vanco trough, BUN/Cr, CBC with diff. ALL LAB RESULTS
SHOULD BE SENT TO: ___ CLINIC - FAX: ___
- if there is any new-onset right leg weakness or new fecal
incontinence, she would need urgent re-evaluation of the
infectious collection in the spine.
CHF
- Daily standing weights. If gaining weight (>5 lbs) despite
taking diuretics, the rehab doctor can call her cardiologist Dr.
___ (___) for guidance as needed.
NEW TYPE 2 DIABETES
- Needs metformin to be increased to 1g BID, provided she does
not have GI side effects from the current dose.
- recheck A1c in six weeks or so. If still above 6.5, consider
Victoza or Jardiance.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB
3. ALPRAZolam 0.5 mg PO Q6H:PRN anxiety
4. Aspirin 325 mg PO DAILY
5. Qvar RediHaler (beclomethasone dipropionate) 80 mcg/actuation
inhalation BID possible small airway disease
6. Cetirizine 10 mg PO DAILY
7. Citalopram 20 mg PO DAILY
8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID:PRN rash
9. Docusate Sodium 100 mg PO BID
10. Furosemide 80 mg PO DAILY HFpEF
11. melatonin 5 mg oral QHS:PRN insomnia
12. Multivitamins 1 TAB PO DAILY
13. Nadolol 20 mg PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. Rosuvastatin Calcium 40 mg PO QPM
16. Spironolactone 100 mg PO DAILY
17. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Lactulose 30 mL PO Q6H:PRN constipation
2. MetFORMIN XR (Glucophage XR) 1000 mg PO QAM
3. Multivitamins W/minerals 1 TAB PO DAILY
4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
5. Vancomycin 1250 mg IV Q 12H
6. Acetaminophen 1000 mg PO Q8H
7. ALPRAZolam 0.5 mg PO Q6H:PRN anxiety
RX *alprazolam 0.5 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
8. Aspirin 325 mg PO DAILY
9. Cetirizine 10 mg PO DAILY
10. Citalopram 20 mg PO DAILY
11. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID:PRN rash
12. Docusate Sodium 100 mg PO BID
13. Furosemide 80 mg PO DAILY HFpEF
14. melatonin 5 mg oral QHS:PRN insomnia
15. Multivitamins 1 TAB PO DAILY
16. Nadolol 20 mg PO DAILY
17. Pantoprazole 40 mg PO Q12H
18. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB
19. Qvar RediHaler (beclomethasone dipropionate) 80
mcg/actuation inhalation BID possible small airway disease
20. Rosuvastatin Calcium 40 mg PO QPM
21. Spironolactone 100 mg PO DAILY
22. Vitamin D ___ UNIT PO DAILY
Greater than 30 minutes was spent discharging this medically
complex patient
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MRSA bloodstream infection
Small ventral epidural abscess at L5 level
Paraspinal abscess/L4-L5 facet joint septic arthritis
Chronic diastolic CHF
CAD/CABG
EtOH cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with a severe infection caused by MRSA (the
same bacteria that causes Staph infections on the skin). The
bacteria was growing in your blood, and also has collected at
the base of your spine. Often this bacteria sticks to heart
valves, but an ultrasound of the heart (trans-esophageal echo)
suggested that the heart valves are OK. It can also stick to
artificial joints, but we tested your hip and found no bacteria.
You will need at least six weeks of IV antibiotics. These will
be given at the rehab - or if you complete your rehabilitation
before then - the antibiotics can also be given at home with the
help of a visiting nurse.
The abscess next to the spine is irritating some of your nerves
and causing pain in your right buttock and right leg, but does
not seem to be causing any other serious issues. The pain should
slowly get better as you continue the antibiotic treatment.
For your history of heart failure, please weigh yourself every
morning and call cardiology clinic (___) if weight goes
up more than 5 lbs.
It was a pleasure caring for at ___. I am sorry you caught
this serious infection, but I wish you the best of luck as you
slowly and steadily recover.
-___ MD and your ___ team
Followup Instructions:
___
|
10354392-DS-17 | 10,354,392 | 27,642,246 | DS | 17 | 2154-12-20 00:00:00 | 2154-12-24 17:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / shellfish derived
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male who fell off bicycle at 0600 onto curb.
Continued to ride on forapproximately 30 miles and presented
later in the day after his
pain worsened. He was initially imaged in the ED and found to
have a right perinephric hematoma. Minutes after returning from
that scan he had acute onset abdominal pain. Given the change in
exam he was then sent back to the scanner for repeat imaging,
where he was found to have active extrav. into the collecting
system.
Past Medical History:
none
Social History:
___
Family History:
unknown
Physical Exam:
Physical Exam: upon admission: ___
Vitals: 93 BP 138/81 RR 16 97% RA
GEN: A&O, NAD, head normocephalic/atraumatic
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Right flank tender to palpation, no overlying skin changes
Physical examination upon discharge: ___:
GENERAL: NAD
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: mild CVA tenderness right side, soft, hypoactive BS,
no hepatomegaly, no splenomegaly
EXT: no calf tenderness bil., no pedal edema bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 06:15AM BLOOD WBC-7.0 RBC-4.63 Hgb-14.2 Hct-42.8 MCV-92
MCH-30.7 MCHC-33.2 RDW-12.4 RDWSD-42.3 Plt ___
___ 04:27AM BLOOD WBC-7.3 RBC-4.41* Hgb-13.8 Hct-40.7
MCV-92 MCH-31.3 MCHC-33.9 RDW-12.6 RDWSD-42.4 Plt ___
___ 04:42AM BLOOD WBC-7.8 RBC-4.38* Hgb-13.6* Hct-41.1
MCV-94 MCH-31.1 MCHC-33.1 RDW-12.5 RDWSD-43.2 Plt ___
___ 04:53PM BLOOD Hct-27.9*#
___ 04:30AM BLOOD WBC-8.0 RBC-4.34* Hgb-13.2* Hct-40.9
MCV-94 MCH-30.4 MCHC-32.3 RDW-12.6 RDWSD-43.8 Plt ___
___ 06:09PM BLOOD WBC-10.8* RBC-4.38* Hgb-13.5* Hct-40.5
MCV-93 MCH-30.8 MCHC-33.3 RDW-12.5 RDWSD-43.0 Plt ___
___ 01:51AM BLOOD WBC-10.7* RBC-4.26* Hgb-13.3* Hct-39.9*
MCV-94 MCH-31.2 MCHC-33.3 RDW-13.2 RDWSD-45.1 Plt ___
___ 06:15AM BLOOD Plt ___
___ 04:27AM BLOOD ___ PTT-28.5 ___
___ 06:15AM BLOOD Glucose-100 UreaN-12 Creat-1.1 Na-141
K-4.0 Cl-103 HCO3-27 AnGap-15
___ 04:27AM BLOOD Glucose-94 UreaN-12 Creat-1.1 Na-142
K-3.9 Cl-104 HCO3-28 AnGap-14
___ 12:50PM BLOOD Glucose-89 UreaN-12 Creat-1.0 Na-139
K-4.2 Cl-100 HCO3-27 AnGap-16
___ 06:15AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.0
___ 05:27PM BLOOD Lactate-2.2*
___: ct of the chest:
. Acute right ___ hematoma likely arising from a
ruptured right upper pole renal cyst or rupture of the upper
renal collecting system. Please see subsequent CT, which better
evaluates collecting system injury.
2. No other acute sequelae of trauma. No fracture.
3. 2.1 cm splenic artery aneurysm.
4. Sub-acute or chronic left sixth through eighth rib fractures.
___: CT abd./pelvis:
Findings concerning for disruption of the right renal collecting
system in the upper pole region. Surgical consultation is
advised.
___: CTU:
1. Improving perinephric hematoma on the right. There is no
extravasation of contrast outside the renal collecting system/
ureter.
2. Stable splenic artery aneurysm.
Brief Hospital Course:
___ year old male who presented to the hospital after falling off
his bicycle onto a curb. He continued to ride on for
approximately 30 miles and presented later in the day after his
right sided pain worsened. Upon review of imaging, he was found
to
have a right ___ hematoma. After imaging, the patient
reported an increase in the severity of his abdominal pain.
Because of this, the patient underwent repeat imaging where he
was found to have active extravasation into the collecting
system. He was having gross hematuria. The patient was made
NPO, given intravenous fluids, and placed no bedrest. A foley
catheter was placed. He underwent serial hematocrits which
remained stable. The Urology service was consulted and
recommended conservative management, including bed-rest, serial
hematocrits and repeat imaging in 3 days.
During the hospitalization, the patient's vital signs remained
stable and he was afebrile. He resumed a regular diet and
continued to have alternating bouts of hematuria. On HD #5, the
patient underwent a CT Urogram which showed a decrease in the
size of the ___ hematoma on the right. There was no
extravasation of
contrast outside the renal collecting system. The foley
catheter was removed and the patient voided without difficulty.
The patient was discharged home on HD #6 in stable condition.
Follow-up appointments were made in the acute care clinic and
with the Urology service. Discharge instructions were reviewed
and questions answered.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
right perinephric hematoma
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 after a fall from your bike.
You sustained bleeding around your kidney. You had foley
catheter placed and your urine output was monitored. You
underwent repeat imaging of your kidney and the bleeding around
your kidney has decreased. You vital signs have been stable and
you are preparing for discharge with the following instructions:
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, increased right flank pain,
inability to urinate
*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 avoid aspirin and motrin/advil/alleve until you follow-up
in the acute care clinic
Followup Instructions:
___
|
10354409-DS-20 | 10,354,409 | 22,687,539 | DS | 20 | 2134-08-24 00:00:00 | 2134-08-25 09:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue, dyspnea
Major Surgical or Invasive Procedure:
Coronary angiogram
Right heart catheterization
History of Present Illness:
___ years old woman from ___ with a history of HIV
on HAART (CD4 count about ___ years ago was about 500 and viral
load has been undetectable for at least ___ years),
hypertension, T cell lymphoma (HTLV-1 positive) s/p 6 cycles
CHOEP last ___, stroke without deficits on lovenox,
presenting fatigue for the past several weeks.
She completed six cycles of CHOEP without any sign of residual
disease on her PET scan on ___. Resolution of hilar
masses per most recent outpatient PET (___).
Of note, she has had persistent resting tachycardia since ___
(unknown baseline prior to chemo.) Today got echo given
persistent tachycardia of unknown etiology. Pt referred to ED
after TTE showed newly depressed EF ___. She also felt her
heart racing this morning, and had some dyspnea during that
time.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
HTLV 1 + peripheral T cell lymphoma
HIV on HAART
Obesity
Social History:
___
Family History:
No known family history of leukemia or lymphoma. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.4 PO 129 / 93 R Sitting 126 18 97 Ra
Weight: 183.5 lb
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate. Laying flat with HOB at 20 degrees
HEENT: NCAT. Sclera anicteric. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 9-10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Decreased air movement,
crackles in bases bilaterally. No wheezes or
rhonchi.
Chest: R port C/D/I
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. Trace lower extremity
edema.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T: 98.7, BP: 92/65, HR: 109, RR: 20, 96% RA
Weight: 176.5 <-- 177.47 <-- 177.69 (183.5 lb on admission)
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 9-10 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
Chest: R port C/D/I
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
===============
ADMISSION LABS:
___
___ 01:20PM BLOOD WBC-6.5 RBC-2.82* Hgb-9.2* Hct-28.4*
MCV-101* MCH-32.6* MCHC-32.4 RDW-19.9* RDWSD-73.7* Plt ___
___ 01:20PM BLOOD Neuts-77.4* Lymphs-10.9* Monos-8.8
Eos-1.5 Baso-0.5 Im ___ AbsNeut-5.03 AbsLymp-0.71*
AbsMono-0.57 AbsEos-0.10 AbsBaso-0.03
___ 01:20PM BLOOD ___ PTT-46.9* ___
___ 01:20PM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-140
K-3.8 Cl-107 HCO3-18* AnGap-15
___ 01:37PM BLOOD Lactate-1.1
___ 01:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:20PM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR*
___ 01:20PM URINE RBC-<1 WBC-3 Bacteri-FEW* Yeast-NONE
Epi-1
___ 01:20PM URINE UCG-NEGATIVE
========================
PERTINENT INTERVAL LABS:
========================
___ 01:20PM BLOOD CK-MB-4 cTropnT-0.06* proBNP-4581*
___ 06:15PM BLOOD cTropnT-0.07*
___ 12:30AM BLOOD CK-MB-3 cTropnT-0.08*
___ 12:30AM BLOOD ALT-15 AST-21 AlkPhos-94 TotBili-<0.2
___ 12:30AM BLOOD Albumin-3.5 Calcium-8.6 Mg-1.5* Iron-33
___ 12:30AM BLOOD calTIBC-224* Ferritn-1449* TRF-172*
___ 12:30AM BLOOD TSH-3.0
___ 12:30AM BLOOD HIV1 VL-3.3*
===============
DISCHARGE LABS:
===============
___ 08:10AM BLOOD WBC-5.2 RBC-2.99* Hgb-9.4* Hct-29.4*
MCV-98 MCH-31.4 MCHC-32.0 RDW-17.8* RDWSD-64.6* Plt ___
___ 08:10AM BLOOD ___ PTT-52.0* ___
___ 08:10AM BLOOD Glucose-108* UreaN-27* Creat-1.3* Na-136
K-5.0 Cl-103 HCO3-16* AnGap-17
___ 08:10AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.2
================
IMAGING STUDIES:
================
CXR (___):
New moderate cardiomegaly and mild pulmonary edema. No pleural
effusion or focal consolidation.
TTE (___):
The left atrial volume index is severely increased. The
estimated right atrial pressure is ___ mmHg. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
moderately thickened. There is no mitral valve prolapse. An
eccentric, anteriorly directed jet of Moderate to severe (3+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a very small pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION:
1) Moderate LV systolic dysfunction with regionalities
suggesting diffuse cardiomyopathic process in addition to CAD in
RCA/LCX. However, regionalities maybe expression of diffuse
cardiomyopathic process.
2) Moderate to severe mitral regurgitation due to restricted
motion of the posterior mitral valve leaflet in setting of mild
LV dilation.
3) Moderate pulmonary systolic arterial hypertension with
normal RV size/function.
4) Very small to small pericardial effusion without signs of
tamponade physiology.
Compared with the prior study (images reviewed) of ___,
LV systolic function has wosened in severity and severity of
mitral regurgitation has worsened significantly. There now is a
pericardial effusion.
Coronary Angiogram (___):
Dominance: Right
* Left Main Coronary Artery
The LMCA is normal
* Left Anterior Descending
The LAD is normal.
* Circumflex
The Circumflex is normal.
* Right Coronary Artery
The RCA is normal.
IMPRESSION: Normal coronary arteries, marked elevation of LVEDP
37 mm Hg
Right Heart Catheterization (___):
Filling pressures:
Site Systolic Diastolic EDP A Wave V Wave Mean HR
AO 106 66 81 113
RV 20 1 112
PA 26 9 15 114
PCW 8 8 7 114
RA 2 -1 113
Oximetry:
Site Oxygen Content Saturation Hemoglobin PO2
PA 7.03 55 9.4
AO 12.78 100 9.4
RA 7.41 58 9.4
SVC 7.54 59 9.4
Cardiac Output L/min 3.95
Cardiac Index L/min/m² 2.17
PV (___): 2.0
SV (___): 20.5
PV(dsc-5): 162.4
SV(dsc-5): 1640.8
IMPRESSION: Low filling pressures
Cardiac ___: RESULTS PENDING AT DISCHARGE
=============
MICROBIOLOGY:
=============
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ years old woman from ___ with a history of HIV
on HAART, T-cell lymphoma (HTLV-1 positive, s/p 6 cycles CHOEP
last ___, hypertension, and history of CVA on Lovenox
without residual deficits who presents with fatigue, persistent
tachycardia and dyspnea found to have newly depressed EF ___.
#HFrEF:
#NON-ISCHEMIC CARDIOMYOPATHY:
Newly depressed EF ___, most likely multi-factorial related
to toxin-induced cardiomyopathy (s/p 6 cycles hydroxydaunorubin)
vs. HIV vs. tachycardia-induced as she has had persistent
resting sinus tachycardia documented since ___. She did
undergo coronary angiogram as there were questionable wall
motion abnormalities on TTE, although no evidence of CAD, making
ischemic cause unlikely. She was started initially on IV Lasix,
although relatively unresponsive to Lasix and diuresis limited
by developing ___. Right heart catheterization was preformed
showing low right sided filling pressures, PCWP 7, with CI 2.1.
Diuresis was discontinued due to low filling pressures, and she
was started on lisinopril 2.5mg and digoxin 0.125mg for
inotropic support. She was counseled on checking her weight
daily at home, and will be discharged on Lasix 20mg PRN to be
taken for weight increase > 3 lbs. Cardiac MRI was preformed
while inpatient, although results still pending at discharge.
Plan to follow up in heart failure clinic on ___. She will need
a digoxin trough level checked at that time, goal trough level
0.5-0.9 ng/mL.
#SINUS TACHYCARDIA:
Patient has had persistent resting sinus tachycardia documented
since ___. TSH and cortisol within normal limits as of
___, and hemoglobin at baseline, although she is anemic
(HgB . Most recent CTA in ___ negative for PE and low
suspicion given that patient is anti-coagulated on lovenox. Most
likely compensatory component in the setting of newly reduced
EF.
#HX EMBOLIC STROKE:
Admitted ___ for subacute embolic stroke, with symptom
resolution (difficulty speaking, slurred speech, L facial droop
and L sided neglect at that time). TTE with bubble study did
show PFO. Started on Lovenox BID. Per last oncology note, plan
to continue anticoagulation for at least a month after
chemotherapy. Lovenox was continued at discharge, along with
home atorvastatin. Plan to follow up with hematology/oncology
(Dr. ___ to determine duration of anticoagulation
treatment.
# HIV:
CD4 count ___ years ago about 500, previously undetectable viral
load for at least ___ years, with newly detectable viral load 3.3
on admission, CD4 count 282. Possibly contributing to cause of
new cardiomyopathy as above. ID consulted while inpatient with
plan to follow up as an outpatient with Dr. ___. Home Atripla
was continued.
#T-CELL LYMPHOMA:
HTLV-1 positive, s/p 6 cycles of CHOEP (last ___ without
any sign of residual disease on her PET scan on ___.
Resolution of hilar masses per most recent outpatient PET
(___). Plan initially to pursue prophylactic intrathecal
chemotherapy within the next month or two. Plan for continued
discussions between cardiology (Dr. ___ and
hematology/oncology with regards to safety and timing of further
chemotherapy as an outpatient.
#HYPERTENSION:
Discontinued home labetolol due to low cardiac index.
TRANSITIONAL ISSUES:
====================
DISCHARGE WEIGHT: 176.5lbs
DISCHARGE CR: 1.3
[ ] Please encourage patient to check daily weights at home
[ ] Home diuretic: furosemide 20mg PRN for weight gain of > 3lbs
[ ] Medications added: lisinopril 2.5mg, digoxin 0.125mg
[ ] Medications discontinued: labetalol
[ ] Repeat BMP at heart failure clinic follow up, if Cr
up-trending (>1.3) consider discontinuation of Lisinopril, as
well as dose adjustments in HAART therapy (tenofivir and
emtricitabine will need to be dose reduced)
[ ] Also, if Cr up-trending (>1.3) please discuss with
hematology/oncology discontinuation of Lovenox or alternative
anticoagulation plan
[ ] Check digoxin level at heart failure clinic follow up,
patient instructed to hold her digoxin the morning of her
appointment so that a level will be accurate, resume digoxin if
level within normal limits, hold if supratherapeutic
[ ] Please follow up results of cardiac MRI, results pending at
discharge
[ ] Follow up scheduled ___ ___
[ ] Patient has newly detectable HIV viral load, follow up with
infectious disease (Dr. ___ scheduled ___
[ ] Continued home Lovenox on discharge for history of embolic
stroke, follow up with hematology/oncology (Dr. ___ to
determine duration of anticoagulation
# CODE: full, presumed
# CONTACT: HCP: ___, son. ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 100 mg PO BID
2. Enoxaparin Sodium 90 mg SC BID
Start: ___, First Dose: Next Routine Administration Time
3. efavirenz-emtricitabin-tenofov ___ mg oral DAILY
4. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Furosemide 20 mg PO DAILY:PRN weight gain
RX *furosemide 20 mg 1 tablet(s) by mouth daily prn Disp #*20
Tablet Refills:*0
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Enoxaparin Sodium 80 mg SC Q12H
5. Atorvastatin 40 mg PO QPM
6. efavirenz-emtricitabin-tenofov ___ mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Non-ischemic Cardiomyopathy
Heart Failure with Reduced Ejection Fraction
Secondary Diagnosis:
====================
HIV
T-cell lymphoma
Anemia
Hx of stroke
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 ___
___!
Why was I admitted to the hospital?
-You were admitted because you were feeling tired and short of
breath.
What happened while I was in the hospital?
- We did an ultrasound of your heart which showed that your
heart muscle is weakened.
- You had multiple procedures to help us decide which
medications would be best for your heart failure.
- We started you on medications to help your heart pump stronger
and lower your blood pressure.
What should I do after leaving the hospital?
- We have made changes to your medication list, so please make
sure to take your medications as directed. You will also need to
have close follow up with your heart doctor and your primary
care doctor. Please take your medications as listed in your
discharge summary and follow up at the listed appointments.
- Please stop taking your home labetalol
- Please start taking lisinopril, digoxin
- Please continue to take your lovenox and atorvastatin
- Please weigh yourself every day in the morning after you go to
the bathroom and before you get dressed. If your weight goes up
by more than 3 lbs please take one tablet of Lasix and please
call your heart doctor to notify them of this change.
- Please seek medical attention if you have new or concerning
symptoms or you develop swelling in your legs, abdominal
distention, or shortness of breath at night.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
10354450-DS-24 | 10,354,450 | 29,591,537 | DS | 24 | 2164-01-10 00:00:00 | 2164-01-12 12:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Wellbutrin
Attending: ___
Chief Complaint:
abdominal pain, fevers, malaise
Major Surgical or Invasive Procedure:
___: US-guided placement of ___ pigtail catheter into
perisplenic fluid collection
___: Successful placement of a left 49 cm brachial approach
double lumen PowerPICC with tip ___ the cavoatrial junction.
History of Present Illness:
Mr. ___ is a ___ s/p sigmoid colectomy for diverticulitis c/b
ostomy retraction requiring revision, and multiple episodes of
alcoholic pancreatitis, who was recently hospitalized
(___) after presenting from OSH with acute
pancreatitis c/b right colonic ischemia s/p R colectomy, treated
with open abdomen, ileostomy, with course complicated by
multiple EC fistulae, who presents with one day of abdominal
pain, fever to 101.4 at home, and malaise. He was last seen ___
clinic ___, when 2 ___ drains were removed. A surgical drain,
his final drain, was removed on ___. Given his multiple EC
fistuale he has been receiving TPN via a LUE PICC line. His mom
notes that he has been complaining of one day of abdominal pain,
fever, and malaise. His blood sugar was also elevation so she
___ him to the ED for further evaluation. ___ the ED patient
was noted to be hypotensive, tachycardic, febrile, and
hyperglycemic. Out of concern for septic shock and DKA, the
patient's LUE PICC was pulled, a right IJ CVL was placed, he was
fluid resuscitated (6L crystalloid), and started on an levophed
and insulin gtt. A CT A/P revealed a splenic fluid collection.
He was then admitted to the TICU.
Past Medical History:
___: ETOH, perforated diverticulitis
PSH: OSH procedure:
___: Exploratory laparotomy, sigmoid colectomy and
formation of ___ pouch colostomy
___ operations:
___: Exploratory laparotomy with revision of sigmoid
colostomy (___)
___: Abdominal washout, liver biopsy, abdominal closure
___: Colostomy takedown (___)
___ - Ex lap, R colectomy, temp abd closure (___)
___ - Second look, LOA, end ileostomy, temp abd closure
(___)
___ - Washout, drain placed, ___ patch (___)
___ - ___ patch, closure w biologic mesh,
vac, new jp x3 (___)
___ - tracheostomy
___ - Split-thickness skin graft, 300 sq cm from left thigh
to abdomen (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Gen: Appears ill. Tachypnic but not dyspnic, flushed. A&Ox3,
appropriate.
Abd: TTP diffusely. Ostomy patent, pink.
Discharge Physical Exam:
VS: T: 98.1, BP: 123/77, HR: 99, RR: 18, O2: 100% RA
GENERAL: A+Ox3, NAD
CV: RRR
PULM:CTA b/l
ABD: soft, mildly distended, ostomy pink, patent. EC fistula
with pouch intact, drainage thin and brown.
EXTREMITIES: No edema. LUE PICC ___ place. Warm, well-perfused
b/l
Pertinent Results:
Admission Labs
___ 10:15AM BLOOD WBC-40.4*# RBC-3.99*# Hgb-10.3* Hct-33.4*
MCV-84# MCH-25.8* MCHC-30.8* RDW-13.9 RDWSD-42.5 Plt ___
___ 10:15AM BLOOD Neuts-82* Bands-14* Lymphs-1* Monos-3*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-38.78*
AbsLymp-0.40* AbsMono-1.21* AbsEos-0.00* AbsBaso-0.00*
___ 10:15AM BLOOD ___ PTT-40.4* ___
___ 10:15AM BLOOD Glucose-583* UreaN-64* Creat-3.7*#
Na-126* K-4.5 Cl-89* HCO3-14* AnGap-28*
___ 10:15AM BLOOD ALT-17 AST-16 AlkPhos-189* TotBili-1.2
___ 10:15AM BLOOD Albumin-3.1* Calcium-11.0* Phos-5.2*
Mg-1.8
___ 10:21AM BLOOD ___ pO2-42* pCO2-39 pH-7.21*
calTCO2-16* Base XS--11
Discharge labs
####
####
Imaging
CT Abd/Pelvis without contrast (___)
1. Bilateral lower lobe nodular opacities concerning for
multifocal pneumonia.
2. Previously noted mild peripancreatic and retroperitoneal
stranding
continues to improve since prior study.
3. Status post right colectomy and partial sigmoidectomy.
Interval removal of
bilateral percutaneous drains with no new fluid collection
identified. No
evidence for bowel obstruction.
4. Subcapsular splenic fluid collection appears slightly
smaller.
___ guided perisplenic abscess drainage (___)
Successful US-guided placement of ___ pigtail catheter into
the collection. Approximately 400 cc of reddish-brown fluid was
drained. Samples was sent for microbiology evaluation.
ECHO (___)
Moderate left ventricular systolic dysfunction. Normal right
ventricular chamber size with mild systolic dysfunction. Overall
left ventricular systolic function is moderately depressed
(LVEF= 30%-35 %).
CT Chest (___)
1. Moderate to large right and small to moderate left pleural
effusions are similar to recent chest radiographs but have
substantially increased ___ size since abdominal CT of ___. Adjacent atelectasis involving the right middle and both
lower lobes.
2. No segmental or lobar areas of consolidation within
non-atelectatic lung to suggest the presence of pneumonia.
CT Abd/Pel (___)
1. There has been interval placement of a pigtail catheter into
a perisplenic fluid collection which is moderately decreased ___
size. Superimposed infection cannot be excluded.
2. Mild peripancreatic stranding is unchanged from the prior
examination, however significantly improved from several prior
CTs.
3. A defect ___ the anterior abdominal wall is unchanged.
ECHO (___)
No valvular vegetations or abscesses were appreciated. Preserved
biventricular systolic function. Simple atheroma ___ the
descending thoracic aorta.
Right upper extremity venous duplex (___)
1. No evidence of deep vein thrombosis ___ the right upper
extremity veins.
2. Nonocclusive thrombus ___ the proximal and mid right cephalic
vein.
Microbiology
___ 10:25 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
Reported to and read back by ___ @ 2300 ON
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI ___ CLUSTERS.
___ 12:29 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 2:07 pm CATHETER TIP-IV Source: PICC.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. <15 colonies.
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---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 6:38 pm ABSCESS Source: perisplenic.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 9:40 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
3+ ___ per 1000X FIELD): BUDDING YEAST.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
YEAST. 10,000-100,000 ORGANISMS/ML..
Brief Hospital Course:
Mr. ___ is a ___ most recently admitted from ___ until
___ for acute pancreatitis and ___ ischemia s/p ex
lap, right colectomy, LOA, ileostomy, and closure with biologic
mesh complicated by delayed abdominal wall closure, infection,
respiratory failure, and enterocutaneous fistula formation, who
presents now with one day of abdominal pain, fever, and malaise.
On arrival to the ED, patient was found to be hypotensive,
tachycardic, febrile, and hyperglycemic. Given signs of septic
shock and DKA, we evaluated for all possible sources of
infection.
On arrival, the patient's LUE PICC (TPN dependent given EC
fistula) was immediately pulled with catheter tip sent for
culture. A right IJ CVL was placed and he was resuscitated (6L
crystalloid), and started on an levophed and insulin gtt. A CT
A/P was subsequently obtained which revealed a stable splenic
fluid collection. However given concern for superinfection of
the splenic fluid collection resulting ___ systemic sepsis, ___
was consulted for drainage. He was admitted to the TICU and
bedside ultrasound guided ultrasound drainage was performed
which resulted ___ drainage of 400 cc of reddish-brown fluid. A
___ pigtail catheter was placed into collection for
drainage. Shortly after arrival to the ICU, he became tachypneic
with altered mental status so he was intubated for airway
protection. The perisplenic fluid collection resulted ___ no
micro-organism growth. However, his blood cultures and PICC
catheter tip resulted ___ MSSA. His septic shock was therefore
concluded to be secondary to MSSA bacteremia from an infected
PICC line. His ICU course was complicated by renal failure
requiring CVVH and right pleural effusion requiring right chest
tube placement and drainage. Please seen below for details
regarding his ICU course.
#Neuro
Patient was intubated on arrival to ___ for respiratory
distress and was placed on fent and prop gtt for pain control
and sedation, respectively. Given continued agitation, he was
transition to precedex gtt prior to extubation. After
extubation, pain was controlled with fentanyl patch, PO
oxycodone, and intermittent PRN dilaudid. At time of transfer
from the ICU patient was alert, appropriate, neurointact, and
interactive
#CV
- Patient developed septic shock from PICC line sepsis resulting
___ profound hypotension requiring maximum epinephrine,
norepinephrine, phenylephrine, and vasopressin gtt doses. These
pressors were slowly weaned off after the picc line was removed.
- Patient was given stress dose steroids from HD2-3 given
continued hypotension despite maximum pressors
- ECHO on ___ showed moderate left ventricular systolic
dysfunction, with overall left ventricular systolic function is
moderately depressed (LVEF= 30%-35 %).
- ECHO on ___ showed no valvular vegetations or abscesses
#Pulm
- Intubated for respiratory distress, tachypnea, and AMS on
arrival to the ICU. Patient was successfully extubated on ___.
- CT Chest (___) showed moderate-large right pleural effusion
and small-moderate left pleural effusion. Right chest tube was
placed on ___, resulting ___ ~600 of initial serosanguinous
fluid drainage.
- MIni-BAL was obtain on ___ with growth of no organisms
#___
During his ICU stay, he was started on TFs and was noted to have
high ECF and ostomy output. Loperamide was started to slow
output rates.
#Renal
Patient developed acute kidney injury and oliguria ___ the
setting of septic shock. He required CVVH from ___ to ___ via
a LIJ HD line.
#Endo
On admission, patient was ___ DKA and started on an isulin gtt.
He was transition to ISS on ___ and ___ was consulted for
further hyperglycemia management via ISS adjustments.
#PPx
- SQH was continued throughout the ICU course
#ID
- Septic shock secondary to PICC line sepsis. Patient initially
treated with broad spectrum antibiotics. Antibiotics were
narrowed once culture speciation and sensitivities resulted
- PICC catheter tip ___ - MSSA
- Blood culture ___ - MSSA
- Nafcillin ___ -
- meropenem (___)
- vancomycin (___)
- clindamycin (___)
- micafungin (___)
- zosyn (___)
Patient was then transferred to the surgical floor ___ stable
condition.
=========================================================
On ___, the patient was noted to have RUE edema and an
ultrasound was ordered and demonstrated a nonocclusive thrombus
___ the proximal and mid right cephalic vein without evidence of
DVT. No new anticoagulation therapy was necessary. He was noted
to have a high stoma output of 1700 ml. He was started on
loperamine 4mg Q6H. His right chest tube was removed and his
post-pull CXR showed no pneumothorax. On ___, the patient's
HD and central lines were removed and the tips were sent for
culture. The patient was started on lomotil to further help
decrease fistula output. On ___, lomotil was increased, his
___ drain was removed, his foley catheter was removed and he
voided appropriately. Tincture of Opium was started to help
decrease fistula output. On ___, the patient was taken to
Interventional Radiology where he received a PICC for fluids,
antibiotics and TPN. TPN was initiated. The patient received
LR fluid boluses of ___ cc per 1 cc of output from the fistula.
The patient was set up for home TPN, antibiotic, and IV fluid
boluses with the home infusion company. ___ continued to
follow the patient for blood sugar control. On ___, it was
communicated with the nurse of the patient's PCP that the
patient's labs would be drawn one day after discharge and it was
established that his PCP would follow the results.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. He was discharged home with
___ services.
Medications on Admission:
Dilaudid, Metoprolol, Oxycodone, Acetaminophen, Insulin
Discharge Medications:
1. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QTHUR
RX *clonidine 0.1 mg/24 hour Apply 1 Patch TD once weekly
___ Disp #*10 Patch Refills:*0
2. Fentanyl Patch 75 mcg/h TD Q72H
RX *fentanyl 75 mcg/hour Apply TD Q72H Disp #*10 Patch
Refills:*0
3. Diphenoxylate-Atropine 1 TAB PO Q6H
RX *diphenoxylate-atropine 2.5 mg-0.025 mg 1 tablet(s) by mouth
every six (6) hours Disp #*80 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) 8 mg PO Q4H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *hydromorphone 8 mg 1 tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
5. LOPERamide 4 mg PO Q6H
RX *loperamide 2 mg 2 capsules by mouth every six (6) hours Disp
#*120 Capsule Refills:*0
6. Metoprolol Tartrate 50 mg PO QID
7. Nafcillin 2 g IV Q4H
8. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN with all dressing
changes
9. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q6H
RX *opium tincture 10 mg/mL (morphine) 0.3 mL by mouth every six
(6) hours Disp ___ Milliliter Refills:*0
10. OxyCODONE SR (OxyconTIN) 40 mg PO Q12H
11. QUEtiapine Fumarate 25 mg PO QHS:PRN sleep
RX *quetiapine 25 mg 1 tablet(s) by mouth at bedtime Disp #*10
Tablet Refills:*0
12. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
13. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
14. Thiamine 100 mg PO DAILY
15. Insulin SC
Sliding Scale
Fingerstick q6hr
Insulin SC Sliding Scale using HUM Insulin
16. Glucose Gel 15 g PO PRN hypoglycemia protocol
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
>MSSA bacteremia due to PICC line infection
>perisplenic fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with sepsis from a PICC line
infection. You were monitored closely ___ the Intensive Care Unit
and briefly required dialysis due to kidney injury. You are now
stable and have been transferred to the general surgical floor.
A PICC line was replaced for TPN. There has been high output
from your fistula, which is requiring repletions of IV fluid to
make up for the volume loss. Infectious Disease is following you
to manage your blood stream infection. You will require 4 weeks
of IV antibiotics and will follow-up ___ the ___ clinic for
surveillance blood cultures. You are now ready for discharge,
please note 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 ___ your
urine, or experience a discharge.
*Your pain ___ 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 ___ your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Followup Instructions:
___
|
10354450-DS-26 | 10,354,450 | 29,783,474 | DS | 26 | 2164-08-01 00:00:00 | 2164-08-01 09:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
Wellbutrin
Attending: ___.
Chief Complaint:
Abdominal pain after abdominal wall spacer implantation
Major Surgical or Invasive Procedure:
spacer implantation ___
History of Present Illness:
Mr ___ is a very unfortunate ___ with perforated
diverticulitis s/p partial colectomy w/ colostomy/takedown in
___, alcoholism (currently clean), DM, and most significantly
severe alcoholic pancreatitis almost ___ year ago with ischemic
bowel requiring emergent exploratory laparotomy and colectomy
with multiple failed closure attempts necessitating mesh/skin
grafting, complicated by enterocutaneous fistula. He presents
with worsening pain after abdominal wall spacer placement for
eventual ECF repair and ostomy takedown.
At the beginning of this calendar year, he was extremely ill
with respiratory failure, renal failure on CVVH, septic shock,
etc and almost died, and required TPN for quite some time. He
was on high doses of long acting and short acting narcotics. He
had an admission for CLABSI with MSSA bacteremia and severe
sepsis/shock. However, he and his mother relate a general trend
toward slow but steady improvement over the course of the past
___ months. He has tapered his opiate medications considerably.
He graduated from TPN and advanced to a regular diet.
He has been working with his surgeons to address his ECF and
ileostomy. Plans were made for staged procedures with placement
of spacer/skin expander implants prior to ECF/ileostomy
takedowns to allow a definitive abdominal closure given his
history of difficult to close abdominal wounds. He came in for
elective spacer implants ___.
Post procedure, he had significant pain which broke through
dilaudid PCA. Pain was in flanks near the site of the spacers,
severe ___, sharp; on the right side there was associated
cutaneous allodynia. Acute pain service was consulted and placed
epidural. He initially had good relief but then epidural
malfunctioned. He reports that he was in tremendous pain and
that it never really improved, and he became frustrated with the
surgical and pain teams' management so he decided to go home,
hopeful that his pain would slowly improve as he adjusted to the
spacers. He does report that prior to discharge he was given a
dose of tizanidine which brought him some relief.
Unfortunately, while pain on the left flank is better, the pain
on his right has not improved. It has continued to impede his
functioning, and his mother noticed that it was affecting his PO
intake. This impaired functioning and diminished appetite due to
severe pain is what brought them back to the hospital. He is
clear that he had no f/c/s, cough/sob, n/v/d/c.
In our ED, he had stable vitals. He was seen by plastic surgery
who declined to admit him to their service. He had an ultrasound
of his abdominal wall which showed expanders but no other
significant findings. CT scan was offered but declined given
history of renal failure and story very suggestive of pain
related to recent surgery. Admission to medicine was requested.
Patient was subsequently transferred to Plastic Surgery for
treatment and disposition planning.
ROS is negative in 10 points except as noted.
Past Medical History:
___: ETOH, perforated diverticulitis, alcoholic pancreatitis,
chronic epigastric abdominal pain (slowly improving) on
narcotics, pancreatitis associated DM, ___ requiring CVVH, resp
failure s/p trach (since decannulated).
Reviewing prior records, he had TTE with depressed EF but has
never behaved like someone with CHF. Presumably this was a
stress induced CM.
PSH: OSH procedure:
___: Exploratory laparotomy, sigmoid colectomy and
formation of ___ pouch colostomy
___ operations:
___: Exploratory laparotomy with revision of sigmoid
colostomy (___)
___: Abdominal washout, liver biopsy, abdominal closure
___: Colostomy takedown (___)
___ - Ex lap, R colectomy, temp abd closure (___)
___ - Second look, LOA, end ileostomy, temp abd closure
(___)
___ - Washout, drain placed, ___ patch (___)
___ - ___ patch, closure w biologic mesh,
vac, new jp x3 (___)
___ - tracheostomy
___ - Split-thickness skin graft, 300 sq cm from left thigh
to abdomen (___)
Social History:
___
Family History:
No history of CHF
Father had HTN
Mother's side of the family has HTN, DM, hypothyroidism
Physical Exam:
Vitals AVSS
Gen NAD, quite pleasant
Abd soft, ND, bs+; mildly tender in the epigastrum (chronic) and
quite tender in RUQ and LUQ
CV RRR, no MRG
Lungs CTA ___
Ext WWP, no edema
Skin no rash, anicteric
GU no foley
Eyes EOMI
HENT MMM, OP clear
Neuro nonfocal, moves all extremities
Psych slightly flat affect
Pertinent Results:
Labs on admission:
Heme -
___ 08:42PM BLOOD WBC-12.7* RBC-4.58* Hgb-11.9* Hct-38.6*
MCV-84 MCH-26.0 MCHC-30.8* RDW-14.2 RDWSD-43.7 Plt ___
___ 04:45PM BLOOD WBC-9.0 RBC-4.78 Hgb-12.2* Hct-41.2
MCV-86 MCH-25.5* MCHC-29.6* RDW-14.2 RDWSD-45.0 Plt ___
Chem -
___ 08:42PM BLOOD Glucose-149* UreaN-9 Creat-0.8 Na-137
K-4.3 Cl-95* HCO3-28 AnGap-18
___ 04:45PM BLOOD Glucose-205* UreaN-11 Creat-1.1 Na-142
K-4.3 Cl-97 HCO3-29 AnGap-20
___ 08:42PM BLOOD ALT-13 AST-21 AlkPhos-159* TotBili-0.7
___ 08:42PM BLOOD Lipase-27
___ 08:42PM BLOOD Albumin-3.8
___ 11:23PM BLOOD Lactate-1.4
Imaging on admission:
Abdominal US -
Symmetric, primarily anechoic structures bilaterally likely just
the
expanders, given similar appearance bilaterally. If there is
continued
clinical concern, CT scan can be performed.
Brief Hospital Course:
___ with perforated diverticulitis s/p partial colectomy w/
colostomy/takedown in ___, alcoholism (currently clean), DM,
and most significantly severe alcoholic pancreatitis almost ___
year ago with ischemic bowel requiring emergent exploratory
laparotomy and colectomy with multiple failed closure attempts
necessitating mesh/skin grafting, complicated by enterocutaneous
fistula. He presents with worsening pain after abdominal wall
spacer placement for eventual ECF repair and ostomy takedown.
# Abdominal pain, acute on chronic: Pain is worst at the site of
expanders, also different in character than his usual chronic
post-pancreatitis abdominal pain, highly suggestive of acute
post-surgical pain related to these. No signs of infection, no
fevers, no leukocytosis (mild on admission but gone on repeat),
no erythema/cellulitis there. Cutaneous allodynia and
distribution of the pain might be suggestive of an ACNEs that
might be amenable to nerve blockade. Started Neurontin 100 TID,
APAP 1000 TID. Increased Dilaudid to ___ q4h PRN with improved
relief. Dilaudid IV q4h PRN breakthrough also started. SW
consult for supportive counseling. After discussion with plastic
surgery attending and chief resident, determined that patient
would be better served on Plastics service given recent surgery
and no active medical issues, transferred ___. Patient
reported resolution of pain with 8 mg Dilaudid Q4 and agreed to
discharge on ___ to follow up with Dr. ___ in clinic
in one week. Patient became hypotensive when hydromorphone was
combined with Tizanadine so Tizanadine was held until meeting
with primary care provider.
# DM: FSG stable in 100s, continued BID long acting insulin and
SSI with slightly reduced glargine dose given variable PO
intake.
# HTN/Tachycardia: Has been on variable doses of Lopressor,
prescribed by surgical teams and continued at discharge. He
tells me that he has recently not really required this and has
had reasonable vitals. HR stable in ___ prior to transfer, can
likely downtitrate metoprolol.
# Ileostomy, enterocutaneous fistula: Stable. Recent poor PO
intake is likely secondary to severe pain. He was clear that the
pain was not worsened by PO intake, just that he was in too much
pain to take interest in eating. mIVF for poor PO intake.
# Possible mild ___: Cr up to 1.1 from 0.8 on admission,
improved to 0.9 with fluids. Likely related to poor intake along
with higher ostomy outputs.
# Hypomagnesemia: Stable on home supplements.
PPX: Heparin
Code: Full
Dispo: HMED
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. QUEtiapine Fumarate 25 mg PO QHS:PRN Insomnia
2. Acetaminophen 1000 mg PO Q6H
3. Metoprolol Tartrate 50 mg PO Q6H
4. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe
5. Tizanidine 2 mg PO BID
6. detemir 17 Units Breakfast
detemir 17 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Magnesium Oxide 400 mg PO BID
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Duration: 2 Weeks Please take ___ mg every four hours as needed
for pain RX *hydromorphone 8 mg 1 tablet(s) by mouth every four
(4) hours Disp #*42 Tablet Refills:*0
2. Tizanidine 2 mg PO BID
3. Acetaminophen 1000 mg PO Q8H
4. detemir 17 Units Breakfast detemir 17 Units Bedtime
5. Magnesium Oxide 400 mg PO BID
6. Metoprolol Tartrate 50 mg PO Q6H
7. QUEtiapine Fumarate 25 mg PO QHS:PRN Insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal tissue expanders
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take your antibiotic as prescribed.
5. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
6. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
7. do not take any medicines such as Motrin, Aspirin, Advil or
Ibuprofen etc
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
10354561-DS-3 | 10,354,561 | 27,054,044 | DS | 3 | 2144-12-27 00:00:00 | 2144-12-27 09:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Bactrim / latex / Novocain / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
right hip pain with TFN cutout
Major Surgical or Invasive Procedure:
___ removal of right TFN hardware and placement of right
cemented long stem hemiarthroplasty
History of Present Illness:
Patient underwent surgery on ___ for a right hip fracture
and had a short TFN placed. Patient had been recovering well at
home after being discharged from rehab. She was staying away
from home and using a low toilet and started to notice
increasing R hip pain over ___ weekend. Since then the
pain continued to increase to the point that she can barely
walk. No specific fall or trauma recently.
Past Medical History:
___ Disease
Hypertension
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS: T 98.4, BP 134/57, HR 84, RR 16, SaO2 100% RA
Gen: Well appearing in NAD, AAOx3
CV: RRR
PULM: respiring easily, CTAB
Focused Exam of RLE: wound without dressing, staples in place,
no erythema/induration appreciated, no discharge/drainage.
Sensation intact to light touch in sural/saphenous/superficial
peroneal/deep peroneal/tibial nerve distributions. Ankle DF/PF
intact. ___ fires. ___ 2+. Digits WWP.
Pertinent Results:
___ 09:30AM BLOOD WBC-9.1 RBC-2.70* Hgb-8.3* Hct-24.7*
MCV-92 MCH-30.7 MCHC-33.6 RDW-16.1* RDWSD-53.3* Plt ___
___ 06:35AM BLOOD Glucose-125* UreaN-12 Creat-0.4 Na-133
K-3.8 Cl-98 HCO3-25 AnGap-14
___ 06:35AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0
Brief Hospital Course:
Hospitalization Summary (ED Admit)
The patient represented to the emergency department after
recently undergoing surgery on underwent surgery on ___ for
a right hip fracture during which she had a short TFN placed.
Patient had been recovering well at home after being discharged
from rehab. She was using a low toilet and started to notice
increasing R hip pain over labor day weekend. Since then the
pain continued to increase to the point that she can barely
walk. The patient was evaluated by the orthopaedic surgery
service and was found to have cutout of her right TFN and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for removal of hardware
and placement of a cemented right hemiarthroplasty, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
to bear weight on the affected extremity as she is able to
tolerate while observing anterior hip precautions, and will be
discharged on lovenox 30mg 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:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 0.25 TAB PO 6X/DAY
2. Rasagiline 1 mg PO QAM
3. Atenolol 12.5 mg PO DAILY
4. Lorazepam 0.5 mg PO QHS:PRN insomnia
5. Denosumab (Prolia) 60 mg SC MONTHLY
6. Requip XL (rOPINIRole) 8 mg oral DAILY
7. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Calcium Carbonate 500 mg PO QPM
Discharge Medications:
1. Atenolol 12.5 mg PO DAILY
2. Calcium Carbonate 500 mg PO QPM
3. Carbidopa-Levodopa (___) 0.25 TAB PO 6X/DAY
4. Acetaminophen 1000 mg PO Q8H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*0
5. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain
RX *acetaminophen-codeine 300 mg-30 mg ___ tablet(s) by mouth
every 4 hours Disp #*80 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*20 Tablet Refills:*0
7. Enoxaparin Sodium 30 mg SC DAILY Duration: 28 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 30 mg SC daily Disp #*28 Syringe
Refills:*0
8. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 (One) tab by mouth twice daily
Disp #*20 Tablet Refills:*0
10. Denosumab (Prolia) 60 mg SC MONTHLY
11. Lorazepam 0.5 mg PO QHS:PRN insomnia
12. Polyethylene Glycol 17 g PO DAILY
13. Rasagiline 1 mg PO QAM
14. Requip XL (rOPINIRole) 8 mg oral DAILY
15. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
previous ___ hardware cutout on right hip
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for repair of a malfunctioning piece
of hardware in your right hip with placement of a one sided hip
inplant by 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:
You may bear weight on your right leg as you tolerate but please
continue to maintain anterior hip precautions as follows:
Do not step backwards with surgical leg. No hip extension.
Do not allow surgical leg to externally rotate (turn
outwards).
Do not cross your legs. Use a pillow between legs when
rolling.
Sleep on your surgical side when side lying.
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 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.
Physical Therapy:
Activity as tolerated
Right lower extremity: Full weight bearing maintain anterior
hip precautions as follows:
Do not step backwards with surgical leg. No hip extension.
Do not allow surgical leg to externally rotate (turn
outwards).
Do not cross your legs. Use a pillow between legs when
rolling.
Sleep on your surgical side when side lying.
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Wound does not need dressing as long as nondraining. Staples
will be removed at 14 day post operative visit.
Followup Instructions:
___
|
10354791-DS-15 | 10,354,791 | 25,842,784 | DS | 15 | 2128-08-30 00:00:00 | 2128-08-30 13:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ with PMH of R papillary urothelial
carcinoma s/p stent placemen and removal, colon cancer s/p
colectomy and chemotherapy ___, MGUS, HFpEF, chronotropic
incompetence s/p PPM, severe TF s/p repair (___), PFO s/p
repair (___), MR, AF on warfarin (s/p ___ stapling), h/o TIA,
cardiac cirrhosis, CKD stage III, DVT on warfarin, MGUS, who
presents with R sided flank pain.
Patient reports worsening R sided back pain over the past 3
weeks, which increased in intensity and migrated to his right
lower flank on the day of presentation. He states the pain is
constant and worsens with any movement. He denies any
association with eating. Denies difficult with urination. Denies
fevers, chills. States pain is different in character than prior
symptoms associated with h/o hydronephrosis.
In terms of his more recent medical history, pt was diagnosed
with papillary urothelial carcinoma in ___, deemed non-surgical
candidate given medical comorbidities. He developed
hydronephrosis of R kidney, managed with ureteral stent, which
was exchanged every 3 months. On ___, at the time of stent
removal, was noted to have adequate drainage w/o obstruction, so
no stent was replaced at that time.
Regarding his heart failure, patient followed by Dr. ___ in
___ clinic, noted to be ___ II. He was noted to be volume
overloaded at last appointment in ___, treated with
increased dose of torsemide (40mg daily). Repeat labs from ___
notable for Cr 2.3, Na 127 on ___, recommended to decrease
torsemide to 10mg daily x2 days, and restart 20mg daily
thereafter. Repeat labs ___ with Cr 2.2, Na 127.
Patient followed by nephrology for CKD and has some degree of
hyponatremia at baseline, thought to be related to ADH in the
setting of CHF and cirrhosis, maintained on ___ fluid
restriction to which he reports adherence.
Patient presented to the ED on the day prior to admission with
worsening R flank pain, migrating lower on his R flank.
In the ED, initial VS were: T 97 HR 85 BP 116/67 RR 15 O2 94%RA
- Exam notable for: R flank tenderness
- Labs notable for: Na 125, Cr 1.9, UA negative. UNa < 20, Uosm
325. Hgb 10.6,
- Imaging showed: Renal US w/mild right hydronephrosis and 1.2cm
hypoechoic lesion in left hepatic lobe. CXR w/RLL opacity
similar to prior and new nodular opacities in RUL and L midlung
c/f multifocal PNA, pulmonary vascular congestion.
- Urology consulted who recommended no urgent surgical
intervention. Recommended monitor PVR.
On arrival to the floor, patient reports some persistent R flank
pain, worse with movement. He denies fevers, chills. Denies
dysuria, hematuria. Denies orthopnea, PND. Endorses ___ edema
right > left, stable from prior.
Past Medical History:
- Pacemaker Dual-Chamber: placed for chronotropic incompetence
in ___ battery replacement in ___
- Severe Tricuspid Regurgitation: s/p TV repair on ___.
___ at ___ with 36 mm CarboMedics partial ring
annuloplasty repair
- Patent foramen ovale: s/p surgical repair at the time of his
tricuspid valve surgery
- Mitral Regurgitation
- Atrial Fibrillation: anticoagulated on warfarin; of note he is
status post external stapling of the left atrial appendage in
___ at the time of his tricuspid valve ring repair
- History of TIA in ___ but no prior stroke
- Cirrhosis: attributed to cardiac congestion; per his wife the
patient has had mild encephalopathy in the past
- Alpha-1 antitrypsin deficiency
- Chronic Kidney Disease: Stage III
- Nephrolithiasis
- DVT: anticoagulated on coumadin
- Colon cancer, status post colectomy and chemotherapy in ___
- Osteoporosis: he was on reclast in the past
- Monoclonal gammopathy of undetermined significance (followed
by Dr. ___ - diagnosed in ___
- Urothelial carcinoma of the right ureter (with recent hx of
right ureteral stent placement)
- TV ring repair (36mm Carbomedics ring) with PFO closure and
___ stapling
- Partial colectomy
- Cholecystectomy
- Basal cell skin cancer removed from behind his knee
- Tonsillectomy
Social History:
___
Family History:
Reviewed and no significant changes.
Father: died of MI at age ___ also had strokes
Mother: ? endometrial cancer, breast cancer
No significant history of cardiomyopathy or sudden cardiac
death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: Temp: 97.9 PO BP: 111/75 HR: 76 RR: 18 O2 sat: 95% O2 RA
GENERAL: NAD
HEENT: MMM
NECK: supple
CV: regular, nl S1 S2, systolic murmur LLSB, no rubs, gallops
LUNGS: CTA anteriorly
ABD: soft, NT, ND, NABS.
BACK: TTP of R flank,
EXT: 1+ ___ edema R > L
PULSES: DP 2+ bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: No rash
DISCHARGE PHYSICAL EXAM:
=======================
24 HR Data (last updated ___ @ 846)
Temp: 98.7 (Tm 98.7), BP: 115/78 (103-125/71-81), HR: 74
(74-81), RR: 18 (___), O2 sat: 95% (92-95), O2 delivery: Ra
GENERAL: Laying comfortably in bed.
CV: Irregular irregular rhythm with nl S1 & S2, I/VI systolic
murmur over RUSB/LUSB and IV/VI over LLSB and apex. No rubs or
gallops.
LUNGS: Normal respiratory effort. No crackles present.
ABD: soft, NT, ND, NABS. No masses.
GU: Slight CVA tenderness on the right. No left CVA TTP or
suprapubic pain.
EXT: Warm, well perfused. 1+ ___ edema R > L. No erythema.
PULSES: DP 2+ bilaterally
Pertinent Results:
ADMISSION LABS:
==============
___ 02:20AM BLOOD WBC-11.8* RBC-3.10* Hgb-10.6* Hct-30.4*
MCV-98 MCH-34.2* MCHC-34.9 RDW-14.4 RDWSD-51.8* Plt ___
___ 02:20AM BLOOD Neuts-81.8* Lymphs-3.6* Monos-12.2
Eos-1.0 Baso-0.5 Im ___ AbsNeut-9.62* AbsLymp-0.42*
AbsMono-1.44* AbsEos-0.12 AbsBaso-0.06
___ 02:20AM BLOOD Glucose-100 UreaN-33* Creat-1.9* Na-125*
K-5.0 Cl-86* HCO3-26 AnGap-13
___ 02:20AM BLOOD ALT-19 AST-38 AlkPhos-196* TotBili-0.4
___ 02:20AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.3
PERTINENT LABS/MICRO:
====================
___ 08:48AM BLOOD proBNP-6937*
___ 02:20AM BLOOD Osmolal-269*
___ 08:48AM BLOOD AFP-2.3
___ 03:30AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:30AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:30AM URINE RBC-1 WBC-1 Bacteri-FEW* Yeast-NONE
Epi-<1 TransE-<1
___ 03:30AM URINE Hours-RANDOM Creat-69 Na-<20
___ 03:30AM URINE Osmolal-325
___ Urine culture: Negative
DISCHARGE LABS:
==============
___ 04:50AM BLOOD WBC-10.5* RBC-3.09* Hgb-10.5* Hct-30.4*
MCV-98 MCH-34.0* MCHC-34.5 RDW-14.6 RDWSD-52.5* Plt ___
___ 04:50AM BLOOD Glucose-85 UreaN-27* Creat-1.8* Na-128*
K-5.3 Cl-91* HCO3-25 AnGap-12
___ 04:50AM BLOOD Calcium-7.8* Phos-3.5 Mg-2.2
PERTINENT IMAGING:
=================
___ Renal Ultrasound:
1. Mild right hydronephrosis. Calices are more dilated in the
lower pole and contain echogenic material, which could be
residual debris status post recent stent removal, with infection
unable to be excluded. Correlation with urinalysis is
recommended.
2. 1.2 cm hypoechoic lesion in the left hepatic lobe is new
compared to prior liver ultrasound. Dedicated contrast enhanced
CT or MRI of the liver on a nonemergent basis is recommended for
further characterization.
___ CXR:
1. Right lower lobe opacity appears similar to ___,
however there are new nodular opacities in the right upper lobe
and left midlung, raising concern for multifocal pneumonia.
2. Moderate cardiomegaly with pulmonary vascular congestion.
3. Small right and trace left pleural effusions.
___ CT Abd/pelvis w/o Contrast:
1. Moderate right hydronephrosis, with irregular soft tissue
thickening of the renal pelvis and proximal right ureter.
Ill-defined spiculated lesion encasing the proximal-mid right
ureter, with increased attenuation of the distal right ureter.
The appearances are compatible with progression of the patient's
urothelial carcinoma.
2. Cirrhotic liver. The hypoechoic lesion seen on ultrasound is
not visualized on this noncontrast study.
3. Please refer to the separate report for intrathoracic
findings.
___ CT Chest w/o Contrast:
Innumerable bilateral pulmonary nodules, compatible with
metastatic disease.
No evidence of pneumonia.
Well-circumscribed high attenuation lesion in the middle
mediastinum measuring up to 7.3 cm. This lesion has a benign
appearance, possibly representing a large bronchogenic cyst.
Its appearance is not significantly changed since the CT scan of
the abdomen and pelvis dated ___.
Calcified mediastinal and hilar lymph nodes, sequelae of
previous granulomatous disease.
Please refer to the separate CT abdomen report for description
of intra-abdominal findings.
Brief Hospital Course:
Mr. ___ is an ___ y/o male with a history of right papillary
urothelial carcinoma s/p stent placement and removal, colon
cancer s/p colectomy and chemotherapy (___), HFpEF,
chronotropic incompetence s/p PPM, severe TF s/p repair (___),
PFO s/p repair (___), MR, AF not on anticoagulation (s/p ___
stapling), h/o TIA, cardiac cirrhosis, CKD stage III, and MGUS
who presented with R sided flank pain, found to have worsening
urothelial carcinoma with moderate hydronephrosis and likely
pulmonary metastases. Urology was consulted and recommended
percutaneous nephrostomy tube for palliation. The patient
ultimately chose to pursue outpatient stenting.
# Right Flank Pain
Presented with right-sided flank pain described as a dull ache
with episodes of sharp pain with movement. His pain felt
different from prior pain associated with hydronephrosis. A
renal ultrasound showed mild hydronephrosis and then a follow up
CT abd/pelvis demonstrated progression of his known urothelial
carcinoma with encasement of the right ureter and associated
moderate hydronephrosis. It was felt that his pain was due to
his disease progression with some contribution from the
hydronephrosis. Urology was consulted and recommended placing a
percutaneous nephrostomy tube as a palliative measure. The
patient decided to pursue outpatient stenting with his
urologist. Additionally, his pain was managed with Tylenol prn
and a lidocaine patch.
# Right Hydronephrosis
# R Papillary Urothelial Carcinoma
The patient had been followed by urology for urothelial
carcinoma managed with stent exchanges. Most recently his stent
was removed and not replaced given adequate urine output. Repeat
imaging as described above showed progression of his malignancy
with encapsulation of the ureter and moderate hydronephrosis.
Additionally, CT chest showed multiple bilateral pulmonary
nodules concerning for metastases. Etiology was unclear though
differential included metastatic disease from his known
urothelial cancer. Urology was consulted recommended either PCN
versus stent. Patient chose stent, to be done as outpatient.
His home tamsulosin was also continued. He should follow up with
urology as an outpatient for further management and for stent
placement. The patient was also scheduled for outpatient
Oncology follow-up.
# Acute on Chronic Hyponatremia
The patient's recent baseline had been between 128-130. Sodium
on admission was 125 without associated symptoms. Etiology was
unclear but felt to be multifactorial from several medical
comorbities. Exam was difficult but appeared to be mildly volume
overloaded with trace ___ edema and JVP elevation (though in the
setting of known valvular disease). Additionally, BNP was
elevated to ~6000, concerning for volume overload. However, the
patient's weight has been at baseline and his creatinine had
actually improved over the prior few weeks with decreasing doses
of torsemide. Urine lytes were consistent with a sodium avid
state, which could have been hyper or hypovolemic in nature.
Decision was made to hold home torsemide and monitor. His Na
improved and torsemide was restarted. His discharge Na was 128.
# Lung Opacities c/f Metastatic Disease
Noted to have bilateral opacities on CXR; follow up CT chest
showed many nodules bilaterally concerning for metastatic
disease. Etiology was unclear though there was concern for
progression of his known urothelial carcinoma vs less likely due
to recurrent colon cancer or an additional primary. Patient will
follow up with oncology as an outpatient.
# Liver Lesion
Noted to have 1.1 x 1.0 x 1.2 hypoechoic lesion in the left
hepatic lobe on ultrasound, though the lesion was not present on
repeat CT scan w/o contrast. There was concern for further
metastatic disease (urothelial, less likely colon cancer
recurrence) vs primary liver malignancy in the setting of his
cirrhosis. AFP was normal pointing against ___. Discussed with
radiology who recommended triphasic MRI for further
characterization as an outpatient.
# Chronic Anemia
Hemoglobin around ___ at baseline, presented with a Hgb of 9.
Prior iron studies were normal. Blood counts were monitored
daily without much change.
# Chronic Stage III CKD
Followed by Dr. ___ as an outpatient. Baseline Cr 1.5-1.7.
Cr 1.9 on admission and improved to baseline with holding
torsemide.
# Atrial Fibrillation
# Chronotropic Incompetence s/p PPM
The patient has a history of atrial fibrillation, on metoprolol
at home. He was not on anticoagulation per outpatient providers
given recurrent bleeding. He was continued on his home regimen
without any issues.
# Cardiac Cirrhosis
History of cirrhosis 2/p HFpEF. Childs B. He had no signs of
hepatic encephalopathy, varices or ascites. He was continued on
his home lactulose and rifaximin. Last EGD in ___ showed no
varices. He should follow up with GI for management and possible
repeat EGD.
# Chronic Diastolic Heart Failure
# Severe TR s/p Repair, MR, PFO s/p Closure:
Followed by Dr. ___. Last TTE on ___ notable for EF
>60%, 4+ mitral regurgitation and 4+ tricuspid regurgitation,
with dilated LA and RA. JVP elevated on exam though likely in
the setting of valvular dysfunction. The remained of his volume
status was difficult as he had trace edema though improvement in
Cr with holding torsemide. Decision was made to hold home
torsemide and monitor given hyponatremia. He was ultimately
discharged on his home dose of torsemide. He should follow up
with his primary care provider for further management.
# Coronary Artery Disease
The patient was continued on his home statin and metoprolol
dosing. He was not given aspirin as no longer needed per
outpatient providers notes.
# H/o Colon Cancer s/p Resection & Chemotherapy
Unknown treatment history. Last colonscopy in ___ was normal.
CT abd/pelvis without contrast did not find a malignancy though
the study was limited and the likely metastases in the lungs was
concerning for possible recurrence vs disease progression of his
known urothelial carcinoma. He should consider outpatient
colonoscopy/imaging pending results of pulmonary nodule biopsy
(if within goals of care).
TRANSITIONAL ISSUES:
==================
- Discharge weight: 58.65kg, 129.3 lbs
- Discharge creatinine: 1.8
- Discharge diuretic regimen: torsemide 20mg
[ ] Repeat BMP to evaluate sodium at next follow up appointment
[ ] Evaluate volume exam and titrate torsemide as needed
[ ] Consider biopsy of pulmonary nodules if within patient's
goals of care
[ ] Consider outpatient MRI (if pacemaker is compatible) to
further evaluate liver lesion
[ ] Needs outpatient GI referral for repeat EGD
[ ] Consider prescription for oxycodone 2.5mg if lower
back/flank pain persists/worsens, although patient was hesitant
to take anything besides Tylenol while inpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO TID
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Rifaximin 550 mg PO BID
4. Rosuvastatin Calcium 2.5 mg PO QPM
5. Tamsulosin 0.4 mg PO QHS
6. Torsemide 20 mg PO DAILY
7. calcium citrate (calcium carbonate-vit D3-min) 200 mg (950
mg) oral BID
8. vit C,E-Zn-coppr-lutein-zeaxan 250-200-40-1 mg-unit-mg-mg
oral BID
9. Fish Oil (Omega 3) 1000 mg PO BID
10. Acidophilus (Lactobacillus acidophilus) oral DAILY
11. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. Acidophilus (Lactobacillus acidophilus) oral DAILY
3. calcium citrate (calcium carbonate-vit D3-min) 200 mg (950
mg) oral BID
4. Ferrous Sulfate 325 mg PO BID
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Lactulose 30 mL PO TID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Rifaximin 550 mg PO BID
9. Rosuvastatin Calcium 2.5 mg PO QPM
10. Tamsulosin 0.4 mg PO QHS
11. Torsemide 20 mg PO DAILY
12. vit C,E-Zn-coppr-lutein-zeaxan 250-200-40-1 mg-unit-mg-mg
oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
#Primary:
Papillary Urothelial Carcinoma
#Secondary:
Right moderate hydronephrosis
Lung nodules concerning for metastatic disease
Acute on chronic hyponatremia
Hepatic Lesion
Chronic kidney disease
Cardiac cirrhosis
Chronic heart failure with preserved ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
Why you were admitted to the hospital:
- You were having pain over your right side
What happened while you were here:
- Imaging showed progression of your known urothelial (lining of
bladder and urinary tract) cancer with some blockage of the tube
connecting your kidney and your bladder
- The urology team evaluated you and recommended a stent to help
drain your kidney. This will be set up as an outpatient.
- Additionally, your pain was treated medications
What you should do once you return home:
- Please continue taking your medications as prescribed and
follow up at the appointments outlined below
- You should have further discussions with your primary care
provider and your urologist regarding your goals of care and
which, if any, tests or treatments you wish to pursue moving
forward
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10354880-DS-9 | 10,354,880 | 23,868,994 | DS | 9 | 2173-07-26 00:00:00 | 2173-07-31 19:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o F with PMH of ITP and seizures, presenting to ED from PCP
due to lab result - Na of 119.
She reports that she regularly gets lab work done and today
after having the lab tests she got a call from her PCP telling
her that her sodium was very low and she needed to come to the
ED. She reports no acute symptoms. No noted seizures at home.
She has not had any headache, dizziness, nausea, increased
urination, lower extremity swelling. States that she is somewhat
unbalanced at baseline, but this has not been worse.
Independently ambulates. She has some chronic confusion and
short term memory loss that has been present since ___
___ and is being worked up. Her seizure d/o is well controlled
with no seizure in over ___ years.
Atrius Labs: ___
Serum Osm ___
-------------<
4.9 25 0.9
Urine OSM 683
In the ED, VS: 97.2 65 132/95 17 100% RA, and was mentating
well.
Notable labs:
\12.0/
4.2 ---- 88
/34.9 \
118 / 83 / 24 / AGap=18
------------- 83
5.1 \ 22 \ 0.8\
Serum Osms:248
___: 10.6 PTT: 40.3 INR: 1.0
EKG ___ sinus ___ degress AV block PR 228 68 BPM, old inferior
infarct.
Imaging: CXR: read pending, but prelim no acute process
Patient was started on fluid restriction at 1700
Given: 22:48 Oxcarbazepine 600 mg PO
On transfer, VS 71 132/74 17 98% RA
On arrival to the FICU, anxious, somewhat forgetful at times,
which patient states is baseline.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias.
Past Medical History:
Hypertension, essential
Thrombocytopenia, immune
Seizure disorder
HEARING LOSS - SENSORINEURAL
SLEEP APNEA, SEVERE
COLONIC POLYPS
Mitral regurgitation
Cataract Cortical, Senile
Atypical nevus of abdominal wall
Memory deficit
Hypercholesterolemia
Pinguecula
Squamous cell carcinoma in situ of skin of forehead
Drusen (degenerative) of retina
Social History:
___
Family History:
Cancer Father
colon, in his ___
Lumbar Disc Disease[Other] [OTHER] Sister
lumbar disc disease s/p car accident
Cancer - Colon Sister
carcinoid
Alzheimer's Mother
Cancer Maternal Grandmother
? kind- some abdominal
Physical Exam:
======================
EXAM ON ADMISSION
======================
Vitals: BP: 122/85 P: 79 R: 23 O2: 93%
GENERAL: thin, alert and oriented, NAD, forgetful at times, at
times difficult to direct
HEENT: mmm, EOMI, NCAT
NECK: no JVD
LUNGS: CTAB
CV: RRR, no murmurs appreciated
ABD: soft, nontender, nondistended
EXT: wwp, no edema
Neuro: EOMI, tongue midline, upper extremity strength ___
======================
EXAM ON DISCHARGE
======================
Vital Signs: 98.2, 101/54, 58, 16, 100% on RA
General: Alert, oriented, no acute distress
HEENT: MMM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, nl S1 S2, no murmurs, rubs, gallops
Abdomen: 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: Without rashes or lesions
Neuro: CN2-12 grossly intact, moving all extremities
spontaneously
Pertinent Results:
==========================
LABS ON ADMISSION
==========================
___/ CXR
___ 05:42PM BLOOD WBC-4.2 RBC-4.03 Hgb-12.0 Hct-34.9 MCV-87
MCH-29.8 MCHC-34.4 RDW-12.2 RDWSD-38.7 Plt Ct-88*
___ 05:42PM BLOOD Neuts-54.4 ___ Monos-10.9 Eos-1.9
Baso-0.2 Im ___ AbsNeut-2.29 AbsLymp-1.33 AbsMono-0.46
AbsEos-0.08 AbsBaso-0.01
___ 05:15PM BLOOD ___ PTT-40.3* ___
___ 05:42PM BLOOD Glucose-83 UreaN-24* Creat-0.8 Na-118*
K-5.1 Cl-83* HCO3-22 AnGap-18
___ 02:43AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.8
___ 05:15PM BLOOD Osmolal-248*
___ 07:55AM BLOOD TSH-5.6*
___ 07:55AM BLOOD Cortsol-9.4
___ 07:05PM BLOOD Hgb-13.2 calcHCT-40
==========================
LABS ON DISCHARGE
==========================
___ 03:30AM BLOOD WBC-4.3 RBC-3.79* Hgb-11.5 Hct-33.3*
MCV-88 MCH-30.3 MCHC-34.5 RDW-12.3 RDWSD-39.8 Plt Ct-93*
___ 03:30AM BLOOD Plt Smr-LOW Plt Ct-93*
___ 11:00AM BLOOD Glucose-79 UreaN-24* Creat-0.8 Na-127*
K-4.8 Cl-96 HCO3-20* AnGap-16
___ 03:30AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0
==========================
MICROBIOLOGY
==========================
___ 01:16AM URINE Color-Straw Appear-Clear Sp ___
___ 01:16AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 01:16AM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE ___
MRSA SCREEN (Final ___: No MRSA isolated.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
==========================
IMAGING
==========================
CHEST (PORTABLE AP) Study Date of ___ 9:39 ___
The lungs are well inflated and clear. There is unfolding of
the thoracic
aorta. The cardiac silhouette is not enlarged. No pleural
effusion or
pneumothorax is identified.
Brief Hospital Course:
Ms. ___ is a ___ year old female with a PMH of ITP, seizure
disorder presenting to ___ with Na of 119.
#Hyponatremia: The patient's was found to have Na of 119 on
routine outpatient labs. She was sent to the ___ ED where her
Na was found to be 118. She was asymptomatic. Urine studies were
consistent with SIADH, thought to be caused by the patient's
oxcarbazepine. The patient's TSH was slightly elevated but her
T4 was within normal limits. Her cortisol was normal. She was
initially admitted to the ICU for frequent monitoring and
eventually transferred to the floor with her Na trending
upwards. The patient was treated with 1L fluid restriction and
her oxcarbazepine was discontinued. The patient was discharged
on 1L fluid restriction with the addition of NaCl 1gm tablets PO
TID. The patient was instructed to have repeat Chem 7 on ___
and follow up with PCP for further management of sodium and
reassessment of the need for NaCl tabs. The patient was
instructed to return to the hospital if she experienced any
lightheadedness or dizziness, weakness, focal symptoms.
#ITP: The patient was continued on her home promacta. She should
f/u with her PCP and oncology as needed.
#Seizure disorder: The patient had a history of seizure
disorder, well controlled, with no seizures over the past ___
years. The patient's oxcarbazepine was discontinued at discharge
given her SIADH. The patient was evaluated by neurology at ___
and she was transitionned to levetiracetam 500mg PO BID and
lamotrigine XR, titrated over a 7 week period using the orange
starter pack to goal 200mg PO qday. These changes were discussed
with the patient's outpatient neurologist.
#Hypertension: The patient had a history of using lisinopril in
the past, which had been previously stopped for unclear reasons.
Her blood pressure remained well controlled while hospitalized.
#Sleep apnea: The patient has a history of severe OSA per
records, intolerant of CPAP. The patient was monitored nighttime
oxygenation without evidence of marked desaturation
#Memory Loss: the patient reported memory loss over the past ___
years, forgetting short term details. The patient reported that
her memory loss and confusion was at her baseline while
hospitalized. Given the chronicity of this symptom, it was
thought to be unrelated to her hyponatremia .The patient should
follow up with her PCP and her neurologist for further
evaluation and management.
Transitional Issues:
- The patient should continue her new anti-epileptic medication
regimen of keppra 500mg PO BID and lamotrigine XR to be titrated
to 200mg PO qday over a 7 week period using the orange starter
pack. The patient should f/u with her neurologist for further
management of seizure disorder
- The patient should have repeat Chem 7 on ___ and this will
be sent to her PCP for ___
- The patient was discharged on salt tabs, 1gram TID. This
medication can be continued at outpatient provider's discretion
depending on the patient's repeat lab testing results
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxtellar XR (OXcarbazepine) 600 mg oral DAILY
2. Promacta (eltrombopag) 12.5 mg oral BID
Discharge Medications:
1. Sodium Chloride 1 gm PO TID Duration: 3 Days
RX *sodium chloride 1 gram 1 tablet(s) by mouth three times per
day Disp #*30 Tablet Refills:*0
2. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth 2 times per day
Disp #*30 Tablet Refills:*0
3. LaMOTrigine 25 mg PO QAM
Please use lamotrigine XR starter pack
4. Promacta (eltrombopag) 12.5 mg oral BID
5. Outpatient Lab Work
Labs: Please check Chem 7
ICD9: 276.1
Contact: Send results to Dr. ___, phone ___
fax ___
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: hypontremia, seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to participate in your ___ at ___.
You were admitted to the hospital with hyponatremia, which is
low sodium in your blood. We believe this was caused by SIADH
which we believe was caused by your oxcarbazepine. We stopped
this medication and we treated you with a 1 liter fluid
restriction and your sodium improved. After discharge, you
should continue your 1 liter fluid restriction. This means that
you should drink less than 1 liter of fluid or less than 4 cups
of fluid per day. You should also continue to take salt tablets
three times per day. It is very important that you follow up
with ___ for a repeat check of your sodium and electrolytes.
While in the hospital, we started you on 2 new anti-seizure
medications, lamotrigine and levetiracetem. You should continue
to take these medications after discharge. You should use the
lamotrigine starter pack to gradually increase your dose. You
should follow up with your outpatient neurologist for further
management.
If you feel any symptoms of increased confusion,
lightheadededness, dizziness, or seizures, you should return to
the emergency department immediately.
We wish you the best!
Sincerely,
Your ___ ___ Team
Followup Instructions:
___
|
10355595-DS-23 | 10,355,595 | 22,882,369 | DS | 23 | 2164-11-07 00:00:00 | 2164-11-08 11:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
urosepsis
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
Patient is a ___ man with a history of EtOH cirrhosis w/
ascites
and SBP with weekly paracentesis (most recent ___, ischemic
heart disease s/p stent x2 (___), CKD stage III, a fib not on
anticoagulation, with a chief complaint of abdominal pain and
penile bleeding after Foley removed. Patient has chronic urinary
retention and had an indwelling Foley. Patient states that Foley
was removed about 8 hours ago to attempt voluntary void. Patient
states that he began having severe 8 out of a 10 pain after
Foley
was taken out, and so Foley was put back in, however he began
having bleeding from the penis. Patient states he has been
unable
to void since. Patient denies fever or chills chest pain.
Patient
endorses lower abdominal pain in the suprapubic region currently
4 out of 10, and feels like he has to urinate. Patient also
endorses diarrhea and states that he was given "excessive"
lactulose at the rehab which is caused him to have nonbloody
watery stools.
In the ED, they were able to insert a foley catheter which
drained purulent urine. Patient's vitals became unstable with
tachypnea to the ___ and tachycardia to the 130s. Patient also
complained of shortness of breath. Patient was immediately
started on 1 L normal saline, Zosyn, followed by Levofed.
Past Medical History:
- Atrial fibrillation
- Insulin dependent type II DM
- High grade stenosis on the right ICA
- GERD
- Anemia
- CKD Stage III ___ HTN and DM
- Essential HTN
- Hypercholesterolemia
- Glaucoma
- Hepatitis B
- COPD
- Cirrhosis ___ EtOH use)
- Past EtOH use
- CAD status post PTCA proximal LAD and circumflex
- Hypothyroidism
- Intermittent urinary obstruction requiring foley
- Hx of e coli bacteremia from UTI ___ urinary obstruction
(admission ___
Social History:
___
Family History:
Mother - ___, thyroid disorder, CAD/PVD
Father - CVA, glaucoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: reviewed in Metavision
GEN: pleasant, no apparent distress
HEENT: no conjuctival pallor, mild scleral icterus
NECK: L IJ in place, dressing c/d/i
CV: irregular rhythm, regular rate
RESP: CTAB
GI: distended abd, ascites, + fluid wave
SKIN: no rash
NEURO: AxO 3
PSYCH: appropriate affect
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 714)
Temp: 97.8 (Tm 98.2), BP: 96/56 (96-122/56-78), HR: 95
(95-121), RR: 18 (___), O2 sat: 98% (96-99), O2 delivery: Ra
GENERAL: NAD, resting comfortably
HEENT: NC/AT, anicteric sclera, MMM
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Moderately distended, soft, nontender, normoactive
bowel
sounds, tympanic to percussion, + fluid wave ,
EXTREMITIES: No cyanosis or clubbing. mild ___ edema in b/l ___.
SKIN: Warm, well-perfused
NEUROLOGIC: A&Ox3, moving all extremities with purpose, no
facial
asymmetry, no asterixis
Pertinent Results:
ADMISSION LABS:
===============
___ 11:00PM BLOOD WBC-5.5 RBC-3.43* Hgb-10.2* Hct-32.3*
MCV-94 MCH-29.7 MCHC-31.6* RDW-19.8* RDWSD-68.3* Plt ___
___ 11:00PM BLOOD Neuts-93* Bands-2 Lymphs-3* Monos-0*
Eos-0* ___ Metas-2* AbsNeut-5.23 AbsLymp-0.17* AbsMono-0.00*
AbsEos-0.00* AbsBaso-0.00*
___ 11:00PM BLOOD ___ PTT-30.2 ___
___ 11:00PM BLOOD Glucose-133* UreaN-69* Creat-2.1* Na-139
K-4.0 Cl-94* HCO3-24 AnGap-21*
___ 11:00PM BLOOD ALT-118* AST-177* AlkPhos-154*
TotBili-1.7*
___ 11:00PM BLOOD Albumin-2.6*
___ 12:16AM BLOOD ___ pO2-24* pCO2-53* pH-7.30*
calTCO2-27 Base XS--1
___ 12:16AM BLOOD Lactate-7.5*
___ 02:47AM BLOOD Lactate-6.3*
___ 12:15AM URINE Color-RED* Appear-Cloudy* Sp ___
___ 12:15AM URINE Blood-MOD* Nitrite-NEG Protein-300*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 12:15AM URINE RBC-73* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-0
___ 09:11AM STOOL CDIFPCR-POS* CDIFTOX-NEG
DISCHARGE LABS:
===============
___ 04:58AM BLOOD WBC-5.0 RBC-2.84* Hgb-8.6* Hct-27.1*
MCV-95 MCH-30.3 MCHC-31.7* RDW-18.7* RDWSD-63.7* Plt Ct-72*
___ 04:58AM BLOOD Glucose-85 UreaN-51* Creat-1.6* Na-140
K-3.9 Cl-104 HCO3-24 AnGap-12
___ 04:58AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.3
MICROBIOLOGY:
=============
___ 12:07 am BLOOD CULTURE # 1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 I
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
___ 12:07 am BLOOD CULTURE #2 RAC PICC LINE.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI.
Identification and susceptibility testing performed on
culture #
___ ___.
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 12:15 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>___ R
CEFEPIME-------------- R
CEFTAZIDIME----------- 16 I
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING/STUDIES:
================
CXR ___:
IMPRESSION:
Stable small left pleural effusion and subsegmental atelectasis
in the left
lower lobe.
Right-sided PICC line projects with its tip over the mid SVC,
unchanged
Renal US ___:
IMPRESSION:
1. No hydronephrosis and no evidence of stones..
2. Unchanged 2.6 cm mildly complex left renal cyst.
CXR ___:
IMPRESSION:
In comparison with the study ___, the monitoring and
support devices
are unchanged. Again there is enlargement of the cardiac
silhouette with
elevated pulmonary venous pressure. Retrocardiac opacification
again is
consistent with volume loss in left lower lobe and associated
pleural
effusion.
Liver US ___:
IMPRESSION:
1. Cirrhotic liver, without evidence of focal lesion. Mild
splenomegaly with
trace abdominal ascites. Portal vein is patent.
2. Unchanged gallbladder wall thickening/edema likely secondary
to third
spacing.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ man with a history of EtOH cirrhosis (MELD
18, Child Class C) decompensated by SBP and refractory ascites,
ischemic heart disease s/p stent x2 (___), CKD stage III, and a
fib not on anticoagulation, admitted for treatment of urosepsis.
Admitted to MICU for hemodynamic instability which improved
following inititation of meropenam. Urine and blood cultures
ultimately grew MDR E. coli sensitive to meropenam. Plan for 14
day total course of antibiotics. Underwent therapeutic
paracentesis ___ w/ 3L fluid removed. Discussion held with
patient regarding removing foley and trialing intermittent
straight catheterization to minimize infection risk however
patient declined to have foley removed at this time.
TRANSITIONAL ISSUES:
====================
[]pt has history of spontaneous bacterial peritonitis. Should be
started on once daily ciprofloxacin 500mg Daily once course of
meropenam is complete.
[]To complete 14 day antibiotic course with meropenem through
___
[]Discharge Hgb 8.6, plt 72, Cr 1.6
ACUTE ISSUES
===============
# Urosepsis
# Complicated UTI
# E. coli bacteremia
Patient presented with hypotension, lactic acidosis in the
setting of recent indwelling Foley removal, most likely septic
secondary to urosepsis. ___ BCx grew E. coli sensitive to
meropenem in ___ bottles. Required MICU stay (___) and
pressors, weaned off on ___. Pt has a history of recurrent UTI,
with chronic urinary retention and indwelling foley, possible
incomplete treatment of previous UTI. Plan for 14 day course of
meropenem ___ - ___. L PICC placed (___) for
outpatient IV abx. Discussed possibility of foley removal and
trial of intermittent straight caths with patient. He
understands the risks associated with chronic indwelling ___
including recurrent UTIs, sepsis, and death but declined
intermittent straight caths or voiding trial due to pain with
foley removal.
# Decompensated EtOH cirrhosis
# Large volume ascites
MELD-Na 18, Child C on admission. Decompensated this admission
by ascites. Ascites has been refractory requiring weekly
paracentesis on ___ with removal of up to 6L. Most recently
s/p 3L paracentesis ___ with 25g albumin administered
afterwards. Home torsemide was held while patient was unstable
with bump in Cr , restarted ___. Last screening EGD ___
showed gastric angioectasias, incomplete study ___ food bolus.
He was started on IV PPI while admitted to the MICU. This was
transitioned to home dose of PO omeprazole. Last CT abdomen
___ without focal lesions (though non-contrast exam, so
limited). Palliative care was consulted this admission.
# Acute on chronic normocytic anemia
Likely due to chronic disease, hemodilution, likely nutritional
deficiency, and frequent phlebotomy. No s/s active bleeding.
# Thrombocytopenia
Patient with cirrhosis, baseline Plt in the 150s, dropped into
the ___ during admission then slowly uptrended. Likely
suppression iso infection and dilutional component. HIT
unlikely, heparin abs negative.
CHRONIC/STABLE ISSUES
======================
# Concern for aspiration
Speech and swallow saw him at bedside, cleared for thins and
soft diet.
# Atrial fibrillation
CHADS2VASC 4. Rates currently adequately controlled
Metoprolol held in the acute setting. Restarted due to HR >100.
Not on home anticoagulation
# IDDM
Insulin sliding scale while in the hospital. Home meds resumed
on discharge
# CKD:
Cr near baseline (1.7 on discharge). Continued home sodium
bicarb
# Essential HTN
- Held home isosorbide mononitrate, metoprolol, torsemide due to
hypotension. Restarted torsemide and metoprolol following
clinical improvement.
# GERD
- Continued omeprazole 20 mg PO BID
# HLD
- Continued home atorvastatin
# Glaucoma
- Continued home latanoprost
# COPD
- Continue duonebs Q6H
- Continue PRN albuterol inhaler and albuterol nebs
# Hypothyroidism
- Continue home levothyroxine
# Intermittent urinary obstruction requiring foley
- Continue tamsulosin and finasteride
#Nutrition
Continue thiamine, folic acid, ascorbic acid,
>30 min spent on discharge planning including face to face time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Finasteride 5 mg PO DAILY
5. Lactulose 30 mL PO BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. Omeprazole 20 mg PO BID
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin D 1000 UNIT PO DAILY
12. fenofibrate micronized 200 mg oral DAILY
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
14. Sodium Bicarbonate 1300 mg PO TID
15. Torsemide 20 mg PO DAILY
16. Torsemide 20 mg PO DAILY:PRN weight gain of 3 lbs or more in
one day
17. FoLIC Acid 1 mg PO DAILY
18. Thiamine 100 mg PO DAILY
19. Multivitamins W/minerals 1 TAB PO DAILY
20. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
21. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
Discharge Medications:
1. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
2. Meropenem 500 mg IV Q8H
3. Senna 8.6 mg PO BID:PRN Constipation
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. fenofibrate micronized 200 mg oral DAILY
9. Finasteride 5 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation DAILY
12. Lactulose 30 mL PO BID
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 150 mcg PO DAILY
15. Metoprolol Tartrate 25 mg PO BID
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Omeprazole 20 mg PO BID
18. Sodium Bicarbonate 1300 mg PO TID
19. Tamsulosin 0.4 mg PO QHS
20. Thiamine 100 mg PO DAILY
21. Torsemide 20 mg PO DAILY:PRN weight gain of 3 lbs or more
in one day
22. Vitamin D 1000 UNIT PO DAILY
23. HELD- Isosorbide Mononitrate (Extended Release) 30 mg PO
DAILY This medication was held. Do not restart Isosorbide
Mononitrate (Extended Release) until you are told to do so by a
physician
___:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
complicated UTI
urosepsis
decompensated Etoh Cirrhosis
refractory ascities
acute on chronic normocytic anemia
thrombocytopenia
Secondary diagnosis:
atrial fibrillation
ischemic HD (s/p stent x2)
CKD stage III
Insulin dependent diabetes
HTN
GERD
Glaucoma
COPD
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
- You were admitted to the hospital because of a condition
called urosepsis. This was caused by infection that started in
your urinary tract then entered your blood.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
- You received multiple medications while in the hospital. Your
blood pressure dropped because of the infection so we admitted
you to the medical intensive care unit where we started you on
intra-venous medications to raise your blood pressure and
antibiotics to treat the infection. During your hospital course
we monitored your vitals and labs while being administered the
medications. The antibiotics treated the infection and you no
longer required medications to increase your blood pressure. We
also removed peritoneal fluid to decrease the volume of ascites
and make you more comfortable. We discussed with you the risk
of recurrent UTI because of the indwelling foley but you
declined additional voiding trials or intermittent straight
catheterizations because of pain associated with both.
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:
___
|
10355641-DS-8 | 10,355,641 | 27,336,000 | DS | 8 | 2138-11-02 00:00:00 | 2138-11-04 10:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Permanent pacemaker placement
History of Present Illness:
Ms. ___ is a ___ yo F with past medical history of CAD,
tachybradycardia syndrome, hypertension, and hyperlipidemia who
presents today as a referral for pacemaker. Five weeks ago,
patient patient had right knee surgery and has been doing
rehabilitation at her house since then. Over the last 2 weeks,
patient has developed worsening dyspnea on exertion and she is
now only able to walk a few rooms at a time before getting short
of breath. She denies any orthopnea, PND, ___, palpitations,
weight gain, lightheadedness, or syncope. Her metoprolol was
recently discontinued and she has been feeling better since
being
off of it. She went to a routine check up today and had an EKG
done concerning for type II AV block block and was referred into
the emergency department for further evaluation.
In the ED initial vitals were notable for HR 42 with BP 172/45.
Exam was notable for bradycardia but otherwise unremarkable.
Trops were negative x2 and proBNP was elevated at 901. D-dimer
was 1188. EKG showed Atrial tachycardia at ~ 150bpm with
variable
block and intermittent junctional escape, conducted rate 44bpm.
CTA was negative for PE, aortic abnormality, or focal
consolidation. Cardiology was consulted who felt this was more
consistent with atrial tachycardia with variable 3:1 or 4:1 AV
nodal block and recommended starting apixaban with plan for
TEE/DCCV in the AM. She was given apixaban and started on NS @
125 cc/hr.
On the floor, she reports the above story. She still feels very
short of breath with any exertion but has no other acute
concerns.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Varicose veins
-Bilateral cataract removal
-Laparoscopic gastric bypass (___)
-Hiatal hernia s/p repair
-Broke left arm/hand with crush injury? Surgical intervention
with external fixation
-Varicose vein stripping (left leg)
Social History:
___
Family History:
Brother has history of "heart rhythm irregularities" diagnosed
as a teenager because of an episode of syncope
Mother deceased at age ___ of ___ cancer
Father deceased at age ___ due to stroke
Physical Exam:
ADMISSION EXAM:
==============
VS: 97.4 PO 189 / 70 48 18 97 ra
GENERAL: Well developed, well nourished older female in NAD.
HEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva pink. No
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. JVP of 5 cm.
CARDIAC: Bradycardic. Regular 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. Normoactive bowel sounds.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM:
==============
___ ___ Temp: 97.6 PO BP: 153/80 R Lying HR: 64 RR: 16 O2
sat: 96% O2 delivery: Ra
___ Total Intake: 416ml PO Amt: 356ml IV Amt Infused: 60ml
___ Total Output: 1025ml Urine Amt: 1025ml
Weight on admission: 92.3kg
Telemetry: V-paced, rates ___
General: lying in bed, appears comfortable and in NAD
HEENT: NC/AT. EOMI. Oral mucosa pink and moist
Lungs: CTA in all lung fields. No respiratory distress or
accessory muscle usage
CV: RRR. No murmurs, rubs, or extra sounds
Abdomen: Bowel sounds present throughout. Abd soft, NT, ND
Ext: Warm, well-perfused. No pitting edema.
Pertinent Results:
___ 08:22PM cTropnT-<0.01
___ 04:08PM GLUCOSE-120* UREA N-33* CREAT-1.1 SODIUM-145
POTASSIUM-5.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
___ 04:08PM cTropnT-<0.01
___ 04:08PM proBNP-901*
___ 04:08PM TSH-0.31
___ 04:08PM T4-8.7
___ 04:08PM WBC-8.3 RBC-4.23 HGB-12.3 HCT-40.8 MCV-97
MCH-29.1 MCHC-30.1* RDW-14.3 RDWSD-50.4*
___ 04:08PM NEUTS-50.4 ___ MONOS-7.1 EOS-3.0
BASOS-0.8 IM ___ AbsNeut-4.19 AbsLymp-3.21 AbsMono-0.59
AbsEos-0.25 AbsBaso-0.07
___ 04:08PM PLT COUNT-361
___ 04:08PM ___ PTT-28.5 ___
___ 04:08PM D-DIMER-1188*
___ 04:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM*
___ 04:05PM URINE RBC-<1 WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-1
___ 04:05PM URINE RBC-<1 WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-1
___ 04:05PM URINE HYALINE-2*
___ 04:05PM URINE MUCOUS-RARE*
IMAGING/TESTING:
==============
CXR ___
Left-side intact dual lead pacemaker is again seen. Heart size
is within normal limits. Lungs are clear. There is a right
total shoulder arthroplasty. There is a nonaggressive sclerotic
lesion within the proximal left humerus which is unchanged
dating
back to studies from ___ and most compatible with an
TTE ___: The left atrial volume index is mildly increased.
The right atrium is mildly enlarged. The estimated right atrial
pressure is >15mmHg. There is normal left ventricular wall
thickness with a normal cavity size.
There is suboptimal image quality to assess regional left
ventricular function. Overall left ventricular systolic function
is normal. The visually estimated left ventricular ejection
fraction is 70%. There is no resting left ventricular outflow
tract gradient. Tissue Doppler suggests an increased left
ventricular filling pressure (PCWP greater than 18 mmHg). There
is echocardiographic evidence for diastolic dysfunction (grade
indeterminate). Mildly dilated right ventricular cavity with
normal free wall motion. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch is mildly dilated with a normal descending aorta
diameter. The aortic valve leaflets (3) are mildly thickened.
There is minimal aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild [1+] mitral
regurgitation. There is both systolic and diastolic mitral (and
tricuspid) regurgitation. Diastolic mitral/tricuspid
regurgitation occurs after nonconducted P waves and is
indicative of significantly elevated left and right heart
filliing pressures. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. There is moderate to severe
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[]follow-up BP, volume status and chem 7 on torsemide and higher
dose of lisinopril
====================
Ms. ___ is a ___ year-old female with past medical history of
CAD, tachybradycardia syndrome, decades of SVT hypertension,
hyperlipidemia, presenting with with 2 weeks of progressive
dyspnea, dizziness, and bradycardia.
# Atrial tachycardia
# Ventricular bradycardia
# ___ second degree heart block
EKG showed second degree variable heart block with atrial
tachycardia, c/w atrial tachycardia with ___ variable heart
block. Per EP, initial goal was to address AT rather than
bradycardia as restoration of sinus rhythm may improve AV nodal
conduction and overall heart rates. When ambulating with the
team, however, degree of block worsened suggesting infranodal
disease. She was symptomatic with dyspnea on exertion while
ambulating so a PPM was placed on ___. She tolerated the
procedure well without issues. ___ interrogation on ___
showed normal pacer function and CXR was without PTX. She was
discharged on apixaban 5mg BID for the atrial tachycardia and
metoprolol XL 12.5 mg daily.
# Elevated proBNP
# Dyspnea on exertion
Her prior TTEs showed normal EF with no evidence of heart
failure. She was very recently started on torsemide as an
outpatient for elevated proBNP and DOE. Her TTE showed MR
elevated filling pressures suggesting component of HFpEF. CTA
negative for PE, pneumonia or pericardial effusion. She was
diuresed with an increased dose of torsemide 20mg x2 days. Her
symptoms resolved overnight after PPM placement, correlating
with time she went into sinus rhythm. She was discharged on her
home dose of torsemide 10mg.
# Hypertension: Noted to be hypertensive after procedure. Her
lisinopril was increased to 10mg daily which should be monitored
as pain may be driving some of her BP.
# Dyslipidemia: Continued Rosuvastatin, ezetimibe, aspirin.
# GERD: Continued home omeprazole.
# Osteoporosis: Continued home MVI and vitamin D.
# Reactive airway disease: Held home albuterol given atrial
tachycardia, to be restarted by PCP if needed.
# Dry eyes: Continued home artificial tears
# Hx of gastric bypass: continued on home MVI, B12 and vitamin D
given gastric bypass
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Torsemide 10 mg PO DAILY
4. Ezetimibe 10 mg PO DAILY
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, SOB
6. Rosuvastatin Calcium 5 mg PO QPM
7. Lisinopril 5 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. cyanocobalamin (vitamin B-12) 1,000 mcg oral DAILY
11. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 tablet(s) by mouth three times a day
Disp #*4 Tablet Refills:*0
3. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
once a day Disp #*15 Tablet Refills:*0
4. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, SOB
6. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
7. Aspirin 81 mg PO DAILY
8. cyanocobalamin (vitamin B-12) 1,000 mcg oral DAILY
9. Ezetimibe 10 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Rosuvastatin Calcium 5 mg PO QPM
13. Torsemide 10 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial tachycardia with high grade AV block
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of shortness of
breath and dizziness.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were found to have an irregular heart beat that was
likely causing your symptoms. We placed a pacemaker while you
were to help your heart function more normally.
- You were found to have more water weight so we gave you an
increased dose of torsemide while here; you should take your
home dose of 10mg and be careful to avoid saltly foods.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Weigh yourself every morning, call your doctor at
___ if your weight goes up more than 3 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
- Your discharge weight: 199 lbs. You should use this as your
baseline after you leave the hospital.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10355745-DS-14 | 10,355,745 | 23,407,995 | DS | 14 | 2177-08-20 00:00:00 | 2177-08-21 07:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female with PMHx of DM2, HTN, polymyositis, postherpetic
neuralgia, presents from the ED with chief complaint of
dizziness with concurrent hyponatremia. Pt is dysarthric but it
appears that she got up to go to the bathroom last night and
felt "swimming" sensation in her head and thought she was going
to fall. She reports having this feeling for some time but
cannot say how long and relates a history of falling that
occured several years ago. Appears to be precipitated by change
in position and she feels better lying down. Pt denies n/v or
other neurologic symptoms. Per ED, overall symptoms sound
consistent with peripheral rather than central etiology.
In the ED, vitals were 98 90 161/78 16 94%. Physical exam showed
crackles and mild ___. Labs were notable for hyponatremia at 125
and troponin of 0.05. Patient underwent EKG, which showed sinus
86bpm LAD and LVH but without active STT changes. CT head head
shows ventriculomegaly of unclear significance and is unlikely
to be related to presenting complaints and not an urgent issue
at this time. CXR was negative. UA and full labs also pending.
Patient was given 500cc NS bolus infusing for hyponatremia and
hypocalcemia (prior CABG, unknown LVEF so conservatively
bolusing) and 325mg ASA for elevated troponin.
Neuro consult recommended outpt MRI for further evaluation for
possible obstructive lesion given ventriculomegaly of unclear
etiology, checking orthostatics, and gentle IV hydration for
hyponatremia with close NA monitoring. Pt admitted to medicine
service for evaluation of hyponatremia.
Past Medical History:
- DM2
- HTN
- Polymyositis
- Postherpetic neuralgia
- CAD s/p 4-vessel CABG in ___
- Intestinal ischemia (>70% SMA stenosis)
- Depression
Social History:
___
Family History:
Maternal and paternal history unknown
2 sisters - deceased
Physical ___:
ADMISSION EXAM
VS: T 97.5 BP 174/93 laying down, 135/75 sitting and
symptomatic P 92 RR 22 96RA
Gen: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cardio: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulmunary: Crackles at bases, R > L
Abdomen: BS+, soft, NT, no rebound/guarding
Extremities: ___ pulses palpable B/L, evidence of venous
stasis on B/L ___
Skin: no rashes or bruising
DISCHARGE EXAM
VS: T 97.8-98.9 BP 118-166/64-100 P ___ RR 18 94-100%RA
BS 74-204
General: NAD, AAOx3
HEENT: PERRL, EOMI
Neck: supple, no carotid bruits
Lungs: CTAB
Heart: RRR, normal S1 S2, no MRG
Abdomen: Soft, NT, NABS, no organomegaly
Extremities: evidence of venous stasis of B/L lower extremities
Pertinent Results:
ADMISSION LABS
___ 01:55AM BLOOD WBC-7.0 RBC-4.44 Hgb-12.9 Hct-39.1 MCV-88
MCH-29.0 MCHC-32.9 RDW-12.7 Plt ___
___ 01:55AM BLOOD Neuts-70.8* ___ Monos-5.0 Eos-2.7
Baso-0.2
___ 01:55AM BLOOD Plt ___
___ 01:55AM BLOOD Glucose-155* UreaN-11 Creat-0.8 Na-125*
K-5.8* Cl-85* HCO3-31 AnGap-15
___ 11:45AM BLOOD CK-MB-8 cTropnT-0.06*
___ 01:55AM BLOOD cTropnT-0.05*
___ 11:45AM BLOOD Osmolal-267*
OTHER PERTINENT RESULTS
___ 11:45AM BLOOD CK-MB-8 cTropnT-0.06*
___ 05:30AM BLOOD CK-MB-5 cTropnT-0.07*
___ 07:05PM BLOOD CK-MB-6 cTropnT-0.06*
___ 05:15AM BLOOD CK-MB-7 cTropnT-0.08*
DISCHARGE LABS
___ 06:38AM BLOOD WBC-6.6 RBC-4.34 Hgb-12.2 Hct-39.1 MCV-90
MCH-28.0 MCHC-31.0 RDW-13.1 Plt ___
___ 06:38AM BLOOD Glucose-186* UreaN-10 Creat-0.4 Na-130*
K-3.9 Cl-88* HCO3-33* AnGap-13
___ 06:38AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.7
IMAGING:
Nuclear Stress Test (___):
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a fixed, moderate
inferolateral defect in the left ventricular myocardium.
Gated images reveal hypokinesis in the area of perfusion defect.
The calculated left ventricular ejection fraction is 49%.
IMPRESSION:
1 - Perfusion images reveal a fixed, moderate inferolateral
defect in the left ventricular myocardium.
2 - EF 49%
Frontal and lateral CXR (___):
Numerous mediastinal clips and sternal wires denote prior
cardiac surgery. Chronic mild to moderate cardiomegaly is of
unknown chronicity. Low lung volumes result in bronchovascular
crowding. Linear bibasilar opacities are most compatible with
atelectasis. Bronchial cuffing is not accompanied by any other
findings of acute heart failure. The central pulmonary vessels
are normal in caliber. There is no pneumothorax, focal
consolidation, or pleural effusion.
IMPRESSION: Bronchial inflammation. Moderate cardiomegaly.
Head CT (___):
There is moderate prominence of the ventricles, out of
proportion relative to the sulci, with extensive periventricular
hypoattenuation (2:17) extending to the vertices (2:24). While
this could reflect central atrophy with superimposed severe
chronic microvascular ischemic disease, early hydrocephalus with
transependymal CSF flow is possible. No obstructing mass is
detected.
There are severe atherosclerotic calcifications within the
cavernous portions of the ICAs bilaterally (2:8). The middle
ear cavities, mastoid air cells, and included views of the
paranasal sinuses are clear. No acute fracture is detected.
IMPRESSION: Abnormally enlarged ventricles, out of proportion
to the sulci, with extensive periventricular hypoattenuation,
may reflect early
hydrocephalus with transependymal CSF flow. No obstructing mass
is
identified. Alternatively, this could represent central atrophy
with severe superimposed chronic ischemia.
EKG (___):
Sinus rhythm. Left anterior fascicular block. Poor R wave
progression.
Cannot exclude anteroseptal wall myocardial infarction of
indeterminate age but also may be due to left anterior
fascicular block. Possible left ventricular hypertrophy by
voltage criteria. No previous tracing available for comparison.
Stress mibi ___:
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a fixed, moderate
inferolateral defect in the left ventricular myocardium.
Gated images reveal hypokinesis in the area of perfusion defect.
The calculated left ventricular ejection fraction is 49%.
IMPRESSION:
1 - Perfusion images reveal a fixed, moderate inferolateral
defect in the left ventricular myocardium.
2 - EF 49%
Brief Hospital Course:
___ y/o female with PMHx of DM2, HTN, polymyositis, postherpetic
neuralgia, CAD s/p 4-vessel CABG in ___, intestinal ischemia
(>70% SMA stenosis), and depression presents for dizziness and
treated for hyponatremia due to hypovolemia.
# Hyponatremia: Na 125 on admission. Baseline Na per outpatient
records in the low 130s. Patient was not symptomatic, without
altered mental status, headache or neurological deficits. Exam
consistent with dehyrdation, and history supports poor PO
intake. Urine studies not consistent with SIADH. Patient not
on diuretics. Sodium level and dizziness both improved with
1000cc NS. Discharge Na 131. Please continue to encourage PO
intake at rehab. Plan to have repeat electrolytes on ___,
patient may need gentle IV NS if Na<130 and patient with poor PO
intake.
# Dizziness: Patient had severe dizziness on admission in the
setting of orthostatic hypotension. Severe dizziness resolved
with IV fluids and improvement of hyponatremia. Neuro consult
in the ED recommended outpt MRI for further evaluation for
possible obstructive lesion vs atrophy given ventriculomegaly
seen on CT of unclear etiology. Plan for outpatient neuro
follow up and to arrange for outpatient MRI.
# HTN: BP elevated at night to 160s and 120s during the day.
Atenolol dose increased to 100mg from 75mg and changed to ___ and
lisinopril qAM was continued.
# DM2: Patient with DM2 on 70/30 30unit qAM and 5 units qPM.
Had episodes of hypoglycemia in the early ___ with sliding scale.
After stopping her ___ 70/30, morning fasting glucose was in the
120-150 range and after decreasing noon time sliding scale,
hypoglycemia was no longer an issue. However, on the day of
discharge, patient inadvertantly recived full AM dose of 70/30
insulin while NPO for stress test. ___ glucose was 50, which
improved with juice and IV dextrose. Fingerstick at the time of
discharge 136. Please monitor ___ closely at rehab and adjust
insulin accordingly.
# Elevated troponin: Troponin 0.05 on admission. EKG showing
left anterior fasicular block vs anterioseptal q waves but no
evidence of acute ischemia. Patient has episodes of fleeting
epigastric discomfort at rest, but cardiac enzymes continue to
be stable (trop 0.05-0.07). Nuclear stress test showed fixed
moderate inferolateral defect and EF 49%. Continued ASA and
simvastatin.
# Neuralgia/polymyositis: denies pain. Prednisone continued and
acetaminophen given prn.
# Depression: Continued amitryptaline, fluoxetine.
Transitional Issues:
- Code status: full code
- HCP: Niece ___
- ___ labs: none
- Medication changes: INCREASED atenolol to 100mg PO HS; stopped
___ 70/30
- Follow-up:
1) Neurologist: Drs. ___ - ___ at 4:00pm
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. PredniSONE 5 mg PO DAILY
2. Omeprazole 20 mg PO BID
3. Simvastatin 20 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Atenolol 75 mg PO DAILY
6. Amitriptyline 25 mg PO HS
7. Aspirin 81 mg PO DAILY
8. Fluoxetine 20 mg PO DAILY
9. 70/30 30 Units Breakfast
70/30 5 Units Dinner
10. Calcium Carbonate 500 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Acetaminophen 500 mg PO Q6H:PRN pain
13. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Amitriptyline 25 mg PO HS
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Fluoxetine 20 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. PredniSONE 5 mg PO DAILY
11. Simvastatin 20 mg PO DAILY
12. Atenolol 100 mg PO HS
Hold for SBP < 100 and HR < 60
13. 70/30 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Hyponatremia
Dizziness
Secondary diagnosis:
Type 2 diabetes
Coronary artery disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mrs. ___,
___ was a pleasure taking care of you at ___. You were admitted
for dizziness and we found that there were low levels of sodium
in your blood. We gave you fluids through your veins and your
sodium level and dizziness improved over several days.
We made the following changes to your medication:
INCREASED atenolol dose to 100mg and changed dose from morning
to evening
STOPPED evening insulin (please continue morning insulin)
Followup Instructions:
___
|
10355745-DS-15 | 10,355,745 | 24,924,037 | DS | 15 | 2177-11-06 00:00:00 | 2177-11-06 15:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Loss of consciousness
Major Surgical or Invasive Procedure:
Endotracheal intubation x2
Tracheostomy placement ___
PEG tube placement ___
History of Present Illness:
___ with hx of type II DM, CAD s/p CABG, polymyositis,
intestinal ischemia found unresponsive at ___. History somewhat
unclear. Patient denies ever losing consciousness, has no
complaints. EMS was called, ___ was given glucagon for FBS of 78,
with return in mental status; despite report of CPR, CPR was not
initiated or performed. ___ denies complaints, no chest pain, no
SOB, no palps, cough n/v/d/f/s/c, denies urinary symptoms or
complaints.
Of note, patient admitted to ___ ___ complaining of
dizziness, found to have Na of 125 which improved to 131 with IV
hydration. CT head showed ventriculomegaly of unclear etiology.
Had persistantly elevated troponin (0.05-0.07) during
hospitalization, nuclear stress test showed fixed moderate
inferolateral defect and EF 49%.
In the ED, initial vitals were 97.0, 100/50, 92, 16, 100%/RA
On arrival to the floor, vitals were 98.1, 98/58, 93, 18, 96%/RA
Past Medical History:
- DM2
- HTN
- Polymyositis
- Postherpetic neuralgia
- CAD s/p 4-vessel CABG in ___
- Intestinal ischemia (>70% SMA stenosis)
- Depression
Social History:
___
Family History:
Maternal and paternal history unknown
2 sisters - deceased
Physical ___:
Admission Physical Exam:
VS - 98.1, 98/58, 93, 18, 96%/RA
GENERAL - ___ yo F who appears comfortable, appropriate and in
NAD
HEENT - NC/AT, PERRL, left pupil 4mm non-reactive (post
surgical), right pupil minimally reactive with visible cataract,
EOMI, sclerae anicteric, MMM, missing teeth/no dentures in place
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1-S2 without murmurs, rubs or
gallops
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c, 1+ pitting edema to the knees
bilaterally, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs IV-XII grossly intact, sensation
grossly intact throughout
.
Discharge Physical Exam:
General: trached, not responsive to voice
HEENT: Sclera anicteric oropharynx clear, PERRL
Neck: supple, JVP quite elevated to 10 cm with hyperdynamic V
waves, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: breath sounds reasonably clear bilaterally without
crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, ___ ___ symmetric edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
unable to perform sensation and strength testing
Pertinent Results:
Admission Labs:
___ 12:45PM ___ PTT-32.7 ___
___ 12:45PM PLT COUNT-209
___ 12:45PM NEUTS-88.4* LYMPHS-7.6* MONOS-2.8 EOS-0.9
BASOS-0.4
___ 12:45PM WBC-9.9 RBC-3.97* HGB-11.0* HCT-35.7* MCV-90
MCH-27.6 MCHC-30.7* RDW-12.8
___ 12:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:45PM OSMOLAL-269*
___ 12:45PM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-1.9
___ 12:45PM cTropnT-0.08*
___ 12:45PM GLUCOSE-78 UREA N-11 CREAT-0.8 SODIUM-132*
POTASSIUM-4.3 CHLORIDE-90* TOTAL CO2-35* ANION GAP-11
___ 12:56PM LACTATE-1.7
___ 02:30PM URINE WBCCLUMP-MANY
___ 02:30PM URINE RBC-12* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 02:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG
___ 02:30PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 02:30PM URINE OSMOLAL-164
___ 02:30PM URINE HOURS-RANDOM UREA N-128 CREAT-24
SODIUM-32 POTASSIUM-25 CHLORIDE-26
.
Discharge Labs:
___ 04:02AM BLOOD WBC-9.1 RBC-2.61* Hgb-7.2* Hct-22.9*
MCV-88 MCH-27.5 MCHC-31.4 RDW-13.9 Plt ___
___ 04:02AM BLOOD ___ PTT-30.7 ___
___ 04:02AM BLOOD Glucose-98 UreaN-22* Creat-0.4 Na-137
K-3.9 Cl-98 HCO3-31 AnGap-12
___ 04:02AM BLOOD Calcium-7.6* Phos-2.9 Mg-2.1
.
Studies:
CXR ___: 1. Tracheostomy, nasogastric tube and right
subclavian PICC line are
unchanged in position in this patient status post median
sternotomy for CABG
with stable post-operative cardiac and mediastinal contours.
The heart
remains enlarged. Lung volumes remain low. Overall, there is
increasing
fullness of the pulmonary vasculature and slight increase in
opacity in the
right lung as compared to the left. These findings could
represent worsening
asymmetric pulmonary edema, although an infectious process
should also be
considered. There are likely small bilateral layering
effusions. A calcified
nodule of the right lung base is consistent with a granuloma.
No
pneumothorax.
Upper extremity u/s ___: IMPRESSION: No evidence of deep
venous thrombosis in the left upper extremity. Soft tissue
swelling in left arm.
Bronchoscopy ___:
Rigid bronchoscopy
Flexible bronchoscopy
Airway exam
Percutaneous tracheostomy tube (size 7 portex perfit cuffed)
placement
PEG Tube placement ___:
Upper GI Endoscopy
PEG tube placement
EMG ___: Abnormal, technically limited study. The
electrophysiologic findings of mild ongoing denervation on
needle EMG and reduced compound motor action potential
amplitudes on nerve conduction study are most consistent with
critical illness myopathy. A mild underlying inflammatory
myopathy may also be present, but the EMG abnormalities were not
clearly consistent with that diagnosis. The studies also do not
clearly support the presence of a defect of neuromuscular
transmission (e.g., myasthenia ___ or ___
myasthenic syndrome) or a motor polyneuropathy (e.g.,
___ syndrome).
EEG ___: CONTINUOUS EEG: The background activity showed a
symmetric low voltage beta
rhythm and intermittent to 10.0-10.4 Hz alpha activity. The
latter was
present posteriorly and the beta activity was seen more
centrally. In both
cases, this activity was seen relatively infrequently because
the patient had,
for long periods of this recording session, continuous EMG
artifact.
SPIKE DETECTION PROGRAMS: There were no automated spike
detections
predominantly for electrode and movement artifact. There were no
epileptiform
discharges.
SEIZURE DETECTION PROGRAMS: There was one automated seizure
detection for an
artifact. There were no electrographic seizures.
QUANTITATIVE EEG: Trend analysis was performed with Persyst
Magic Marker
software. Panels included automated seizure detection, rhythmic
run detection
and display, color spectral density array, absolute and relative
asymmetry
indices, asymmetry spectrogram, amplitude integrated EEG, burst
suppression
ratio, envelope trend, and alpha delta ratios. Segments showing
abnormal
trends were reviewed and showed mainly high frequency EMG
artifact and
occasional beta frequency activity.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: No sleep or sleep cycling was identified.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate of
60-70 bpm with what also appears to be an intraventricular
conduction delay.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
the background slowing seen relatively infrequently between the
runs of muscle
artifact. No epileptic activity, either an interictal or ictal
nature, was
seen. Compared to the prior day's recording, there were no
significant
changes.
CT ___: IMPRESSION:
1. No evidence of an acute intracranial abnormality.
2. Stable disproportionate enlargement of the ventricles
relative to the
sulci, most likely due to central atrophy. Non-communicating
hydrocephalus is
less common, but could be considered if the patient has
associated symptoms.
Microbiology:
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. >100,000 ORGANISMS/ML.
Brief Hospital Course:
___ year old female with history of t2DM, CAD s/p CABG, and HTN,
with newly altered mental status and found to be in hypercarbic
respiratory failure, s/p re-intubation x2 with subsequent trach
placement.
# Respiratory failure: Given her unresponsiveness on the medical
floor and hypercarbia, pt was transferred to the MICU and
started on BiPaP. However, she failed this and was intubated.
Given improvement in her mental status and ABGs, extubation was
attempted on on ___ and ___ but patient failed each time
requiring reintubation. Etiology of her failure on extubation
was felt to be from supraglottic edema from multiple
intubations. Less likely neuromuscular weakness or Polymyositis
(EMG not overwhelming for NM weakness, and rheumatology did not
think this was an acute presentation of polymyositis). She was
started briefly on pyrdostigamine given concern for NM weakness
but this was stopped after EMG findings. SHe was started on
mythylprednisone for possibility of polymyositis which was
eventually stopped given lower concern for this. She will
remain on low dose 5mg prednisone until she follows up with
rheumatology. Her CXR showing new RLL opacity concerning for
pneumonia, and was started on HCAP coverage with vanc/cefepime
to be completed on ___. The patient eventually underwent
tracheostomy on ___ successfully, and a PEG was placed on ___
with tube feeds initiated. Please note that the patient often
requires restraints to avoid pulling at her trach tube. Low
dose seroquel was started to help with this. The patient
tolerates trach collar well, but also requires occasional
ventilatory support with PSV or CMV.
# VAP: RML consolidation on CXR and increasing mucus
production. As above, this was treated with vanc/cefepime to be
completed ___
# metabolic alkalosis: Likely in setting of chronic hypercarbia
compounded by overdiuresis. Bicarb peaked at 37 but improved to
31 on discharge after diuresis was stopped
# Guardianship/dispo: Dispo/guardianship was an issue for the
patient. However, a court date was held and her niece was named
HCP. SHe consented to trach/peg
# h/o polymyositis: Rheumatology was consulted given concern
that polymyositis (which the pateint has a history of) was
contributing to her respiratory failure. She was initially
stared on IV methylprednisone to treat this, but it was
eventually determined that his was very low on teh differential
and she was weaned back to low dose prednisone 5mg daily. She
should remain on this until her outpatient rheumatology follow
up. She is on BID famotidine for ulcer prophylaxis.
# Type 2 diabetes mellitus: Home insulin regimen was adjusted
throughout admission and on discharge was lantus 15U QHS and Q6H
humalog. Blood sugars well controlled on discharge has been
relatively well-controlled during this hospitalization, but she
does have evidence of glucosuria and ketonuria.
# CAD s/p CABG: Cont home carvedilol, ASA 81mg daily, lisinopril
10 mg daily, simvastatin daily
# Unresponsiveness: Unclear etiology of original unresponsive
episode based on limited history, though most likely a syncopal
episode as opposed to seizure given she denies aura, post-ictal
symptoms, or h/o trauma. Syncope ___ orthostasis is possible as
she appeared hypovolemic on exam. Though she has a h/o CAD,
cardiac syncope was less likely w/ her baseline troponins and
EKG. Neurologic less likely, though she has known hydrocephalus.
Hypoglycemic episode possible though less likely given her blood
sugar was not markedly low. Patient did have an episode of
unresponsiveness in the hospital on ___, where she was found
slumped in chair and drooling and then opened eyes and scanned
but did not respond. She returned to baseline in a few minutes,
with no new neurologic deficits, possibly consistent with
seizure and post-ictal phase. Blood sugars were normal.
# Hyponatremia: Patient found to have Na of 120 on ___.
Thought to be component of prerenal/SIADH, and improved over
admission to 137 on discharge.
# ? Hydrocephalus: Noted on CT head on ___ for her AMS.
Noted to have stable disproportionate enlargement of the
ventricles relative to the sulci, most likely due to central
atrophy. Non-communicating hydrocephalus is less common, but
could be considered if the patient has associated symptoms.
# UTI: UA on ___ w/ >182 WBC, lg leuks, and few bacteria. She
was asymptomatic and started on ceftriaxone in the ED. She
remained afebrile overnight w/ WBC wnl. Her ceftriaxone was
d/c'ed after receiving her AM dose on ___. She was put on a 5
day course of cephalexin but refused it. The abx for her HCAP
would cover most UTIs
.
# HTN: Had several episodes of high BPs (SBPs in 180s) on the
floor as she intermittently refused antihypertensive meds. BPs
well-controlled on days she adhered to med regimen.
.
# Elevated troponins: Troponins 0.5-0.7 during prior admission,
stress test at that time showed fixed wall motion abnormality.
Patient was asymptomatic w/ EKG and troponins similar to
baseline which were stable x 2.
.
# Depression: We held her amitriptyline and continued her
fluoxetine. Amytriptiline was added back on discharge
.
Transitional issues:
- Tracheostomy care
- Please use restraints to prevent pulling at trach. Can try
seroquel for this
- Niece ___ is now ___
- Outpt Rheumatology f/u is scheduled
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from ___.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Amitriptyline 25 mg PO HS
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Fluoxetine 15 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
hold for SBP<100
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. PredniSONE 4 mg PO QAM
11. Simvastatin 20 mg PO DAILY
12. Carvedilol 25 mg PO BID
13. Mirtazapine 15 mg PO HS
14. 70/30 28 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Carvedilol 25 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Fluoxetine 15 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
hold for SBP<100
8. Mirtazapine 15 mg PO HS
9. Multivitamins 1 TAB PO DAILY
10. PredniSONE 5 mg PO QAM
11. Simvastatin 20 mg PO DAILY
12. 70/30 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Quetiapine Fumarate 25 mg PO BID PRN anxiety
14. Vancomycin 1000 mg IV Q 24H
15. Bisacodyl 10 mg PR HS:PRN constipation
16. Ipratropium Bromide MDI 2 PUFF IH QID
17. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze, sob
18. Famotidine 20 mg PO BID
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. CefePIME 2 g IV Q12H
21. Heparin 5000 UNIT SC TID
22. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL BID
Use only if patient is on mechanical ventilation.
23. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypercarbic respiratory failure
Ventilator associated pneumonia
Polymyositis
Syncope
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:
Dear ___,
___ were admitted to the hospital because they were having
difficulty waking ___ up at ___. ___ were found to
have a urinary tract infection, and were started on antibiotics.
___ were also mildly dehydrated.
Changes to your home medications include:
-Bactrim DS 1 tablet BID for 5 days
It was a pleasure taking care of ___ during your hospitalization
and we wish ___ the best.
Followup Instructions:
___
|
10356403-DS-15 | 10,356,403 | 27,356,489 | DS | 15 | 2187-02-27 00:00:00 | 2187-03-01 16:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
one week of left-sided weakness and 3 days of word-finding
difficulty with bilateral basal ganglia hemorrhages noted on
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
NEUROLOGY STROKE ADMISSION/CONSULT NOTE
___ Stroke Scale Score: 2
NIHSS, GCS, and ICH score performed within 6 hours of
presentation at: 0115
NIHSS Total: 2
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 1
10. Dysarthria: 0
11. Extinction and Neglect: 0
GCS Score at the scene: 15
ICH Score: 0
Pre-ICH mRS: 0
REASON FOR CONSULTATION:
HPI:
___ man with a history of hypertension, hyperlipidemia,
type II diabetes presents to ED with one week of left-sided
weakness and 3 days of word-finding difficulty with bilateral
basal ganglia hemorrhages noted on ___
About one week ago the patient first began to notice that he was
weak, particularly on the left side (leg > arm). Had difficulty
moving from side to side in bed. He also had difficulty going up
the stairs with his left leg. He does not have a headache. He
had
some word-finding difficulty that started 3 days ago. He has not
noticed any sensory changes.
He presented to the ___ at the request of his PCP where
BP was 190/98. A ___ revealed bilateral basal ganglia
hemorrhages and he was transferred to ___ for further
management.
Past Medical History:
-Hypertension (reportedly well-controlled on meds)
-BPH
-Type II diabetes
-HLD
Social History:
___
Family History:
No family history of stroke.
HTN in father.
Physical Exam:
PHYSICAL EXAMINATION:
Vitals:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented 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.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. Able to register 3 objects and recall
___ at 5 minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: Left pupil w/ coloboma. EOMI without
nystagmus.
Normal saccades. VFF to confrontation.
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. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 4+ 5 5 5 5 5 4+ 4+ 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Diminished sensation to pinprick on the left forearm.
-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: Unsteady. Lists to left.
DISCHARGE EXAM
==============
PHYSICAL EXAMINATION:
Vitals: HR 64 BP 136/84 T 98.6 O2 94 RR 18
General: Awake, cooperative, NAD.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. There were no paraphasic errors. No
dysarthria. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
II, III, IV, VI: Left pupil w/ coloboma. 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 bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA]
L 5 5 4+ 5 5- 5- 5 5 4+ 4+
R 5 5 5 5 5 5 5 5 5 5
-Sensory: Not tested
-Reflexes:
Not tested
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait: Not tested today
Pertinent Results:
Admission Labs
=-===============
___ 09:29PM BLOOD WBC-9.0 RBC-5.01 Hgb-15.2 Hct-45.8 MCV-91
MCH-30.3 MCHC-33.2 RDW-13.5 RDWSD-45.5 Plt ___
___ 09:29PM BLOOD Neuts-50.4 ___ Monos-9.0
Eos-16.1* Baso-0.7 Im ___ AbsNeut-4.52 AbsLymp-2.12
AbsMono-0.81* AbsEos-1.44* AbsBaso-0.06
___ 09:29PM BLOOD ___ PTT-31.4 ___
___ 09:29PM BLOOD Plt ___
___ 09:29PM BLOOD Glucose-147* UreaN-23* Creat-1.3* Na-143
K-3.9 Cl-107 HCO3-23 AnGap-13
___ 09:29PM BLOOD Glucose-147* UreaN-23* Creat-1.3* Na-143
K-3.9 Cl-107 HCO3-23 AnGap-13
___ 09:05AM BLOOD ALT-25 AST-21 CK(CPK)-113 AlkPhos-87
TotBili-0.7
___ 09:29PM BLOOD cTropnT-<0.01
___ 09:29PM BLOOD Calcium-9.3 Phos-2.8 Mg-2.1
___ 09:05AM BLOOD Triglyc-119 HDL-36* CHOL/HD-4.8
LDLcalc-114
___ 09:05AM BLOOD %HbA1c-5.9 eAG-123
Discharge Labs
==============
___ 06:45AM BLOOD WBC-7.3 RBC-4.49* Hgb-13.6* Hct-41.1
MCV-92 MCH-30.3 MCHC-33.1 RDW-13.3 RDWSD-45.0 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-108* UreaN-13 Creat-1.0 Na-142
K-3.9 Cl-105 HCO3-27 AnGap-10
___ 09:05AM BLOOD Triglyc-119 HDL-36* CHOL/HD-4.8
LDLcalc-114
___ 09:05AM BLOOD %HbA1c-5.9 eAG-123
___ 09:05AM BLOOD TSH-1.9
Studies
=========
Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
___ 11:46 ___
IMPRESSION:
1. 11 x 7 mm oval-shaped acute hemorrhage in the right thalamus
with mild
surrounding edema, but no significant mass effect.
2. 5 mm triangular hyperdensity in the left lentiform nucleus
without clear
evidence for edema, which may represent calcification versus
hemorrhage.
3. Despite the reported history of subarachnoid hemorrhage, no
subarachnoid
hemorrhage is definitively seen. However, CT has limited
sensitivity for
subacute subarachnoid hemorrhage, particularly compared to MRI.
Comparison
with prior studies would be helpful.
4. No evidence for an intracranial aneurysm or arteriovenous
malformation.
5. Questionable dehiscence versus severe thinning of the lateral
wall of the
left sphenoid sinus, with questionable uncovering of the
cavernous left
internal carotid artery.
6. Non dominant left vertebral artery arises directly from the
aortic arch,
with calcified plaque causing mild-to-moderate stenosis at its
origin. No
carotid stenosis by NASCET criteria.
7. Multiple thyroid nodules measuring up to approximately 2 cm
on the left.
RECOMMENDATION(S):
1. Consider non urgent dedicated sinus CT with thin cuts through
the sphenoid
sinuses, if not previously performed elsewhere, to better assess
the suspected
left lateral wall dehiscence versus severe thinning.
2. Thyroid nodule. Ultrasound recommended if not previously
performed
elsewhere. ___ College of Radiology guidelines recommend
further
evaluation for incidental thyroid nodules of 1.0 cm or larger in
patients
under age ___ or 1.5 cm in patients age ___ or ___, or with
suspicious
findings. ___, et al, "Managing Incidental Thyroid Nodules
Detected on
Imaging: White Paper of the ACR Incidental Findings Committee".
J ___
___ ___ 12:143-150.
NOTIFICATION: Electronic preliminary report was provided at
1:09 a.m. on ___ ___, including the
intracranial hemorrhage
and thyroid nodules. The additional findings and recommendations
related to
the left sphenoid sinus and the left cavernous carotid artery
were discussed
with ___, M.D. by ___, M.D. on the
telephone on
___ at 5:40 pm, 5 minutes after discovery of the
findings.
Radiology Report MR HEAD W & W/O CONTRAST Study Date of
___ 8:23 ___
IMPRESSION:
1. Subacute right thalamic hemorrhage versus hemorrhagic infarct
with mild
surrounding edema corresponding to the hyperdensity on prior CT
and possibly
hypertensive in origin given clinical history of hypertension.
Susceptibility
artifact in the bilateral basal ganglia, possibly related
calcifications or
hemorrhagic byproducts.
2. Acute to subacute infarcts in the left corona radiata and
splenium of the
corpus callosum with mild regional edema. Embolic etiologies are
a
differential consideration
3. Remote lacunar infarcts in the corona radiata, bilateral
basal ganglia,
left thalamus and right cerebellum.
4. Sequelae of chronic small vessel ischemic disease.
5. No significant mass effect, midline shift or enhancing
intracranial mass.
Brief Hospital Course:
Ms. ___ is a ___ male with HTN, DMII, HLD who is
admitted to the Neurology stroke service with weakness secondary
to an acute hemorrhagic stroke in the bilateral basal ganglia,
he was weak for over a weak and acutely got worse on the day of
presentation . His stroke was most likely secondary to
hypertensive bleeds in the setting of small vessel disease. He
initially required a nicardipine gtt, but was able to be
restarted on his home medications. We increased his carvedilol
to 12.5 bid. His deficits improved greatly prior to discharge
and the only notable weakness was in the left arm and leg,
minimally. He will continue rehab at a rehab center.
Her stroke risk factors include the following:
1) DM: A1c _5.9_%
2) Moderate intracranial atherosclerosis
3) Hyperlipidemia: LDL 114, cholesterol 174, his statin was
increased to 80mg prior to arrival at the hospital.
[ ] HE WAS FOUND INCIDENTALLY TO HAVE a thyroid nodule which
will need outpatient follow up and ultrasound. Additionally he
was found with thinning/dehiscence of the left lateral wall of
the sphenoid sinus which will require a dedicated sinus CT to
evaluate. Consider ENT referral in the outpatient setting.
[ ] Monitor for side effects of atorvastatin 80mg in combination
with diltiazem as this can lead to elevated statin levels and
subsequent rhabdo.
[] Carvedilol increased to 12.5 bid, consider uptitrating as
tolerated
[ ] He will need a video swallow study while at rehab, he is on
nectar liquids regular diet
Transitional Issues
[]1. Consider non urgent dedicated sinus CT with thin cuts
through the sphenoid
sinuses, if not previously performed elsewhere, to better assess
the suspected
left lateral wall dehiscence versus severe thinning.
[]2. Thyroid nodule. Ultrasound recommended if not previously
performed
elsewhere. ___ College of Radiology guidelines recommend
further
evaluation for incidental thyroid nodules of 1.0 cm or larger in
patients
under age ___ or 1.5 cm in patients age ___ or ___, or with
suspicious
findings. ___, et al, "Managing Incidental Thyroid Nodules
Detected on
Imaging: White Paper of the ACR Incidental Findings Committee".
J ___ ___ 12:143-150.
[] Repeat CBC Diff within one week of discharge, noted to have
absolute eosinophilia on admission CBC diff, will need to be
followed up.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No. If
no, reason why:
2. DVT Prophylaxis administered? () Yes - (x) No. If no, why not
(bleeding risk, hemorrhage)
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Lisinopril 40 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Diltiazem Extended-Release 240 mg PO DAILY
5. CARVedilol 6.25 mg PO BID
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
Discharge Medications:
1. CARVedilol 12.5 mg PO BID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Atorvastatin 80 mg PO QPM
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right thalamocapsular hemorrhage
Left anterior limb internal capsule hemorrhage
hypertensive hemorrhagic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of weakness resulting from
an hemorrhagic STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by
bleeding from a blodd vessel in the brain. 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
Diabetes
We are changing your medications as follows:
You will be started on a statin medication
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10356680-DS-9 | 10,356,680 | 27,208,419 | DS | 9 | 2134-05-06 00:00:00 | 2134-05-06 14:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ ___ with PMHx of multiple spinal surgeries who
was transferred from ___ with concern for C1 fracture
after presenting s/p fall.
According to the patient's wife, the patient had been napping in
the chair in front of the TV. He was going to get ready for bed
around 10:30/ 11pm. He was trying to get out of his chair by
pushing on the arms and was unable to stand or sit and was
perched and ultimately fell on his face. His face hit the floor
and his nose started bleeding profusely. The patient's wife does
not think he passed out. Talking the whole time. Daughter and
husband came and helped get him up. They were worried because he
was bleeding so much from his nose so brought him to the ED at
___. In ___, there was concern for C1 fracture so the
patient was transferred to ___ for spine evaluation. This CT
scan was reviewed by radiology and it was determined that this
is
an old fracture. When asking the patient the details of his
fall, he told me an entirely different story about falling in
his
kitchen and his legs giving way. His wife does report that the
patient has memory problems which have been getting worse.
In addition to his recent falls, the patient's wife reports the
patient has been having some skin problems. He recently went to
see a dermatologist for a skin check and she prescribed cream
and
recommended compression stockings. When going to buy compression
stockings, the woman in the store recommended a vascular surgery
evaluation which the patient had and subsequently cancelled. The
patient's wife reports his lower extremity edema is unchanged
although the redness may be slightly worse.
Currently, the patient reports he feels well. He denies pain,
denies neck pain. He also denies fevers or chills, palpitations,
cough, dysuria, recent illness. He has been eating and drinking
normally.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Cognitive impairment
Hypertension
Chronic venous hypertension with bilateral lower extremity
swelling
GERD
Overactive bladder
Surgical History:
S/P C1-C2 fusion ___- Dr. ___
C-spine surgery at the ___ in ___
S/P post debridement of the postsurgical dehiscence in
___
S/P b/l shoulder surgery
S/P B/L Hip replacement
S/p bladder pacemaker
Social History:
___
Family History:
Mother died age ___ ___ disease, father
died at age ___ unknown, has 4 brothers, one died at age ___ of
esophageal cancer and the other more recently of cancer.
Physical Exam:
EXAM(8)
VITALS:97.8 BP: 184/92 P:78 R: 20 95 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round and react to light
ENT: Ears and nose with some erythema/swelling, no 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: Some erythema of right shin with some peeling skin
NEURO: Alert, oriented to person, not place or time, face
symmetric, gaze conjugate with EOMI, speech fluent, moves all
limbs, sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Exam on discharge:
VITALS:97.3 BP: 133/71 HR: 65 R:18 94 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round and react to light
ENT: Ears and nose with some healing excoriations, bruising
under eyes, no 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: Some erythema of right shin with quarter size ulcer on
posterior without drainage. +skin peeling
NEURO: Alert, oriented to person, not place or time, face
symmetric, gaze conjugate with EOMI, speech fluent, moves all
limbs, sensation to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Labs:
___ 05:08AM BLOOD WBC-4.3 RBC-3.97* Hgb-13.4* Hct-39.4*
MCV-99* MCH-33.8* MCHC-34.0 RDW-12.5 RDWSD-45.1 Plt ___
___ 07:30AM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-144
K-4.0 Cl-104 HCO3-29 AnGap-11
___ 07:30AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.8
___ 05:01AM BLOOD Lactate-2.7*
IMAGING:
Maxolofacial ___
IMPRESSION: Nasal fracture and possible fracture of anterior
nasal septum.
C- Spine CT: ___
IMPRESSION:
No acute fracture or malalignment identified. Postoperative
changes and old fracture of C1 are again noted.
Head CT: ___
Impression:
No acute intracranial abnormality identified. Nasal fracture.
CXR:
Impression:
1. There is no evidence of an acute cardiac or pulmonary
process.
2. There is no definite acute fracture. Focused imaging of an
area of concern would be more sensitive if clinically indicated.
Femur xray:
IMPRESSION:
1. There is no acute right femur fracture.
Pelvis xray:
IMPRESSION:
1. There is no gross evidence of right hip hardware fracture or
loosening
2. No acute right hip bony fracture or dislocation.
3. There is no acute pelvic fracture in the field-of-view.
Pelvis Fracture:
IMPRESSION:
1. There is no acute pelvic fracture or diastasis.
Brief Hospital Course:
Mr. ___ is a ___ male with PMH of cognitive
impairment, hypertension and chronic lower extremity edema who
presents with mechanical fall and concern for C1
fracture
#Fall
#Nasal Fracture
#C1 fracture
Per wife, in setting of rising from chair/gait instability with
resultant nasal fracture. Orthostatic vital signs were checked
and were negative. Patient without warning signs concerning for
syncope/seizure or cardiac etiology of fall. C1 fracture is
old-confirmed by radiology read and review by ortho-spine here.
For nasal fracture, the patient can follow up in ___ weeks with
Plastic Surgery Chief resident- Dr. ___ ___. The
patient was seen by ___ who recommended rehab.
#Dementia:
#Toxic Metabolic Encephalopathy
Per wife, cognitive impairment has been getting worse over the
past year and even worse in the past few months. The patient has
been more difficult to manage at home. We discussed resources in
the communitity including PCP, elder services and ___
association. The patient would also benefit from neurology
evaluation/ neuropsychiatric testing if he is agreeable. The
patient had one episode of agitation/delirium requiring Haldol.
He was started on ___ to maintain sleep wake cycle which
he frequently refused. At baseline, he is alert and oriented to
person, place but not time.
___ edema
#Concern for cellulitis
Per wife ___ has had some increasing erhtyema. The patient was
treated with Keflex for non-purulent cellulitis x 7 days total.
He should continue local skin care and consider referral to
vascular surgery or dermatology as an outpatient.
#Hypertensive urgency
BP was elevated on admission in setting of missed medications.
Quinipril dose was increased to 20mg daily with improved BP
control.
Transitional issues:
- Patient and family would benefit from ongoing support,
increased resources
- Consider referral to neurology for dementia evaluation
- Continue local wound care for leg ulcer and consider referral
to vascular surgery
# Contacts/HCP/Surrogate and Communication: Wife ___-
___
# Code Status/Advance Care Planning: (please also see current
POE
order) DNR/DNI- confirmed with patient and his wife
Patient seen and examined on day of discharge. >30 minutes on
coordination of complex discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Quinapril 10 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Mechanical Fall
Cellulitis
Cognitive impairment
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your admission to
___. You were admitted after a fall. There was concern that
you broke your vertebrae, after review, we determined that this
fracture is old. You also broke your nose. If you would like,
you can follow up with plastic surgery after discharge. You
were also treated with antibiotics for a leg infection. You
should keep your legs elevated and follow up with a vascular
surgeon or return to see your dermatologist.
You were seen by physical therapy who recommended you go to
rehab for physical therapy.
We wish you the best,
Your ___ Care team
Followup Instructions:
___
|
10356845-DS-23 | 10,356,845 | 20,221,735 | DS | 23 | 2171-06-14 00:00:00 | 2171-06-14 15:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Midazolam / Zyrtec / Haldol / Bactrim DS / Rosuvastatin /
Gemfibrozil
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
CVL ___
History of Present Illness:
Mr. ___ is a ___ yo M with PMH significant for advanced ___
body dementia with confusion and combative behavior, multiple
falls, DM, CAD, and HTN who presents from nursing home facility
with fever. Per report pt had a fever of 104 while at Nursing
home. He was taken to ___ ED where a CXR showed
pneumonia. He was reportedly given vanco for antibiotics and had
initial SBP in the 60, he was given 4L IVF and transferred to
___ for further management. Of note he was recently on
Geriatric Psychiatry service for ___ issues (admitted ___
and was also treated for c. diff with completion of abx course
in mid ___.
Of note from ___ patient was admitted to ___ for
syncope and a LLL PNA for which he was treated with levofloxacin
for 5 days before being discharged to a nursing facility.
In the ED, initial VS were: T:100.8 P: 80 BP: 88/45 RR:24
Pox:100%
He was hypotensive with initial SBP 60. He got 1L NS and SBP
rose to 90's and a L subclavian CVL was inserted (CVP was 10),
and he was started on low dose norepi and then MAP were in the
___. Exam was notable for multiple decubitus ulcers and TTP in
abdomen. Labs in the ED were notable for Na: 166, Cl 125, AG 18,
BUN 96, Cr 4.2, glucose 192, lactate 1.5, CK ___, CKMB 1.3, MBI
0.1, Tn 0.07. ALT: 50 AST: 56 AP: 34 Tbili: 0.3 Alb: 2.9. He was
making urine.
CXR showed a patchy left lower lobe consolidations concerning
for PNA and a small left effusion. He was given cefepime +
levoquin (he already received vancomycin at ___. He
was also TTP in abdomen so a CT abd was obtained and was
negative for an acute intrabdfominal process.
On arrival to the MICU, Vitals were: 99.7 83 115/53 23 96%. Pt
is not responding to verbal or tactile stimuli but opening eyes.
REVIEW OF SYSTEMS:
(+) Per HPI, fever, sacral ulcer
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias.
Past Medical History:
CAD: s/p MI in ___ treated with TNK and subsequent PCI to RCA
and LAD in ___ at ___. nuclear ETT ___ without evidence
of cardiac ischemia
Hypertension
Hyperlipidemia
DM
Depression
___ Body Dementia
c. diff infection s/p tx ___
Social History:
___
Family History:
His father had problems with alcohol and passed away at ___ from
coronary artery disease. His mother died suddenly at the age of
___ secondary to a stroke
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:98.8 BP:106/55 P:85 R:18 O2:
General: Awake, non-verbal, in no apparent distress
HEENT: Sclera anicteric, dry MM, thrush on tongue, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Back: large 5cmx4cm non-stagable pressure ulcer on coccyx/sacrum
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: contracted upper/lower extremities, non-verbal, not
following commands
Pertinent Results:
___ 02:20PM LACTATE-1.0
___ 02:15PM GLUCOSE-190* UREA N-95* CREAT-3.6*#
SODIUM-167* POTASSIUM-3.7 CHLORIDE-131* TOTAL CO2-22 ANION
GAP-18
___ 02:15PM estGFR-Using this
___ 02:15PM ALT(SGPT)-50* AST(SGOT)-56* CK(CPK)-1655* ALK
PHOS-34* TOT BILI-0.3
___ 02:15PM LIPASE-59
___ 02:15PM cTropnT-0.07*
___ 02:15PM ALBUMIN-2.9* CALCIUM-8.0* PHOSPHATE-5.3*#
MAGNESIUM-2.8*
___ 02:15PM URINE HOURS-RANDOM CREAT-478 SODIUM-11
POTASSIUM-GREATER TH CHLORIDE-13
___ 02:15PM URINE HOURS-RANDOM
___ 02:15PM URINE OSMOLAL-571
___ 02:15PM URINE UHOLD-HOLD
___ 02:15PM URINE GR HOLD-HOLD
___ 02:15PM WBC-12.3*# RBC-3.59* HGB-10.8* HCT-34.3*
MCV-96 MCH-30.1 MCHC-31.6 RDW-12.8
___ 02:15PM NEUTS-87.0* LYMPHS-9.2* MONOS-3.6 EOS-0
BASOS-0.1
___ 02:15PM PLT COUNT-205
___ 02:15PM ___ PTT-30.6 ___
___ 02:15PM URINE COLOR-YELLOW APPEAR-Cloudy SP ___
___ 02:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 02:15PM URINE RBC-17* WBC-33* BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-1
___ 02:15PM URINE HYALINE-10*
___ 02:15PM URINE MUCOUS-MANY
MICROBIOLOGY:
___: Blood Cx x2 pending
___: influenza swab pending
IMAGING:
CXR ___ cardiomediastinal silhouette is unremarkable.
Lung volumes are overall low. Patchy left lower lobe
consolidations are concerning for infection. The left
costophrenic angle is not well seen and may represent a small
effusion. A left subclavian central venous catheter is in place
with the tip terminating at the expected location of the of the
low inferior vena cava. No acute bony
changes.
CT Abdomen (___):
1. No acute intra-abdominal process to explain the patient's
symptoms.
2. Moderate colonic fecal load which also distends the rectum.
3. Renal hypodensity in the left upper pole measuring 43 mm is
likely a simple cyst but is poorly assessed due to streak
artifact and nonemergent renal ultrasound could be obtained if
not previously evaluated elsewhere.
4. Moderate to severe coronary atherosclerotic calcification
___ ___
1. DVT in the right leg in the superficial femoral vein and the
popliteal
vein with complete occlusion of the lumen. A small nonocclusive
thrombus
extends into the common femoral vein at the level of the
junction with the
greater saphenous vein.
2. Small non-occlusive thrombus in the superficial femoral vein
immediately distal to the junction with the deep femoral vein.
CT head ___
FINDINGS: This is a very limited exam due to patient motion,
despite multiple attempts. Given this limitation, there is no
obvious evidence of large acute hemorrhage, edema, mass effect,
or infarction. The ventricles appear to be grossly normal in
size and configuration.
IMPRESSION: No obvious evidence of acute intracranial process
on this very limited exam.
# CXR port (___): The cardiomediastinal silhouette is
unremarkable. Lung volumes are overall low. Patchy left lower
lobe consolidations are concerning for infection.
# Influenza swab (___): negative
# MRSA screen (___): negative
# +VRE carrier
# Abd/pelvic CT (___): No acute intra-abdominal process. Mod
colonic fecal load which also distends the rectum may relate to
constipation. Renal hypodensity in the left upper pole measuring
43 mm is likely a simple cyst but is poorly assessed due to
streak artifact. Moderate to severe coronary atherosclerotic
calcification
# ___ (___): DVT in the R SFV and pop vein with
complete occlusion of lumen. Small nonocclusive thrombus
extends into the CFV at level of the junction with the greater
saphenous vein.
Small non-occlusive thrombus in the L SFV immediately distal to
the junction with the deep femoral vein.
Brief Hospital Course:
Mr. ___ is a ___ yo M with PMH significant for advanced ___
body dementia, DM, CAD, and HTN who presents from nursing home
facility with fever and was found to be in septic shock.
#)Septic Shock: Pt met SIRS criteria and had hypotension not
fluid responsive and pneumonia which was consistent with septic
shock. Pt was initiated on HCAP coverage vanc, cefepime, and
levofloxacin for 8 days (___) empirically, however,
subsequent blood Cx, urine Cx, and flu swab were all
negative/pending on ___. Thus, vanc was dc-ed, because pt's
MRSA screen was negative and there was no positive culture data.
Pt was influenza negative. While pt initially presented with a
fever and leukocytosis, no source was identified, and it is
possible that his leukocytosis was hemoconcentration. During
course of ICU admission, it was not clear if pt's hypotension
was clearly sepsis vs. severe hypovolemia. Since he had fevers,
pt was treated with antibiotics. He completed an 8 day course of
cefepime and flagyl for pneumonia.
#) Hypernatremia: Pt with sodium of 167 on admission. Pt appears
very dehydrated/ hypovolemic on exam. Pt with concentrated urine
with high urine osm and low urine Na consistent with volume
depletion. FENA is 0.05%. This is likely hypovolemic
hypernatremia. Pt was given free water repletion for 3 days to
slowly correct hypernatremia.
#) ___: Pt with Cr of 3.6 up from baseline of 0.8 with acute
kidney injury. Pt's Cr downstrended with free water repletion.
Cr trended to 0.9.
#)Rhabdomyolysis: Pt with a CK 1655 on admission. Possible
etiologies include trauma, muscle compression, drugs, toxin, or
infection. Does not appear to be associated in this case with
NMS or malignant hyperthermia. UA not consistent with
rhabdomyolysis. Cr also elevated with BUN/Cr ratio > 20. Pt
received 4 L NS in the ED. CK peaked and downtrended while in
the ICU. Etiology of elevated CKs is likely ___ to prolonged
immobilization.
#) Delirium/Acute metabolic encephalopathy: Consistent with ___
body dementia. Trigger likely dehydration and sepsis. On
admission pt was agitated and disoriented. As pt's hypernatremia
resolved, pts mental status improved so that he could answer
some questions, but pt was still unable to fully, clearly
communicate. Clonazepam, trazodone and seroquel were stopped.
The patient became more arousable but did not require
medications for agitation. Exelon patch was continued.
An EEG report was pending on discharge.
#) HTN: Pt with history of hypertension but currently
hypotensive. Initially, antihypertensive home medications were
held (home regimen of Toprol XL 25 mg daily, amlodipine 10 mg
daily, lisinopril 40 mg daily, and HCTZ 25 mg daily). On
discharge amlodipine was restarted.
#) HL: Pt developed agitation and confusion on gemfibrozil and
statin per cards note in OMR. The plan was to try ezetimibe per
cards note ___. Ezetimibe was held in house.
#) CAD: s/p IMI in ___ and subsequent PCI to RCA and LAD in
___ at ___. No echo report in our records. Aspirin was
continued.
#) DM2, controlled: no home medication for diabetes, Last A1C
6.1
___. started humalog insulin sliding scale.
#) Bilateral lower extremity DVTs: Started on lovenox and
coumadin. Once the INR is >2, lovenox can be discontinued.
Code status: Patient was full code during this hospitalization.
Communication: With daughter ___ who is applying to become
___ and ___ for patient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Quetiapine Fumarate 75 mg PO QHS
6. Quetiapine Fumarate 25 mg PO QAM:PRN agitation
7. rivastigmine *NF* 4.6 mg/24 hour Transdermal q24hr
8. Sertraline 50 mg PO DAILY
9. traZODONE ___ mg PO HS:PRN insomnia
10. Clonazepam 0.5 mg PO QHS
11. Ezetimibe 10 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using HUM Insulin
3. Warfarin 3 mg PO DAILY16
4. Amlodipine 10 mg PO DAILY
Hold for SBP<100
5. rivastigmine *NF* 9.5 mg/24 hour TRANSDERMAL Q24HR
6. Enoxaparin Sodium 80 mg SC Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bacterial pneumonia
Sepsis
Dysphagia
Encephalopathy
___ Body Dementia
Rhabdomyolysis
Acute renal failure
Bilateral Deep Vein Thromboses lower extremities
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with a pneumonia likely related to aspiration.
You were initially treated for this in the intensive care unit,
and then on the medical floor. You received 8 days of
antibiotics for this.
You had several other medical problems during this
hospitalization. You had confusion, muscle breakdown called
rhabdomyolysis and two deep vein thromboses were found in your
legs. You were started on a blood thinning medication for this
(anticoagulation).
You were very sleepy, and unable to eat regularly, so a feeding
tube was placed through the nose. You pulled this tube out on
___, and subsequently became more awake and were able to
start eating pureed foods. The neurology service saw you while
you were here, and they asked that we check a CT scan of the
brain (unremarkable) and an EEG which was still pending on
discharge.
Followup Instructions:
___
|
10356845-DS-24 | 10,356,845 | 25,012,980 | DS | 24 | 2171-06-29 00:00:00 | 2171-06-29 17:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Midazolam / Zyrtec / Haldol / Bactrim DS / Rosuvastatin /
Gemfibrozil
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ M with ___ Body Dementia, HTN, HLD, DVT on
coumadin recently discharged from ___ on ___ for
hospitalization for sepsis who presents from nursing home with
fever.
Patient had a fever to 103.6 at nursing home and dyspnea by
report. Patient is unable to provide history. Patient is
minimally responsive to questioning. Follows commands
intermittently. Daughter at bedside reports baseline mental
status on a good day will be answering to yes/no questions, able
to tell his name, ___ where he is. Patient does not
speak sentences. Since recent hospitalization, patient's
daughter noted that patient has been improving and was starting
to work with OT.
In the ED, initial VS were: 98.7 86 114/70 20 96% RA. Patient
had a Foley placed and UA was highly suggestive of UTI. Patient
was given 1gram IV ceftriaxone and 1L IVFs. Blood and urine
cultures were drawn.
On arrival to the floor, patient lying in bed awake, able to
open eyes when prompted.
Past Medical History:
CAD: s/p MI in ___ treated with TNK and subsequent PCI to RCA
and LAD in ___ at ___. Nuclear ETT ___ without evidence
of cardiac ischemia
Hypertension
Hyperlipidemia
DM type II
Depression
___ Body Dementia
C. diff infection s/p tx ___
Social History:
___
Family History:
FAMILY HISTORY: (per recent d/c summary)
His father had problems with alcohol and passed away at ___ from
coronary artery disease. His mother died suddenly at the age of
___ secondary to a stroke.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: 98.1 Axillary, BP 111/41 HR 78 O2 Sat 95% on RA
GENERAL: Elderly man in NAD
HEENT: NC/AT, PERRLA, patient fights to have eyes formally
examined. sclerae anicteric, dryMM, tongue midline
NECK: supple,
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox0, CNs II-XII grossly intact, unable to
formally assess ___ to mental status. With lots of prompting,
patient will open eyes on command.
SKIN: 2 pressure blisters over the right heel. Stage 2 sacral
ulcer with no purluence or erythema noted.
PHYSICAL EXAM ON DISCHARGE:
Afebrile, vital signs within normal limits. Sleeping but easily
arousable to voice commands. Opens eyes spontaneously. Chest is
clear. RRR, normal S1 and S2 with no murmur. Soft, non-tender,
non-distended abdomen with no masses. Normal active bowel
sounds. Extremities with no edema and 2+ radial, DP and ___
pulses. He has pressure ulcers on L heel and ankle, R ankles and
a stage II decubitus ulcer. He is alert and oriented to name
and birth date today. Responds to questions with repeated voice
commands.
Pertinent Results:
MICROBIOLOGY:
___ 7:59 pm URINE TAKEN FROM ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ 1:24 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
IMAGING:
___ CHEST XRAY:
IMPRESSION: Possible retrocardiac opacity and effusion.
Consider lateral view to better assess. Cardiomegaly with LV
configuration.
Brief Hospital Course:
___ year old man with history of advanced ___ body dementia, DM,
CAD, and HTN who presents from nursing home with fever and found
to have urinary tract infection and urine cultures growing E.
coli.
# Acute complicated cystitis: Pt uses foley at rehab facility.
Source of fever secondary to acute complicated cystitis. CXR neg
for any obvious pneumonia and blood cultures were negative. He
was treated initially with IV Cefepime until urine cultures
showed E. coli resistant to Cefepime but sensitive to Meropenem.
He was started on Imipenem 500mg Q6H. On day of discharge, he
had a PICC line placed by interventional radiology. He will
continue imipenem from ___ through ___ for total 14 day
course.
# Skin ulcers: He has a known stage II decubitus ulcer, L heel
and bilateral ankles with pressure ulcers. he recieved routine
daily wound care by nursing. On exam, he had a yeast skin
infection in his bilateral axilla which was treated with
Nystatin cream.
#) Hypertension: He was normotensive during admission and did
not require his anti-hypertensives. On discharge his BP was
140s/80s and home amlodipine may be resumed after discharge.
#) History of Bilateral lower extremity DVTs: continued on
Lovenox and coumadin bridge. INR 1.6 at discharge. He will
continue lovenox until INR is therapeutic ___ range.
# Diarrhea: He had multiple loose stools with no gross blood.
His C. difficile antigen assay was negative. His home bowel
regimen was held.
CHRONIC STABLE ISSUES
#) ___ Body Dementia: Continued rivastigmine PATCH Q24H.
#) Diabetes Mellitus type II: He has no home medication for
diabetes. His last A1C 6.1 on ___. Per wife, he has no formal
diagnosis of diabetes. No insulin requirement this during
admission.
#) Hyperlipidemia: Patient developed agitation and confusion on
gemfibrozil and statin per cardiology note in OMR. He was
prescribed and approved for ezetimibe per cards note ___ with
LDL goal <70. He was not taking ezetimibe in his nursing home.
We held his ezetimibe during this admission.
TRANSITIONAL ISSUES:
- CAD/DVT: INR 1.6 (goal ___ bridging with lovenox and coumadin
- UTI: Imipenem Q6H for 14 days, day ___
- Hypertention: restart Amlodipine 10mg QD
CODE STATUS: FULL (confirmed with daughter), CONTACTS: ___
(Daughter ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous
sliding scale
2. Amlodipine 10 mg PO DAILY
3. rivastigmine *NF* 9.5 mg/24 hour Transdermal Q24H
4. Enoxaparin Sodium 80 mg SC Q12H
5. Warfarin 5 mg PO DAILY16
6. Acetaminophen 650 mg PO Q4H:PRN pain;fever
7. Milk of Magnesia 30 mL PO DAILY:PRN constipation
8. Bisac-Evac *NF* (bisacodyl) 10 mg Rectal daily:prn
constipation
9. Enema Disposable *NF* (sodium phosphates) ___ gram/118 mL
Rectal daily;prn constipation
10. Antacid Anti-Gas *NF* (alum-mag
hydroxide-simeth;<br>calcium-simethicone) 200-200-20 Oral
q6h;prn GI upset
11. Guaifenesin 10 mL PO Q4H:PRN cough
12. Aspirin 325 mg PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. ProMod Protein *NF* (protein supplement) 30 mL Oral TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain;fever
2. Enoxaparin Sodium 70 mg SC Q12H
3. Ferrous Sulfate 325 mg PO DAILY
4. rivastigmine *NF* 9.5 mg/24 hour Transdermal Q24H
5. Warfarin 5 mg PO DAILY16
6. Imipenem-Cilastatin 500 mg IV Q6H
7. Nystatin Cream 1 Appl TP BID
8. Aspirin 325 mg PO DAILY
9. Bisac-Evac *NF* (bisacodyl) 10 mg Rectal daily:prn
constipation
10. Enema Disposable *NF* (sodium phosphates) ___ gram/118 mL
Rectal daily;prn constipation
11. Guaifenesin 10 mL PO Q4H:PRN cough
12. HumaLOG *NF* (insulin lispro) 100 unit/mL Subcutaneous
sliding scale
13. Milk of Magnesia 30 mL PO DAILY:PRN constipation
14. ProMod Protein *NF* (protein supplement) 30 mL Oral TID
15. Antacid Anti-Gas *NF* (alum-mag
hydroxide-simeth;<br>calcium-simethicone) 200-200-20 Oral
q6h;prn GI upset
16. Amlodipine 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Fever
Urinary tract infection
Decubitus ulcer
Lower extremity pressure ulcers
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was an absolute pleasure taking care of you during your
admission to the ___. You were
admitted because you had a fever.
We performed blood and urine tests which showed that you have a
urinary tract infection. We treated your infection with
antibiotics. You will continue to take antibiotics when you are
discharged back to your rehab facility.
Your DVT was managed with lovenox and coumadin. Please continue
to check your INR everyday to make sure that your blood is thin
enough. You can stop the lovenox when your INR is therapeutic at
___.
Followup Instructions:
___
|
10356874-DS-6 | 10,356,874 | 21,680,504 | DS | 6 | 2170-07-08 00:00:00 | 2170-07-10 06:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Zosyn / Benadryl Itch Relief Stick / Reglan
Attending: ___.
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
___ laparoscopic cholecystectomy
History of Present Illness:
___ year old man with history of Down's syndrome, gastritis, iron
deficiency anemia, chronic thrombocytopenia,chronic aspiration
with pneumonia in ___ complicated by empyema, gastro-paresis,
hyperlipidemia, with multiple ED visits to ___ recently
(including ___ for UTI, ___ for mechanical fall (no
associated LOC), ___ (admitted) for hypotension/fever, and
found
to be influenza B positive and started on Tamiflu) who was
referred from his PCP office due to hypotension s/p CT abdomen
at
OSH which showed new intra/extra-hepatic ductal dilatation (LFTs
normal); transferred to ___ for MRCP/ERCP evaluation. LFTs
have
remained normal despite CT findings.
Past Medical History:
Pancytopenia of unknown significance (?low grade MDS)
UTI
Down's syndrome
gastritis
iron deficiency anemia
chronic aspiration with pneumonia in ___ complicated by
empyema
gastro-paresis
hyperlipidemia
scoliosis
OA
Hepatitis B carrier
Social History:
___
Family History:
Mother is alive
Physical ___:
ADMISSION EXAM
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, reports yes when asked if palpation elicits
tenderness, no localization, ND, BS+
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
DISCHARGE EXAM
VS: 97.8, 115/69, 59, 18, 91 RA
Gen: Alert, selectively answering questions, sitting in chair in
NAD
CV: HRR
Pulm: LS ctab. + cough
Abd: soft, NT/ND. Lap sites CDI closed with dermabond
Ext: WWP. No edema
Pertinent Results:
___ 09:50AM BLOOD WBC-2.9* RBC-3.12* Hgb-9.9* Hct-29.5*
MCV-95 MCH-31.7 MCHC-33.6 RDW-14.4 RDWSD-47.7* Plt ___
___ 07:50AM BLOOD WBC-2.8* RBC-3.35* Hgb-10.4* Hct-31.8*
MCV-95 MCH-31.0 MCHC-32.7 RDW-14.1 RDWSD-48.1* Plt ___
___ 06:24AM BLOOD WBC-4.7 RBC-3.15* Hgb-9.8* Hct-30.3*
MCV-96 MCH-31.1 MCHC-32.3 RDW-14.1 RDWSD-49.1* Plt ___
___ 06:40AM BLOOD WBC-4.0 RBC-3.50* Hgb-10.9* Hct-32.7*
MCV-93 MCH-31.1 MCHC-33.3 RDW-13.9 RDWSD-46.6* Plt ___
___ 01:05PM BLOOD WBC-3.5* RBC-3.45* Hgb-10.9* Hct-32.3*
MCV-94 MCH-31.6 MCHC-33.7 RDW-14.0 RDWSD-47.4* Plt ___
___ 06:40AM BLOOD Neuts-73.6* Lymphs-12.9* Monos-10.4
Eos-1.0 Baso-0.3 Im ___ AbsNeut-2.91 AbsLymp-0.51*
AbsMono-0.41 AbsEos-0.04 AbsBaso-0.01
___ 09:50AM BLOOD Plt ___
___ 06:40AM BLOOD ___ PTT-28.2 ___
___ 07:50AM BLOOD Glucose-91 UreaN-5* Creat-0.9 Na-141
K-4.5 Cl-103 HCO3-30 AnGap-13
___ 10:00PM BLOOD ALT-51* AST-71* AlkPhos-76 TotBili-0.6
DirBili-0.4* IndBili-0.2
___ 06:40AM BLOOD ALT-13 AST-18 AlkPhos-71 TotBili-0.6
___ 02:50PM BLOOD Lipase-45
___ 07:50AM BLOOD Calcium-7.7* Phos-3.3 Mg-2.3
___: CXR:
Persistent streaky bibasilar opacities, left-greater-than-right
which could potentially represent atelectasis or scarring.
Please note that infection or aspiration cannot be excluded.
___: CT abd. and pelvis:
1. New mild intrahepatic and extra-hepatic biliary dilatation
with an apparent filling defect seen in the distal common bile
duct, possibly reflective of choledocholithiasis. Further
assessment with MRCP/ERCP is recommended.
2. Unchanged appearance of mild thickening of the urinary
bladder.
Correlation with urinalysis is recommended to exclude infection.
3. Persistent ill-defined nodular opacities in the left lower
lobe, minimally improved in the interval, concerning for
aspiration pneumonia. Small left pleural effusion is new.
4. Large hiatal hernia, as before.
RECOMMENDATION(S): 1. An MRCP or ERCP could be obtained for
further
evaluation of the filling defect in the distal common bile duct.
2. Recommend correlation with urinalysis for thickened urinary
bladder.
___: MRCP:
-Cholelithiasis.
-The examination is nondiagnostic for choledocholithiasis as the
patient could not tolerate the scan.
-Consider ERCP for further evaluation.
Brief Hospital Course:
___ year old male who was seen by his PCP ___ ___ for a routine
visit. Upon examination, he was noted to be hypotensive and
reporting abdominal pain. Besides this, he was reported to have
a poor tolerance to food. He was given intravenous fluids with
improvement of his blood pressure and underwent imaging. A cat
scan of the abdomen was done which showed new
intra/extra-hepatic ductal dilatation. His LFT were normal. He
was also reported to have persistent ill-defined nodular
opacities in the left lower lobe concerning for aspiration
pneumonia. He was given a dose of ciprofloxacin in the
emergency room and transferred here for further evaluation. Upon
admission, the patient was made NPO and given intravenous
fluids.
Based on the findings of the cat scan, the patient underwent an
MRCP with non-diagnostic findings. On HD #3, the patient
underwent an EUS. The bile duct was normal in appearance with
no stones or sludge. The patient was taken to the operating room
on HD #4 where he underwent a cholecystectomy. The operative
course was stable with minimal blood loss. The patient was
extubated after the procedure and monitored in the recovery
room.
The post-operative course was stable. The patient experienced
difficulty voiding and required placement of a foley catheter
which was removed in 48 hours. Bowel function was slow to return
after the surgery and the patient's appetite was diminished.
The patient was discharged to his group home on POD #5, once he
was taking adequate PO. His vital signs were stable and he was
afebrile. He was voiding without difficulty. A follow-up
appointment was made in the Acute Care clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO TID:PRN constipation
2. Guaifenesin-Dextromethorphan 10 mL PO Q8H:PRN cough
3. Psyllium Powder 1 PKT PO BID:PRN constipation
4. Vitamin D 1000 UNIT PO DAILY
5. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild/Fever
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Senna 8.6 mg PO DAILY:PRN constipation
9. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY
2. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
3. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild/Fever
4. Docusate Sodium 100 mg PO TID:PRN constipation
5. Guaifenesin-Dextromethorphan 10 mL PO Q8H:PRN cough
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Psyllium Powder 1 PKT PO BID:PRN constipation
9. Senna 8.6 mg PO DAILY:PRN constipation
10. TraZODone 50 mg PO QHS:PRN insomnia
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
cholelithiasis
s/p cholecystectomy
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
You were admitted for low blood pressures and dilation of some
of your biliary ducts.
While you were here you had an endoscopic ultrasound which
showed no biliary obstruction but did show gallstones in your
gallbladder.
For this, you had your gallbladder removed. You are slowly
getting better and will be discharged with the following
instructions:
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
10357000-DS-16 | 10,357,000 | 27,830,407 | DS | 16 | 2156-04-24 00:00:00 | 2156-04-25 20:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ laparoscopic cholecystectomy
History of Present Illness:
HPI: Ms. ___ is a ___ ___ F from ___ who
was in ___ visiting her ill family member when she began to
develop RUQ and L flank pain, unrelenting x 20 hrs. She has been
having pain like this for the past year, worse after meals, but
typically it will last 10 hrs maximum and abate with Tylenol ___
or without any intervention. Today it is associated with nausea.
Typically, it is associated with nausea, but no vomiting. She
did
vomit several times with the pain 1 wk prior to presentation.
The pain is stabbing at this point, and does not radiate to her
back. She has undergone ___ ___ which was negative,
aside
from gastritis, and she has been on a PPI for the gastritis,
which she takes religiously. She has no known h/o PUD or
diverticulitis. She has never had a kidney stone. On ROS, she
denies f/c, dysuria, hematuria, unexplained weight loss
Past Medical History:
HTN, h/o UGI and colonoscopy ___ (sig findings gastritis)
Social History:
___
Family History:
unknown
Physical Exam:
Physical Exam: upon admission: ___:
Vitals: 98.7 107ST 154/88 18 100%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Negative ___, soft, nondistended, TTP RUQ, LUQ, L CVA,
no rebound or guarding, normoactive bowel sounds, no palpable
masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___:15AM BLOOD WBC-9.3 RBC-3.86* Hgb-11.7 Hct-35.5
MCV-92 MCH-30.3 MCHC-33.0 RDW-14.1 RDWSD-47.8* Plt ___
___ 07:10AM BLOOD WBC-7.1 RBC-3.96 Hgb-12.2 Hct-36.2 MCV-91
MCH-30.8 MCHC-33.7 RDW-14.0 RDWSD-46.8* Plt ___
___ 10:35AM BLOOD WBC-10.2* RBC-4.39 Hgb-13.7 Hct-40.6
MCV-93 MCH-31.2 MCHC-33.7 RDW-13.8 RDWSD-47.1* Plt ___
___ 10:35AM BLOOD Neuts-62.1 ___ Monos-8.0 Eos-0.5*
Baso-0.2 Im ___ AbsNeut-6.33* AbsLymp-2.94 AbsMono-0.82*
AbsEos-0.05 AbsBaso-0.02
___ 09:15AM BLOOD Plt ___
___ 09:15AM BLOOD ___
___ 05:55AM BLOOD Glucose-109* UreaN-12 Creat-0.5 Na-136
K-4.5 Cl-104 HCO3-22 AnGap-15
___ 05:25AM BLOOD Glucose-69* UreaN-15 Creat-0.6 Na-139
K-3.5 Cl-101 HCO3-23 AnGap-19
___ 05:25AM BLOOD ALT-72* AST-63* AlkPhos-78 TotBili-0.4
___ 10:35AM BLOOD Lipase-32
___ 05:55AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
Brief Hospital Course:
The patient was admitted for RUQ pain. His HIDA scan was
positive for cholecystitis, thus the patient presented to the
Operating Room on ___ for the laparoscopic cholecystectomy.
The procedure occurred without complication. For more
information about the procedure please refer to the operative
report. The patient was transferred to the PACU in the immediate
post operative period, and when appropriate, the patient was
transferred to the floor. Pain was controlled with PO pain
medication when patient was tolerating PO. Diet was advanced in
a stepwise fashion after the patient had return of bowel
function until regular diet was tolerated without difficulty.
The patient was discharged home on POD 1. At the time of
discharge, the patient was urinating and stooling normally, pain
was controlled with oral pain medication, and the patient was
out of bed to ambulate without assistance. The patient was
discharged home with plan to follow up with acute care surgery
in ___ weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fosinopril 40 mg oral DAILY
2. Pantoprazole 40 mg PO Q24H
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
Take this medication if you are taking the narcotic pain
medication
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
5. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
RX *tramadol [Ultram] 50 mg ___ (half) tablet(s) by mouth every
four (4) hours Disp #*10 Tablet Refills:*0
6. fosinopril 40 mg oral DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
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.
Followup Instructions:
___
|
10357000-DS-17 | 10,357,000 | 25,468,087 | DS | 17 | 2156-09-24 00:00:00 | 2156-09-24 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left facial droop, dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 10 minutes
Time/Date the patient was last known well: ___ 0600
___ Stroke Scale Score: 1
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: low NIHSS,
outside of time window to give tPA
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
___ Stroke Scale score was 1:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 1
Name/MRN: ___ ___
Reason for consult: left facial droop, dizziness
HPI:
Ms. ___ is a ___ yo woman with a history of HTN who
presented with dizziness, nausea, vomiting.
She took a red-eye overnight flight from ___ to ___ on
___ night, and when she got off the plane at 6 am on ___
she felt dizzy, nausea and vomiting. The dizziness felt like
unsteadiness, not spinning. She is unsure if these symptoms
started acutely or came on gradually. She went to her daughter's
house, slept, and felt better afterwards. However, this morning
around 10:30 am, she again had unsteadiness, nausea and vomiting
so she came to the ED.
A neurology consult was called because the ED resident and
attending noticed a left facial droop. This was not present in
triage and not noted later on neurology examination.
She has chills. No fevers, diarrhea, abdominal pain, double
vision, gait problems, or change in symptoms with changes in
position.
Past Medical History:
HTN
Arthritis
Social History:
___
Family History:
Father - ___
Physical ___:
==============
ADMISSION EXAM
==============
T= 98.5F, BP= 147/75, HR= 95, RR= 18, SaO2= 99%
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
but without many details. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was unable to name ___ objects on
stroke card - named chair and feather correctly, but called
cactus a leaf, called glove a hand, called key a baton, and did
not know hammock. Able to name watch but not sleeve. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Inattentive, unable to name ___ backward. Pt. was
able to register 3 objects and recall ___ at 5 minutes. There
was no evidence of neglect. Speech soft, with slow response
time.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5
R ___ ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 1
R 3 3 3 3 1
- Plantar response was extensor bilaterally.
- Pectoralis Jerk was present, and Crossed Adductors are
present.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
==============
DISCHARGE EXAM
==============
UNREMARKABLE
Pertinent Results:
====
LABS
====
___ 05:15PM BLOOD WBC-9.9 RBC-4.25 Hgb-13.2 Hct-39.2 MCV-92
MCH-31.1 MCHC-33.7 RDW-14.1 RDWSD-48.4* Plt ___
___ 05:41AM BLOOD WBC-9.6 RBC-4.15 Hgb-12.7 Hct-38.1 MCV-92
MCH-30.6 MCHC-33.3 RDW-14.2 RDWSD-47.8* Plt ___
___ 05:15PM BLOOD ___ PTT-25.6 ___
___ 05:15PM BLOOD Plt ___
___ 05:41AM BLOOD ___ PTT-25.9 ___
___ 05:41AM BLOOD Plt ___
___ 05:15PM BLOOD Glucose-149* UreaN-17 Creat-0.6 Na-138
K-4.2 Cl-97 HCO3-26 AnGap-19
___ 05:41PM BLOOD Creat-0.6
___ 05:41AM BLOOD Glucose-108* UreaN-11 Creat-0.5 Na-140
K-3.5 Cl-101 HCO3-27 AnGap-16
___ 05:15PM BLOOD ALT-29 AST-39 AlkPhos-86 TotBili-0.2
___ 05:15PM BLOOD Lipase-81*
___ 05:15PM BLOOD cTropnT-<0.01
___ 05:15PM BLOOD Albumin-4.4
___ 05:41AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.9 Cholest-167
___ 05:41AM BLOOD %HbA1c-5.8 eAG-120
___ 05:41AM BLOOD Triglyc-43 HDL-78 CHOL/HD-2.1 LDLcalc-80
___ 05:41AM BLOOD TSH-0.76
___ 05:42PM BLOOD Glucose-133* Lactate-2.1* Na-137 K-3.6
Cl-98 calHCO3-27
___ 05:41AM BLOOD Glucose-108* UreaN-11 Creat-0.5 Na-140
K-3.5 Cl-101 HCO3-27 AnGap-16
___ 02:04AM URINE Color-Straw Appear-Clear Sp ___
___ 08:30PM URINE Color-Straw Appear-Clear Sp ___
___ 02:04AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 08:30PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 08:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
=======
IMAGING
=======
1. CT/CTA H&N:
Non-contrast head CT: No acute intracranial hemorrhage. CTA
head/neck: No dissection, occlusion or aneurysm greater than 3
mm involving the major arteries of the head and neck. Stable 5
mm right thyroid nodule. Final read pending 3D reformats.
2. CXR: Lungs are fully expanded and clear. Cardiomediastinal
and hilar silhouettes and pleural surfaces are normal.
3. MRI HEAD W/O CONTRAST:
No acute infarcts. Early changes of small vessel disease.
Brief Hospital Course:
___ is a ___ yo ___ speaking woman with history of
hypertension and arthritis who presented initially with acute
onset severe dizziness, nausea, and vomiting after a long
flight. A code stroke was called and her NIHSS was 1 for
extinction and neglect. She was imaged with CT/CTA/MRI which did
not show any evidence of acute stroke. Her stroke risk factors
were assessed with A1C 5.8%, cholesterol 167, LDL 80. Her
neurologic exam was only notable for mild inattention, and her
gait was steady. At this time we believe she had an episode of
vestibular migraine. Her nausea and dizziness improved
overnight. However she continues to complain of unilateral
headache. We have recommended ondansetron if the nausea recurs.
She should follow with her primary care doctor once she goes
back home to ___.
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 = 80) - () 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? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) 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. Hydrochlorothiazide 25 mg PO DAILY
2. fosinopril 40 mg oral DAILY:PRN
Discharge Medications:
1. fosinopril 40 mg oral DAILY:PRN
2. Hydrochlorothiazide 25 mg PO DAILY
3. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*10 Tablet Refills:*0
4. Ibuprofen 400 mg PO Q8H:PRN headache
Please do not exceed three doses daily.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Vestibular migraine
Secondary:
Hypertension
Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the hospital with symptoms of dizziness,
nausea, vomiting. Initially we were concerned about an acute
ischemic stroke. However, we have imaged your brain and blood
vessels with CT, CTA, MRI and found no evidence of stroke. We
also checked your vascular risk factors which were: A1C (5.8%),
LDL (pending), Cholesterol (pending). We have given you some
fluids and pain medication which have improved your symptoms. At
this time we think the cause of your issues is likely a migraine
headache precipitated by long hours of travel and dehydration.
We recommend you continue to drink plenty of fluids and take
ibuprofen as needed to relieve your headache and neck pain.
Instructions:
Please take your other medications as prescribed.
Please follow up with your primary care doctor once you return
home 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
Followup Instructions:
___
|
10357251-DS-5 | 10,357,251 | 24,289,868 | DS | 5 | 2186-02-22 00:00:00 | 2186-02-22 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
colchicine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
Sigmoidoscopy
History of Present Illness:
___ with PMHx HIV2, PE, crohn's disease and c diff colitis who
presents with 2d of diarrhea. Profuse and watery, no blood. He
also has accompanying lower quadrant pain that has been
worsening. Positive for chills/subjective fevers but has not
taken temp at home. No recent antibiotics. His appetite is
decreased but is able to take PO fluids. No N/V. He states that
this pain and profuse diarrhea.
Labs in the ED significant for 62.9 PTT: 57.7 INR: 6.0 (1.7 in
___, ED held Warfarin), Lactate 2.2. Negative UA. K+ 3.1
(Received 40 meq) H&H of 9.___
ON Exam in ED:98.5 88 100/66 24 97%
mod distress, crackles b/l lung. TTP in lower quadrants R>L.
rectal exam: no frank blood or hemorrhoids visualized. Trace+
guaiac.
In the ED: 3L NS Fluid Bolus. IV Flagyl and Cipro. 40meq of K+.
On the Floor pt is stable and states he has too many to count
BM. No sick contacts, undercooked beef, travel, or recent Abx.
Denies CP, cough, fever, vision changes, or HA. Positive for
pain with urination and chills.
Past Medical History:
HIV2
history of NSAID induced colitis
h/o C. difficile colitis
In the last year he was diagnosed with Crohn's disease (in
___ and was started on Humira for an unknown period of
time.
gout
subsegmental PE
C diff
AAA
Social History:
___
Family History:
No known TB in any family members
No known liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
General - NAD A&Ox3,
HEENT: EOMI, anicteric sclera, no oral thrush
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Slight course breath sounds in Lower lobes, breathing
comfortably without use of accessory muscles
ABDOMEN: distended, +BS, nontender in lower R and L (worse in
L), no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 97.3 99-130/51-70 ___ 18 99RA
IO 24: BMx3
General - NAD A&Ox3,
HEENT: EOMI, anicteric sclera, no oral thrush
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Slight course breath sounds in Lower lobes, breathing
comfortably without use of accessory muscles
ABDOMEN: distended, +BS, mildy tender in lower R and L (worse in
L), no rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 11:00AM BLOOD WBC-7.3 RBC-3.47* Hgb-9.9* Hct-32.1*
MCV-92 MCH-28.7 MCHC-31.0 RDW-19.1* Plt ___
___ 11:00AM BLOOD Neuts-36.8* Lymphs-48.2* Monos-9.1
Eos-5.0* Baso-0.8
___ 11:52AM BLOOD ___ PTT-57.7* ___
___ 11:00AM BLOOD Glucose-111* UreaN-14 Creat-1.2 Na-136
K-3.1* Cl-104 HCO3-25 AnGap-10
___ 07:50AM BLOOD Calcium-7.4* Phos-2.3* Mg-1.4*
___ 11:00AM BLOOD Albumin-2.3*
___ 07:45AM BLOOD ALT-12 AST-31 LD(LDH)-348* AlkPhos-61
TotBili-0.2
___ 07:25AM BLOOD calTIBC-75* VitB12-628 Folate-11.5
Ferritn-938* TRF-58*
___ 11:00AM BLOOD CRP-22.2*
___ 11:41AM BLOOD Lactate-2.2*
___ 03:20PM BLOOD QUANTIFERON-TB GOLD- NEGATIVE
___ 03:36PM BLOOD ADALIMUMAB LEVEL - PND
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-7.3 RBC-3.45* Hgb-10.2* Hct-31.6*
MCV-92 MCH-29.5 MCHC-32.2 RDW-20.0* Plt Ct-88*
___ 07:45AM BLOOD ___
___ 07:45AM BLOOD Glucose-59* UreaN-12 Creat-1.0 Na-139
K-3.5 Cl-104 HCO3-30 AnGap-9
___ 07:45AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.7
MICRO:
__________________________________________________________
___ 3:14 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 10:23 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
__________________________________________________________
___ 12:55 pm Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
__________________________________________________________
___ 2:25 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
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.
.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
__________________________________________________________
___ 11:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:42 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 2:40 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
PATHOLOGIC DIAGNOSIS:
Rectum, mucosal biopsy - ___:
1. Chronic moderately active colitis with foci of
non-necrotizing granulomas present within the lamina propria.
Some (but not all) of the granulomas are seen in association
with crypt damage.
2. A CMV immunohistochemical stain is negative.
3. No dysplasia identified.
4. Additional levels were examined.
IMAGING:
+ MR ENTEROGRAPHY - ___:
The small bowel is normal, without wall thickening, abnormal
enhancement or mass effect. The terminal ileum is unremarkable.
Mild wall thickening and stratification, and mucosal
hyperenhancement are seen in the rectum and the sigmoid
(___). Mesorectal fat edema and hypervascularity are seen.
Mesorectal lymph nodes measuring up to 4 mm are seen (13:106).
+ MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Small amount of bilateral pleural effusion is present, more on
the left. The liver is normal in size and morphology. No focal
liver lesions are seen. The portal and hepatic veins are patent.
Conventional arterial hepatic anatomy is demonstrated.
Status post cholecystectomy. The intra and extrahepatic biliary
ducts are not dilated. The pancreatic parenchyma is atrophic.
The pancreatic duct is normal in caliber. Bilateral cortical
renal cysts are seen. Otherwise the kidneys are normal. Single
renal arteries present on both sides. The adrenal glands are
normal. Infrarenal abdominal aortic aneurysm measuring up to 4
cm due to therosclerotic disease is seen (13:17). The aneurysm
extends into both common
iliac arteries (13:55). The aneurysm increased in size from ___
when it measured 3 cm.
+ MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The urinary bladder, the prostate are grossly unremarkable.
There is no free fluid in the abdomen and pelvis. There is no
retroperitoneal or mesenteric lymphadenopathy. The bone marrow
signal is normal.
IMPRESSION:
1. Proctosigmoiditis, most likely inflammatory in nature.
2. Atherosclerotic abdominal aortic aneurysm measuring 4 cm
extending into the common iliac arteries bilaterally.
+ Sigmoidoscopy - ___:
FINDINGS: Mucosa - Segmental linear ulcerations, with erythema
and abnormal vascularity were noted in the rectum with skipped
areas. These findings are compatible with colitis. Cold forceps
biopsies were performed for histology at the rectum.
IMPRESSION: Segmental linear ulcerations, with erythema and
abnormal vascularity were noted in the rectum with skipped
areas. These findings are compatible with colitis. (biopsy)
Otherwise normal sigmoidoscopy to proximal sigmoid colon
Brief Hospital Course:
___ with PMHx HIV2, PE, crohn's disease and c diff colitis who
presents with 2d of water non-bloody diarrhea and lower L and R
ABD pain. CT ABD showing proctocolitis most notably involving
the rectum and sigmoid.
# Proctocolitis: IN HIV+ men the etiology includes infection,
malignancy, or medications. GI and ID consulted/following.
Believed to be a Crohn's Flare. CMV DNA not detected. Infectious
workup negative.
- hydrocortisone rectal foam
- Mesalamine (Rectal) ___ID
- Avoid NSAIDS in this patient with NSAID induced colitis.
# HIV: New diagnosis this year after multiple partners besides
his wife. CD4 count 423.
# PE prophylaxis: INR supratherapeutic on admission. On Warfarin
for questionable PE at OSH. Old notes show patient denied OSH
finding a PE, while son was unsure. INR reversed with vitamin K
for sigmoidoscopy and biopsy. Restarted warfarin 5mg daily
without a bridge.
TRANSITIONAL ISSUES:
- f/u humira level.
- f/u final biopsy results
*)CODE: DNR/DNI
*)CONTACT: ___ (son ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocortisone Acetate Suppository 1 SUPP PR PRN pain
2. Ferrous Sulfate 325 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Tamsulosin 0.4 mg PO HS
5. Warfarin 5 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Allopurinol ___ mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Tamsulosin 0.4 mg PO HS
5. Warfarin 5 mg PO DAILY
6. Mesalamine (Rectal) ___AILY
RX *mesalamine [Canasa] 1,000 mg 1 suppository(s) rectally daily
Disp #*30 Suppository Refills:*1
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Hydrocortisone Acetate Suppository 1 SUPP PR PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Crohn's Proctocolitis Flare
SECONDARY DIAGNOSIS: HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you. You came to us with
diarrhea. We gave you IV antibiotics and replaced the
electrolytes you lossed through diarrhea. We consulted both GI
and infectious disease services who provided care. On admission,
your blood was too thin to perform diagnostic procedures, so we
gave you vitamin K to stabalize your INR from excess warfarin.
Once your INR was stable, GI performed a sigmoidoscopy and took
biopy of your large bowel to assess for Crohn's flare versus an
infection.
All of our workup points toward a Crohn's Flare and we treated
you accordingly. You improved and continue to do so. You will
need to follow up with you GI doctor to for management of
Crohn's Disease. It is VERY important to take all your
medications to lower your risk of having another flare.
You should followup with your PCP and gastroenterologist below.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10357251-DS-6 | 10,357,251 | 26,436,988 | DS | 6 | 2186-04-06 00:00:00 | 2186-04-06 19:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
colchicine / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Abdominal pain/diarrhea
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy on ___
History of Present Illness:
___ with recently dx HIV-2, subsegmental PE (on warfarin), hx
of Crohn's disease, stable 3.5 mm AAA presents c/o of 2 days
abdominal pain and diahrrea. Abd pain is diffuse and sharp; no
provacative or alleviating factors. Associated diarrhea (non
bloody). Denies fever, chills, n/v, chest pain, urinary symtoms.
Pt was admitted for these symptoms in early ___
found to have crohn's flare.
In the ED, initial VS were 98.2 73 ___ 99% .
Exam was significant for reassuring vitals, but his exam
revealed significant diffuse abd tenderness with voluntary
guarding. No rebound or distension. Normal rectal exam; no sign
of abcess, guiac negative. CT abdomen showed evidence of
proctocolitis. No fluid collections or SBO.
Labs showed H/H 10.7/34.1, normal WBC with lymphocytosis, sodium
127, INR 1.7,
Received 2 mg IV morphine for pain and 2L NS.
Transfer VS were 98 55 110/69 22 100% RA.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports that he has had
abdominal pain for the last ___ days before and after bowel
movements. He denies watery diarrhea and insists that his stools
are hard. The pt also describes very poor PO intake for the last
several days. He denies nausea/vomiting/hematochezia/melena. Per
son, he has had diarrhea for quite a while, has been sleeping
most of the day, and the son ___ is concerned about the
patient returning to home.
Past Medical History:
HIV-2
history of NSAID induced colitis
h/o C. difficile colitis
Crohn's disease: Diagnosed in ___. briefly on humira, on PO and
PR mesalamine
gout
subsegmental PE
C diff
AAA
Social History:
___
Family History:
No known TB in any family members
No known liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98 55 110/69 22 100% RA
Gen: Pleasant, calm initially; Grew aggravated after abdominal
exam.
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Soft, supple; Subcutaneous nodule along border of SCM on
left.
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. End-inspiratory crackles at the bases
bilaterally
ABD: NABS. Soft, non-distended. Voluntary guarding. tenderness
to light palpation of RLQ and diffuse TTP to deep palpation. No
hepatosplenomegaly noted.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: Alert and oriented to self, hospital, and month/year. No
gross deficits based on observation.
DISCHARGE PHYSICAL EXAM:
98.7 55-60 ___ 98-100% RA
Gen: Aggravated during exam, but cooperative
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Soft, supple; Subcutaneous nodule along border of SCM on
left.
LYMPH: No cervical or supraclav LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. End-inspiratory crackles at the bases
bilaterally
ABD: NABS. Soft, non-distended. No voluntary guarding. TTP to
deep palpation of RLQ and LLQ, improved from yesterday. No
hepatosplenomegaly noted.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: Alert and oriented to self, hospital, and month/year. No
gross deficits based on observation.
Pertinent Results:
ADMISSION LABS:
___ 11:15AM BLOOD WBC-8.7 RBC-3.70* Hgb-10.7* Hct-34.1*
MCV-92 MCH-28.9 MCHC-31.4 RDW-18.7* Plt ___
___ 11:15AM BLOOD Neuts-26.7* Lymphs-59.0* Monos-8.5
Eos-5.3* Baso-0.6
___ 11:15AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Target-OCCASIONAL Acantho-OCCASIONAL
___ 11:15AM BLOOD ___ PTT-43.2* ___
___ 11:15AM BLOOD Glucose-88 UreaN-20 Creat-1.1 Na-127*
K-7.1* Cl-98 HCO3-21* AnGap-15
___ 05:35AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.6
___ 11:15AM BLOOD Albumin-2.8*
___ 11:15AM BLOOD ALT-24 AST-74* AlkPhos-72 TotBili-0.3
___ 11:15AM BLOOD Lipase-28
___ 01:14PM BLOOD K-4.8
___ 04:00PM URINE Color-Straw Appear-Hazy Sp ___
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
MICRO:
___ 4:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 6:52 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
PERTINENT LABS:
___ 07:00AM BLOOD CRP-9.6*
___ 10:34AM BLOOD Lactate-2.2*
___ 05:35AM BLOOD ___ PTT-42.2* ___
___ 07:00AM BLOOD ___ PTT-41.9* ___
___ 08:46AM BLOOD ___
___ 06:00AM BLOOD ___ PTT-47.9* ___
___ 07:20AM BLOOD ___
___ 08:19AM BLOOD Lactate-1.6
DISCHARGE LABS
___ 07:20AM BLOOD WBC-6.8 RBC-3.29* Hgb-9.6* Hct-30.3*
MCV-92 MCH-29.2 MCHC-31.8 RDW-18.8* Plt Ct-86*
___ 07:20AM BLOOD Glucose-77 UreaN-14 Creat-1.1 Na-136
K-3.6 Cl-105 HCO3-23 AnGap-12
___ 07:20AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.5*
IMAGING:
___ CT ABDOMEN & PELVIS IMPRESSION:
1. Findings consistent with active proctocolitis including
mucosal
hyperenhancement, fat stranding, and mild bowel wall thickening.
No focal
fluid collection. No pneumotosis or free air.
2. Stable lung fibrosis, unchanged since prior.
3. Stable abdominal and right common iliac aneurysms.
___ Pathology Tissue: UPPER GASTROINTESTINAL BIOPSY
- chronic severely active colitis with focal ulceration
- CMV pending
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ with PMHx HIV2, PE, crohn's disease,
c diff colitis and recent crohn's flare in ___ presents with
2 days abdominal pain and ?diarrhea. CT ABD showing
proctocolitis.
# Proctocolitis: Most likely persistent or recurrent flare of
Crohn's disease. Patient presented with abdominal pain and
?diarrhea (family reported diarrhea, however, patient denied it)
similar to presentation last month, during which he was found to
have crohn's flare and a negative infectious work-up. He has
been on PO and PR mesalamine since ___ after seeing Dr.
___ as an outpatient. He was previously on humira, but this
was held recently due to HIV status. CTab&pelvis in ED this
admission showed active proctocolitis including mucosal
hyperenhancement. He continued his home PO and PR mesalamine and
was briefly on cipro/flagyl (IV then PO) for 3 days. GI was
consulted and recommended to stop the antibiotics. Stool
cultures for salmonella/shigella/O&P and C.dif were negative. ___
performed a sigmoidoscopy on ___, showing ulceration,
granularity, friability and erythema in the rectum and distal
sigmoid colon compatible with colitis. Biopsy with evidence of
colitis and focal ulceration, with CMV pending. He was
discharged on PO and PR mesalamine with outpatient GI follow-up
scheduled. Of note, he did not have diarrhea during this
admission. Abdominal pain and tenderness on exam was much
improved on discharge.
# Crohn's disease: Diagnosed in ___. He was previously on
humira prior to flare in ___. On last admission, His
sigmoidoscopy in ___ done showed mild colitis and bx did show
non-caseating granulomas. CT and MRE both showed inflam in
rectum and sigmoid only. He was discharged on mesalamine PO and
PR. Sigmoidoscopy on this admission (___) showed colitis
and biopsy as above. CRP on admission was 9.6, much decreased
from 13.4 during last admission. He was discharged on PO and PR
mesalamine with plans for outpatient GI follow up. He was
having soft stools one time per day without significant
abdominal pain on day of discharge.
# Social: Son was concerned about patient's ability to take care
of himself at home and wife (previous care giver) is currently
unable to. Social work was consulted to assist with HCP
planning. ___ and OT saw the patient recommending patient go to
rehab to work on strength and conditioning.
# Hypoalbuminemia: Most likely ___ poor nutrition and Crohn's.
Nutrition was consulted and recommended added nutritional
supplements TID.
Chronic Issues:
# Anemia: Chronic. Outpatient labs consistent with anemia of
chronic disease. No blood in diarrhea per patient and guiaic
negative in ED. H/H was stable on discharge.
# HIV: New diagnosis this year after multiple partners besides
his wife. CD4 count CD4 count of 650 on ___. Not on
antiretrovirals.
# PE: Subsegmental PE and diagnosed at ___ in
___. Has been on anticoagulation (warfarin) since ___ and
___ remain on this through ___. INR was monitored daily
while on cipro (last day ___ and INR on discharge was ***.
# Hyponatremia: Most likely hypovolemic in the setting of
diarrhea and decreased PO intake. No AMS, most likely chronic.
Improved with IVF.
# Hyperlactatemia: Most likely secondary to hypoperfusion from
anemia and hypovolemia. Peaked at 2.2
Transitional Issues:
#Thrombocytopenia: Platelets have been downtrending since
___. There was no acute drop during this hospitalization
and HIT was not suspected. This should be followed up. Platelets
on day of discharge were 86.
#CMV immunohistochemical stain was pending on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. mesalamine 800 mg oral daily
2. Mesalamine (Rectal) ___AILY
3. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
4. Allopurinol ___ mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Tamsulosin 0.4 mg PO HS
7. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN wheezing/SOB
8. Warfarin 5 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID
3. Mesalamine (Rectal) ___AILY
4. Pantoprazole 40 mg PO Q24H
5. Tamsulosin 0.4 mg PO HS
6. Warfarin 5 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN wheezing/SOB
8. Mesalamine ___ 800 mg PO TID
9. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Proctocolitis
2. Crohn's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for abdominal pain
and diarrhea. A picture of your abdomen showed that there is
inflammation in your colon. The special colon doctors also
looked at your colon with a camera and saw the inflammation.
They took a sample to examine under a microscope. We feel that
the abdominal pain you had is due to your Crohn's disease, or
inflammatory bowel disease. You should continue to take your
medicines (especially the mesalamine by mouth and suppository)
to treat this. Please follow up with your primary care Dr. ___
___ your gastrointestinal Dr. ___ on the dates below. The
nutritionists and physical therapists also saw you. They
recommend that you drink an ensure supplement three times daily
with meals. You were evaluted by physical therapy and are going
to a rehab facility to work on strength and conditioning.
Please see below for your medications and appointments.
Followup Instructions:
___
|
10357417-DS-17 | 10,357,417 | 22,443,934 | DS | 17 | 2164-12-06 00:00:00 | 2164-12-07 20:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
___ - diagnostic laparascopy to mini laparotomy, Lysis of
Adhesions, repair of umbilical hernia
History of Present Illness:
The patient is a ___ man with PMH of afib on Xarelto,
HTN, HLD, DMII, CHF, CKD, CVA x 2, presenting with LLQ abdominal
pain that began this morning at 5am. Patient reports the pain is
pulsating and constant, worsened when he moves or sits up, and
alleviated by pain medications given in the ED (morphine). He
drank some water and took Pepto Bismol and his usual home
medications this morning, but otherwise denies PO intake today.
His last BM was on ___ or ___. He does not recall passing
flatus today. He denies fever, chills, nausea, vomiting,
diarrhea, constipation, black/bloody stools. At bedside, the
patient was comfortable but had taken morphine 5 minutes prior
to
exam.
12-point ROS is positive as per HPI and otherwise negative.
Past Medical History:
PMH:
- adhesive capsulitis,
- HTN
- HLD
- AF on xarelto
- CHF
- CVA c/b seizure ___
- diverticulosis
- DM
- Disc herniation
- CKD stage three
PSH: none
Social History:
___
Family History:
Father with MI in early ___, Mother with CVA in early ___.
Physical Exam:
VS T 97.7, BP 134/89, HR 82, RR 18, O2 94% RA
General: well-appearing man in NAD
HEENT: NC, AT, sclera anicteric, PERRL, EOMI
CV: normal S1, S2, RRR, no m/r/g
Respiratory: breathing comfortably on room air, CTAB
Abdomen: +BS, abdomen soft, appropriately tender around
incision. Incision well approximated without erythema covered by
steri strips.
Extremities: WWP, no clubbing, cyanosis, edema
Neuro: A&O x 3, moving all four extremities
Skin: no rash
Pertinent Results:
___ 09:24AM BLOOD WBC-7.1 RBC-3.87* Hgb-13.1* Hct-36.1*
MCV-93 MCH-33.9* MCHC-36.3 RDW-13.2 RDWSD-44.8 Plt ___
___ 06:08AM BLOOD ___ PTT-150* ___
___ 09:24AM BLOOD Glucose-213* UreaN-15 Creat-1.1 Na-145
K-3.7 Cl-106 HCO3-24 AnGap-15
___ 09:24AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.9
___ 09:36PM BLOOD Lactate-1.3
CT Abd/Pelvis ___:
1. Findings concerning for closed loop small-bowel obstruction
with 2
transition points in the left lower abdomen as described above.
Questionable decreased bowel wall enhancement and moderate
associated mesenteric edema/small amount of mesenteric free
fluid raise concern for ischemia. Surgical consult
recommended.
2. 1.1 cm left adrenal adenoma.
Brief Hospital Course:
___ w ___ afib on Xarelto, HTN, HLD, DMII, CHF, CKD, CVA x 2,
was admitted to the Acute care surgery service on ___ w LLQ
abdominal pain and anorexia with vital stable signs, left-sided
guarding and palpable bowel loops, and CT demonstrating
mesenteric free fluid, all concerning for ischemic bowel in this
patient with no past surgical history. Given his history of
xarelto, we monitored his vital signs, laboratory values, and
clinical exam closely for worsening or non-improving symptoms.
On ___, he was taken for diagnostic laparoscopy, mini
laparotomy with lysis of adhesion band and repair of umbilical
hernia. Please seem operative note for further details of the
procedure.
He tolerated the procedure well and on ___, he was started on a
regular diet without issues. He was started on all of his home
medications including his home furosemide. he had some low urine
output, which was treated by keeping his foley in place for
further monitoring and giving him IV fluids as needed. On ___,
his foley was removed and his urine output remained stable and
normal. On ___, we also restarted his xarelto.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 25 mg PO TID
4. Furosemide 20 mg PO DAILY
5. LevETIRAcetam 500 mg PO BID
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Rivaroxaban 20 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Carvedilol 25 mg PO TID
4. Furosemide 20 mg PO DAILY
5. LevETIRAcetam 500 mg PO BID
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
8. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Closed loop bowel obstruction from Adhesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to the ___ for abdominal pain, which was
determined to be secondary to ischemic bowel that was treated
with a small laparotomy with lysis of adhesions that was
identified to be causing the obstruction. ___ tolerated this
procedure well and your diet was slowly advanced and pain well
controlled
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
___ experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If ___ are vomiting and cannot keep down fluids or your
medications.
___ 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.
___ see blood or dark/black material when ___ vomit or have a
bowel movement.
___ experience burning when ___ 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.
___ 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
___.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until ___ 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 ___ have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
___ may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If ___ have staples, they will be removed at your follow-up
appointment.
*If ___ have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10357783-DS-4 | 10,357,783 | 24,705,440 | DS | 4 | 2164-03-04 00:00:00 | 2164-03-04 17:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / levofloxacin
Attending: ___
___ Complaint:
Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
============================
"Ms. ___ is a ___ year old woman with a history of AF on
Eliquis, COPD on ___ @ night, CAD with prior MI, h/o CVA (no
residual deficits), presenting with SOB and lightheadedness.
She was in her usual state of health until 5 days ago when she
started having worsening fatigue and SOB at rest. She was
following up at ID outpatient appointment today where her Hgb
was found to be 6.5 so she was referred to ED. She has
chronically black BMs (on PO iron). She denied any dark or tarry
stools. Her daughter has noted some drops of BRB on toilet seat
but never in
stool. Per daughter, last colonoscopy was several years ago and
also had EGD ___ years ago, findings unknown. Did have a prior
episode of anemia ___ years ago, thought to be GI per daughter,
although source was never found. She was started on PO iron at
that point. Last took eliquis on ___ at 1100.
Of note she gets most of her care at ___. She had
recent hospitalization at ___ from ___ for e coli
bacteremia/urosepsis and MRSA cellulitis. She completed
cellulitis treatment as outpatient with Keflex and linezolid.
In the ED,
- Initial Vitals: T 97.5, HR 81, BP ___, RR 16, SpO2 100% on
RA
- Exam: Mild conjunctival pallor, Irregularly irregular rhythm,
Abd NTND, guiac positive stools
- Labs:
EKG: AF
Hgb 5.9, Hct 18.7
INR 2.2, ___ 23.5
Lactate 1.1
Cr 1.6
- Imaging: CTA abd with and without contrast
- Consults: Seen by GI who recommended transfusing, starting PO
protonix, trend HgB. NPO at midnight for possible procedure
tomorrow. GI to see in AM.
- Interventions: 2 PIVs, IV PPI, transfuse 2 units, IV
phytonadione 5mg, Kcentra, 1g CTX IV
ROS: Positives as per HPI; otherwise negative. "
Past Medical History:
Chronic atrial fibrillation on eliquis
COPD on ___ L at night
CAD with h/o MI
Cardiomyopathy
Social History:
___
Family History:
Has daughter who is alive and healthy
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 97.6, HR 95, BP 105/71, RR 23, SpO2 100% on RA.
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. Wearing dentures.
NECK: Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy. JVP mildly elevated to 9-10cm.
CARDIAC: Irregularly irregular rhythm, normal rate. Audible S1
and S2. Systolic murmur heard best over LUSB.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. Some bruising over b/l forearms.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Oriented to person and place, not to time.
========================
DISCHARGE EXAM:
VITALS: 24 HR Data (last updated ___ @ 1551)
Temp: 98.4 (Tm 98.4), BP: 93/57 (93-128/51-73), HR: 84
(72-100), RR: 18, O2 sat: 97% (95-97), O2 delivery: RA
GENERAL: Alert and in no apparent distress, appears comfortable,
conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Mildly hard of hearing. Oropharynx without visible lesion,
erythema or exudate. Moist mucus membranes.
CV: RRR, no murmurs/rubs, no S3, no S4. 2+ radial pulses
bilaterally.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No GU catheter present
MSK: Moves all extremities, no edema or swelling
SKIN: No rashes or ulcerations noted
NEURO: Alert, face symmetric, speech fluent, moves all limbs
PSYCH: Pleasant, appropriate affect, calm, cooperative
Pertinent Results:
ON ADMISSION:
___ 11:09PM LACTATE-1.1
___ 07:40PM GLUCOSE-137* UREA N-50* CREAT-1.6* SODIUM-136
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-13
___ 07:40PM estGFR-Using this
___ 07:40PM ALT(SGPT)-40 AST(SGOT)-38 LD(LDH)-286* ALK
PHOS-77 TOT BILI-0.2
___ 07:40PM ALBUMIN-3.6
___ 07:40PM HAPTOGLOB-170
___ 07:40PM WBC-5.1 RBC-2.03* HGB-5.9* HCT-18.7* MCV-92
MCH-29.1 MCHC-31.6* RDW-13.2 RDWSD-44.3
___ 07:40PM NEUTS-55.9 ___ MONOS-11.3 EOS-0.4*
BASOS-0.4 IM ___ AbsNeut-2.83 AbsLymp-1.60 AbsMono-0.57
AbsEos-0.02* AbsBaso-0.02
___ 07:40PM PLT COUNT-78*
___ 07:40PM ___ PTT-33.4 ___
Hb: 8.3 <-- 8.4 <-- 8.4
INR 1.2 <-- 2.2
Cr: 1.2 <-- 1.2 <-- 1.6 (Baseline 1.2)
BUN: 18 <-- <-- 50
Lactate 1.0
=====================
ON DISCHARGE:
___ 01:15PM BLOOD WBC-8.2 RBC-3.09* Hgb-8.9* Hct-28.0*
MCV-91 MCH-28.8 MCHC-31.8* RDW-15.1 RDWSD-49.5* Plt ___
=====================
Urine culture ___:
ENTEROBACTER AEROGENES. >100,000 CFU/mL.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
GRAM NEGATIVE ROD #2. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood culture x2 ___: No growth to date
=====================
CTA abd with and without contrast ___:
1. No active contrast extravasation noted in the abdomen or
pelvis.
2. Diverticulosis without evidence of diverticulitis.
3. Extensive atherosclerotic calcification noted throughout the
aorta, with atherosclerotic calcification causing stenosis of
the
celiac and superior mesenteric artery origin. However, there is
no pneumatosis intestinalis or portal venous gas to suggest
acute
mesenteric ischemia.
Brief Hospital Course:
====================
PATIENT SUMMARY:
====================
Ms. ___ is a ___ year old woman with a history of chronic atrial
fibrillation on eliquis, COPD on ___ L at night, CAD with prior
MI, h/o CVA, who presented with fatigue and lightheadedness. She
presented to the ED with her daughter after about 5 days of
worsening fatigue and SOB. In the ED she was hypotensive to SBPs
in ___ and found to have Hgb of 5.9 and received 2 units PRBCs.
Her Hgb responded to 7.6 but given concern for hypotension, she
was admitted to the ___. On arrival her BPs were 100s/40-70s.
Home meds including eliquis, furosemide, losartan and diltiazem
were initially held. GI was consulted for possible scope,
however Ms. ___ HCP, her daughter, and rest of family decided
it would not be within her goals of care to pursue further
workup. She had no active signs of bleeding in the ICU and
remained hemodynamically stable. She was transferred to the
floor for further management.
====================
TRANSITIONAL ISSUES:
====================
[ ] Repeat CBC and BMP on/around ___ for monitoring anemia
and renal function
[ ] Held home ___ and Mineralocorticoid/Thiazide given SBP
100s with plan for possible resumption with PCP BP recheck
[ ] Follow up blood cultures from ___ - no growth to date'
[ ] Patient and family refused ___ services - daughter is her
caretaker and feels she can care for her mother. Case
management spoke with family and advised to call if they get
home and change mind and want ___ services.
====================
ACUTE ISSUES:
====================
#GI bleed
#Acute blood loss anemia:
#Hypotension
Hgb on admission 5.9 from baseline ~11 per daughter. Received 2
units PRBCs in the
ED with appropriate response to 7.6. BPs in 100s/70s on arrival
to the floor. No sign of active bleeding in the ICU. GI
consulted but patient and family felt not within goals of care
to pursue further work up with EGD and/or colonoscopy. Her Hb
was 8.0 on ___ and she had 3 bowel movements, so repeat CBC was
obtained and Hb was 8.9. Checked orthostatic vitals and she had
increase in SBP from 108 to 128 with sitting but decreased from
128 to 93 with standing. Discussed with her and her daughter
about giving IV fluids for hydration, rechecking BP after, to
make sure she was not dizzy. Discussed whether to keep for
another 1 day of monitoring of orthostatic vitals and CBC, but
the patient felt well and wanted to go home and her daughter was
in agreement. The patient will drink fluids by mouth per
discussion. We discussed contingency plan for returning to ED if
she has recurrent bloody or black bowel movements or multiple
bowel movements in a day or other concerning symptoms.
#Coagulopathy
#Thrombocytopenia
INR on admission 2.2 ___.5. Given phytonadione 5mg and
Kcentra. INR improved to 1.8 and Pt improved to 19.6. Unclear
baseline CBC. Possibly thrombocytopenia in part caused by recent
linezolid. Plts improved to 188 on discharge. INR was 1.2 on
___.
#Chronic atrial fibrillation:
Currently in atrial fibrillation but rates controlled in the ___
(78-102). On eliquis 5mg BID at home, last dose was ___ AM. Her
home diltiazam was held as well as her home eliquis in setting
of GIB. Discussed risk benefits of holding/resuming Apixiban
(CHADS2Vasc 7 = 11.2% annual stroke risk vs HAS-BLED 3 = 5.8%
risk of rebleed) with daughter/HCP ___ and patient. Decision
to restart Apixiban for stroke prophylaxis which was done 24
hours prior to discharge with stable Hb. She was discharged on
Apixaban with instructions to return to ED if recurrent
bleeding.
___
Cr on admission 1.6 from unknown baseline. Likely pre-renal in
setting of hypotension. Improved while in the ICU after
resuscitation and was 1.2 on discharge.
#Recent E. coli bacteremia: Discharged from ___ on ___ after
E. coli bacteremia/ urosepsis and MRSA cellulitis. Treated with
Keflex and linezolid on
discharge, course completed. UA on admission with pyuria but few
bacteria. S/p 1g Ceftriaxone IV ___ in the ED. On admission to
floor was not tachycardic, was afebrile, denied dysuria or
suprapubic TTP.
#Enterobacter aerogenes UTI: Urine culture grew with >100,000
CFU Enterobacter that was pan-sensitive except intermediate
sensitivity to Nitrofurantoin, as well as ___ CFU/mL GNR
#2. She had no classic urinary symptoms but had presented with
fatigue (though more likely due to anemia), but opted to treat
for 3 days with Bactrim. Per culture results, Enterobacter may
develop resistance to ___ generation cephalosporins and she has
Levofloxacin allergy, so chose Bactrim.
====================
CHRONIC ISSUES:
====================
#COPD: On ___ L O2 at night at home. She was not hypoxic during
daytime. Continued home inhalers, nebs PRN and montelukast
#CAD: Continued home Simvastatin 20mg QPM
#Cardiomyopathy?: Daughter reported she has been told patient
has a failing heart
although does not know further detail. Held home losartan and
Spironolactone-HCTZ given SBP 100s on discharge. Resumed home
Furosemide 20mg MWF in setting of GIB, ___, but needs careful
monitoring and would stop if she gets hypotensive or dizzy
again.
====================
Ms. ___ is clinically stable for discharge today. The total
time spent today on discharge planning, counseling and
coordination of care was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Arnuity Ellipta (fluticasone furoate) 100 mcg/actuation
inhalation DAILY
3. nystatin 100,000 unit/gram topical BID
4. Simvastatin 20 mg PO QPM
5. Apixaban 5 mg PO BID
6. spironolacton-hydrochlorothiaz ___ mg oral DAILY
7. Furosemide 20 mg PO 3X/WEEK (___)
8. Levalbuterol Neb 0.63 mg NEB BID:PRN dyspnea
9. Diltiazem Extended-Release 360 mg PO DAILY
10. Losartan Potassium 50 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
13. Ferrous Sulfate 325 mg PO DAILY
14. Xopenex HFA (levalbuterol tartrate) 45 mcg/actuation
inhalation Q6H:PRN cough
15. GuaiFENesin ER 600 mg PO BID:PRN cough
16. Nitroglycerin SL 0.4 mg SL PRN chest pain
17. Breo Ellipta (fluticasone furoate-vilanterol) 200-25
mcg/dose inhalation DAILY
Discharge Medications:
1. Senna 8.6 mg PO BID
2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
4. Apixaban 5 mg PO BID
5. Arnuity Ellipta (fluticasone furoate) 100 mcg/actuation
inhalation DAILY
6. Breo Ellipta (fluticasone furoate-vilanterol) 200-25
mcg/dose inhalation DAILY
7. Diltiazem Extended-Release 360 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Furosemide 20 mg PO 3X/WEEK (___)
10. GuaiFENesin ER 600 mg PO BID:PRN cough
11. Levalbuterol Neb 0.63 mg NEB BID:PRN dyspnea
12. Montelukast 10 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL PRN chest pain
14. nystatin 100,000 unit/gram topical BID
15. Omeprazole 40 mg PO DAILY
16. Simvastatin 20 mg PO QPM
17. Xopenex HFA (levalbuterol tartrate) 45 mcg/actuation
inhalation Q6H:PRN cough
18. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until Your PCP follow up
appointment for a blood pressure check
19. HELD- spironolacton-hydrochlorothiaz ___ mg oral DAILY
This medication was held. Do not restart
spironolacton-hydrochlorothiaz until Your PCP follow up
appointment for a blood pressure check
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Acute blood loss anemia
Hypotension
Chronic atrial fibrillation on chronic anticoagulation
Acute kidney injury
Enterobacter 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:
You were admitted for likely gastrointestinal bleed. For this
you were given 2 blood transfusions with spontaneous resolution
of the bleed. After having a thorough conversation with you and
your daughter, we respect your wishes not to have any additional
procedures/interventions done. Additionally, after weighing the
risks of a subsequent gastrointestinal bleed while on Eliquis
against the potential risk of having a stroke if not on Eliquis,
we respect your wishes to resume Eliquis.
As we discussed, please have your blood counts and kidney
function rechecked by your primary care doctor on/around
___.
Drink plenty of fluids to stay well hydrated.
It was a pleasure taking care of you
- Your ___ Team
Followup Instructions:
___
|
10357836-DS-4 | 10,357,836 | 20,410,536 | DS | 4 | 2139-06-22 00:00:00 | 2139-06-22 12:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
ACE Inhibitors / Diovan / fentanyl / hydrochlorothiazide /
Penicillins / codeine
Attending: ___
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. ___ is an ___ year-old woman receiving hospice care at
home (lung cancer) who presented to ___ after
sustaining a mechanical fall while at home. She denies any loss
of consciousness of head strike. After falling, she could not
get up on her own, so she used her medical alert button and she
was taken to the hospital by EMS. While there, she underwent a
CT of the abdomen and pelvis (concerns for hemoperitoneum) which
showed a T12 burst fracture with retropulsion. Due to both of
those issues, the patient was transferred to ___ for
further evaluation.
Mrs. ___ was cooperative on exam, but it was difficult to
obtain a detailed history from her. Medical records were
utilized to piece together the below information.
While in the ED, a CT scan of her head also revealed a small
left
external capsule intraparenchymal contusion. There was no mass
effect or shifting of structures.
ACS was consulted to address the concern for hemoperitoneum.
The
patient underwent further imaging and that issue has been ruled
out.
Medications prior to admission:
Furosemide once a day), diltiazem (once a day), lorazepam(once a
day), morphine (qd prn ), Hyoscamine oral (once a day)
Social Hx:
___
Family Hx:
Non-contributory.
ROS:
Denies headaches, changes in vision/hearing, seizures, loss of
consciousness, numbness/tingling of arms and legs.
PHYSICAL EXAM:
O: T97.8 HR 58, BP 127/64 RR 16, O2 sat 97% on 3L nasal
cannula.
Gen: WD/WN, comfortable, slightly uncomfortable due to back
pain.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
Sensation: Intact to light touch throughout.
Mid-line tenderness of spine at level of T12, L1 area.
CT abd/pelvis without contrast:
1. Unchanged burst fracture of the T12 vertebral body with mild
bony retropulsion.
2. No evidence of solid organ injury within the abdomen and
pelvis. Intermediate density fluid seen on prior noncontrast CT
corresponds to multiple decompressed small bowel loops within
the
pelvis.
3. Left basilar nodular opacities, likely reflects sequela of
chronic aspiration or atypical infection.
Non-contrast head CT:
11 x 5 x 11 mm hyperdensity within the left subinsular white
matter concerning for intraparenchymal hemorrhage, particularly
given the history of trauma. No significant mass effect. Close
clinical and imaging follow-up was recommended.
CT cspine without contrast:
1. No evidence of cervical spine fracture.
2. Severe multilevel degenerative changes including mild
anterolisthesis of C2/3 and complete loss of disc high at C3
through C7.
Labs:
WBC 12, Hgb 12, Hct 36.5, plat 225
Neut 87
___ 11.6, PTT 27.8, INR 1.1
Na 134, K 4.5, Cl 97, HCO3 26, BUN 18, Cr 0.5
Assessment/Plan:
Mrs. ___ is a ___ year-old female who presents after
sustaining a mechanical fall at home. She was found to have a
T12
burst fracture with retropulsion and a small left sided external
capsule IPH. She is currently neuro intact and full strength,
although she has low back pain.
Plan:
- Admit to Neurosurgery inpatient ward
- Pain management
- ___ quick-draw brace
- Repeat NCHCT in am to assess for interval change in IPH
- Physical therapy consult
I have reviewed this case with Dr. ___ formulated the
above plan. Thank you for this consult.
Attending Physician:
___, MD
Past Medical History:
Osteomyelitis, hypertension, left ventricular hypertrophy,
osteopenia, SIADH, hemorrhoids, peripheral vascular disease,
cancer of bronchus and lung, COPD dependent on oxygen 3l at home
All:
ACE Inhibitors, Diovan, fentanyl, HCTZ, PCN, codeine
Social History:
___
Family History:
NC
Physical Exam:
O: T97.8 HR 58, BP 127/64 RR 16, O2 sat 97% on 3L nasal
cannula.
Gen: WD/WN, comfortable, slightly uncomfortable due to back
pain.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
IP Q H AT ___ G
Sensation: Intact to light touch throughout.
Mid-line tenderness of spine at level of T12, L1 area.
CT abd/pelvis without contrast:
1. Unchanged burst fracture of the T12 vertebral body with mild
bony retropulsion.
2. No evidence of solid organ injury within the abdomen and
pelvis. Intermediate density fluid seen on prior noncontrast CT
corresponds to multiple decompressed small bowel loops within
the
pelvis.
3. Left basilar nodular opacities, likely reflects sequela of
chronic aspiration or atypical infection.
EXAM ON DISCHARGE:
Full strength in LEs. Sensation intact throughout.
Point-tenderness to T12, L1 spine. A&Ox3. Neurologically intact.
Pertinent Results:
CT abd/pelvis without contrast:
1. Unchanged burst fracture of the T12 vertebral body with mild
bony retropulsion.
2. No evidence of solid organ injury within the abdomen and
pelvis. Intermediate density fluid seen on prior noncontrast CT
corresponds to multiple decompressed small bowel loops within
the
pelvis.
3. Left basilar nodular opacities, likely reflects sequela of
chronic aspiration or atypical infection.
Non-contrast head CT:
11 x 5 x 11 mm hyperdensity within the left subinsular white
matter concerning for intraparenchymal hemorrhage, particularly
given the history of trauma. No significant mass effect. Close
clinical and imaging follow-up was recommended.
CT cspine without contrast:
1. No evidence of cervical spine fracture.
2. Severe multilevel degenerative changes including mild
anterolisthesis of C2/3 and complete loss of disc high at C3
through C7.
Labs:
WBC 12, Hgb 12, Hct 36.5, plat 225
Neut 87
___ 11.6, PTT 27.8, INR 1.1
Na 134, K 4.5, Cl 97, HCO3 26, BUN 18, Cr 0.5
___ CT head
No change in left subinsular small area of hemorrhage compared
to the previous
CT of ___.
Brief Hospital Course:
Mrs. ___ was admitted the night of ___ with an acute T-12
compression fracture. She was admitted to the neurosurgical
floor for monitoring.
On ___, the patient remained neurologically and hemodynamically
intact. A repeat head CT was obtained and her IPH was stable.
Her Aspen quick draw brace was ordered and physical therapy was
consulted.
On ___ Patient was fitted with smallest size of Aspen quick
draw brace which was still too large. Given brace is for comfort
only it was decided no bracing was necessary. ___ was consulted
to evaluate patient's mobility.
On ___, the patient was stable and there were no events over
night. She had a rehab bed available and was discharged to
rehab in stable condition. There was no need for brace after
discharge.
Medications on Admission:
Furosemide once a day), diltiazem (once a day), lorazepam(once a
day), morphine (qd prn ), Hyoscamine oral (once a day)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 10 mg PO DAILY
5. Hyoscyamine 0.125 mg SL QID
6. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed Disp #*20 Tablet Refills:*0
7. Senna 17.2 mg PO HS
8. LeVETiracetam 500 mg PO BID Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
T-12 Compression fracture
Left IPH
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Discharge Instructions
Spine Fracture
Activity
-You do not require a brace
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
You may take Ibuprofen/ Motrin for pain.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
-You have been given a prescription for keppra 500mg to be taken
twice a day. You will continue this medication for 7 days after
discharge.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10358580-DS-20 | 10,358,580 | 27,307,471 | DS | 20 | 2158-03-15 00:00:00 | 2158-03-15 16:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Cephalosporins / ceftriaxone
Attending: ___.
Chief Complaint:
respiratory distress
Very limited data is currently available to piece together the
HPI and other history.
Major Surgical or Invasive Procedure:
Placement of a PICC Line
History of Present Illness:
___ yo. ___ female with unknown handedness and unknown
medical history hx AFib, DM,
dyslipidemia, HTN, dementia), transferred from nursing home
after
developing respiratory distress and fever. Pt returned to
nursing
home after a recent admit for stroke from ___ yesterday. It was unclear what her clinical status at
the time of discharge was, although the presence of a fresh PEG
suggests that she probably had a prolonged stay and failed
speech/swallow there. I called the nursing home, and spoke to
the
nurse who saw her today but she was not able to provide me with
any insight regarding her clinical status and level of
functioning before this. It appears that yesterday (___) in pm,
pt developed a fever to 100.6 F axillary. She was noted to be
nonverbal, have heavy oral secretions, and to be in respiratory
distress. RNs initially paged an NP on call, who prescribed a
scopolamine patch. However, her distress persisted despite the
patch and vigorous suctioning, and eventually decision was made
to transfer pt back to ___. ___. However, for unclear reasons,
EMS
brought pt here. In transit, pt developed hypoxia and required
NRM. She was quickly seen by respiratory therapy here, who noted
"an intermittent but strong cough" and ability to partially
clear
airway. They suctioned "a large amount of thick, yellow sputum
from upper oropharynx, after which pt resumed quiet breathing".
Neurology was then consulted emergently.
Past Medical History:
Hypertension
Hyperlipidemia
Atrial fibrillation
Multiple previous strokes
Difficulties with anticoagulation and antiplatelet related
epistaxis and cutaneous bruising
S/p PEG tube placement
Neuromuscular dysphagia
Social History:
___
Family History:
Not contributory
Physical Exam:
On admission:
T 97.8 HR 65 BP 133/64 RR 21 O2sat 100% RA
Gen: initially appeared in moderate respiratory distress with
transmitted noisy upper airway sounds; after suctioning by RN,
appeared more comfortable
Resp: nonlabored
CV: RRR
Abd: fresh PEG tube, overlying bandage without strikethrough, no
tenderness/rigidity/guarding
Ext: WWP, DP pulses palpable
MS: arouses to tapping the shoulder, does not follow commands
but
answers a few questions appropriately (e.g., when asked whether
she speaks ___, answers "only a little", denies pain),
perseverates on the phrase "let me go"
CN: blink-to-threat decreased from right, surgical-appearing
oval
R pupil, L pupil briskly reactive, R gaze deviation that can be
partially overcome by VOR to about midline, corneals present, L
droop, gag present
Motor: flaccid LUE with some withdrawal vs reflex flexion, moves
R side spontaneously and well, brisk withdrawal of LLE
Sensory: responds to noxious throughout
Reflexes: decresed on L, absent Achilles, L toe upgoing, R d
On discharge:
Ms. ___ was mostly asleep for the duration of the entire day. She
would arouse to calling her name and open her eyes. She had a
prominent right gaze preference. At times, she would interact
with nurses and answer questions, and may occasionally follow
commands. She always recognized her family members and was more
responsive to them. The left pupil would react, and she had a
nonreactive right pupil (surgical). Plegic left arm, right arm
is mostly antigravity with a strong grasp reflex. Both lower
extremities would withdraw to noxious stimulation.
Pertinent Results:
On admission:
___ 12:50AM BLOOD WBC-9.5 RBC-3.77* Hgb-11.8* Hct-34.5*
MCV-91 MCH-31.2 MCHC-34.2 RDW-13.4 Plt ___
___ 12:50AM BLOOD Neuts-73.9* Lymphs-17.2* Monos-6.7
Eos-1.7 Baso-0.4
___ 12:50AM BLOOD ___ PTT-28.5 ___
___ 12:50AM BLOOD Glucose-252* UreaN-14 Creat-0.6 Na-136
K-4.2 Cl-99 HCO3-25 AnGap-16
___ 02:50PM BLOOD ALT-8 AST-22 CK(CPK)-671* AlkPhos-52
TotBili-0.5
___ 02:51AM BLOOD CK-MB-3 cTropnT-<0.01
___ 12:50AM BLOOD cTropnT-<0.01
___ 02:50PM BLOOD Albumin-3.6 Calcium-7.7* Phos-2.8 Mg-1.9
___ 12:50AM BLOOD Digoxin-0.6*
___ 01:00AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 01:00AM URINE RBC-12* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
___ 01:00AM URINE Color-Yellow Appear-Hazy Sp ___
On Discharge:
___ 05:30AM BLOOD WBC-7.1 RBC-3.80* Hgb-12.0 Hct-34.3*
MCV-90 MCH-31.5 MCHC-34.9 RDW-12.9 Plt ___
___ 08:56AM BLOOD Neuts-68.7 ___ Monos-8.6 Eos-3.5
Baso-0.6
___ 05:30AM BLOOD Glucose-253* UreaN-11 Creat-0.5 Na-134
K-3.8 Cl-96 HCO3-26 AnGap-16
___ 05:30AM BLOOD Calcium-7.7* Phos-2.3* Mg-1.8
___ 08:56AM BLOOD Digoxin-0.5*
MICROBIOLOGY:
___ 1:00 am URINE
URINE CULTURE (Preliminary):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
NITROFURANTOIN Susceptibility testing requested by ___
___
AT 12:15PM ON ___.
AZTREONAM Sensitivity testing per ___ ___ ___
___.
SENSITIVITIES: MIC expressed in MCG/ML
________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
______________________________________
___ 12:50 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ___ MORPHOLOGY.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0030.
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS
EKG ___:
Sinus rhythm with occasional native conduction but mostly
ventricular demand pacing. Compared to the previous tracing
findings are similar.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
60 0 92 342/342 0 -3 96
CXR ___: Pulmonary vascular engorgement.
CT Head ___:
Large late acute or subacute infarct in the right middle
cerebral artery
territory with lateral occipital involvement; the latter may be
related to a fetal PCA or other arterial variation. MRI could
help date the infart. No acute hemorrhage. Chronic infarcts in
bilateral frontal and medial right occipital lobes.
Brief Hospital Course:
Ms. ___ was admitted to the ___ Neurology Wards for new onset
fever and breathing difficulties. She lives in an elderly home
and was to at first be transferred to ___ (from where
she had originally been discharged few days prior following the
discovery of a large new stroke). In the ED, she received some
gentle suctioning which relieved her tachypnea in the ED. Labs
showed a WBC of 9.5 and a urinary tract infection, and she
received one dose of treatment with ceftriaxone. She sustained
an allergic reaction to this medication, with stridor, facial
and tongue swelling. A repeat CXR was no different from the
admission CXR, and simply showed "pulmonary vascular
engorgement". Her presumed anaphylactic reaction was addressed
aggressively with the administration of nebulizer treatments and
one dose of methylprednisolone and diphenhydramine.
She was switched to bactrim DS for a few days, but then her
urine culture sensitivities identified the growth of Proteus
that was resistant to multiple agents including bactrim and
cephalosporins. Given her allergy and the sensitivity results,
we discussed with ID team and she was switched to AZTREONAM. A
repeat UA was checked while on this medication and showed little
by way of signs of UTI. The last dose of this medication should
be on ___. For the delivery of long term antibiotics, a
PICC line was placed. Of note, blood cultures drawn at the time
of ED visit grew out GPCs, and so she was initiated on
vancomycin. However, these returned as coagulase negative staph,
and so the patient's vancomycin was discontinued.
A NCHCT done in the ED showed no new hemorrhage, but a
combination of old strokes of various ages. While in the
hospital, she was maintained on the remainder of her
medications. We obtained further history from her son that she
had been previously on warfarin and aspirin, but this caused
difficulties with epistaxis and serious cutaneous bruising. She
had been actually off of aspirin prior to her most recent
stroke, and had recently been started. From the neurological
perspective, given her recent stroke, active atrial fibrillation
and previous history of bleeding, we decided on continuing an
antiplatelet agent. Her son, ___, was updated on the day of
discharge and he agreed with this plan.
While in house, she sustained no further allergic reactions. She
had one episode of AF RVR which improved with beta blockade. Her
HR on discharge was in the 90-110 range, and so she was started
on a low dose of metoprolol for rate control. Her blood sugars
remained on the higher side (200-270) while in house, likely
related to the administration of dextrose containing agents
(aztreonam), her current infection (UTI) and non-diabetic TF
administration. The latter was switched to Glucerna 1.0 one day
prior to discharge.
Transitional issues:
- Please have the patient follow up with Dr. ___ the
___ of Stroke Neurology. We defer the remainder of her
medical care to the physicians at her facility.
Medications on Admission:
- ASA 325 mg daily
- digoxin 0.125 mg daily
- amlodipine 5 mg daily
- rosuvastatin 2.5 mg daily
- niacin XR (Niaspan) 500 mg daily
- Insulin: glargine 15 u qhs + aspart SSI
- rivastigmine (Exelon patch) 4.6 mg daily
- ranitidine 150 mg daily
- solifenacin (Vesicare) 5 mg daily
- bisacodyl PRN
- Fleet's PRN
- senna PRN
- docusate
- Ca
- artificial tears
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain / fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Amlodipine 5 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Aztreonam 1000 mg IV Q8H proteus UTI
6. Calcium Carbonate 500 mg PO TID
7. Digoxin 0.125 mg PO DAILY
8. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
9. Labetalol 200 mg PO Q6H:PRN SBP > 180
10. Metoprolol Tartrate 25 mg PO BID
11. Niacin 500 mg PO DAILY
12. Ranitidine 150 mg PO DAILY
13. Rosuvastatin Calcium 2.5 mg PO DAILY
14. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infections
Recent acute ischemic stroke
Discharge Condition:
Mental Status: ___ make some eye contact at times, variably
interacts with caregivers ___ only family)
Level of Consciousness: Lethargic.
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___ was admitted to the ___ Neurology Wards for new onset
fever and breathing difficulties. She received some gentle
suctioning which relieved her tachypnea in the ED. We found a
urinary tract infection, and she received one dose of treatment
with ceftriaxone. She sustained an allergic reaction to this
medication, with stridor, facial and tongue swelling, and she
was switched to other agents. Ultimately, she was transitioned
to AZTREONAM, based on the pattern of sensitivies. Blood
cultures grew out skin contaminants. She needs to remain on
AZTREONAM until ___. A PICC line was placed.
A NCHCT done in the ED showed no new hemorrhage, but a
combination of old strokes of various ages. While in the
hospital, she was maintained on the remainder of her
medications. Her son, ___, was updated on the day of
discharge.
Followup Instructions:
___
|
10358580-DS-22 | 10,358,580 | 23,032,063 | DS | 22 | 2158-03-29 00:00:00 | 2158-04-04 05:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / ceftriaxone
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___ rectal ulcer repair, elective endotracheal intubation and
extubation
History of Present Illness:
___ yo F w/ PMHx of multiple CVAs resulting in neuromusc
dysphagia w/ G-tube, recent admission for UTI s/p IV aztreonam
for ___ presented with AMS and fever. Pt from nursing facility w/
report of fever 101.2, lethargy, AMS compared to baseline.
Normally, pt responds to painful stimuli and occassionally
follows simple commands although she is largely nonverbal
secondary to multiple strokes.
On the floor, she was being treated for UTI with aztreonam again
and she was recieving IVF at 100 cc/hr for volume resuscitation
in the setting of soft blood pressures felt due to
cephalosporins and previous cultures grew proteus resistant to
other agents. Her blood pressures were between 100s and 120s.
___ in the morning about 10 am she had a large bowel movement
with blood clots, estimated about 200 cc. This is the only
bowel movement that she has had since then. She had a normal,
nonbloody bowel movement, overnight. She is not having any
abdominal pain and she has a ___ tube which has not had any
bloody output. It is not known if she has a history of
diverticulosis or ischemic bowel, but obviously has the history
of strokes.
On arrival to the MICU, her blood pressure is 122/66. At MS
baseline per son.
Past Medical History:
Hypertension
Hyperlipidemia
Atrial fibrillation
Multiple previous strokes
Difficulties with anticoagulation and antiplatelet related
epistaxis and cutaneous bruising
S/p ___ tube placement
Neuromuscular dysphagia
Social History:
___
Family History:
Not contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General- moderate distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP low, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, ___ tube in place, no
rebound tenderness or guarding, no organomegaly
GU- foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- non-verbal, moves upper extremities spontaneously
DISCHARGE PHYSICAL EXAM
98.3 97.4 114/57 (91-121 / 43-61) 72 (64-77) 20 98RA
I/O since MN: 610/inc, since 24h: 4000 / ___ + inc
General: Pt lying in bed, difficult to arouse
HEENT: supple neck,
CV: irregular, irregular; S1/S2, II/VI systolic murmur
Lungs: anterior clear
Abdomen: soft, nontender in limited exam, ___ in place
Ext: WWP, 2+ pulses,
Neuro: Nonverbal patient, limited neuro exam, orients to voice,
blinks to hand approaching face, moves right hand and
right-sided toes spontaneously, no movement noted of left side
Pertinent Results:
ADMISSION LABS:
___ 02:55PM BLOOD WBC-9.1 RBC-3.70* Hgb-11.3* Hct-34.2*
MCV-92 MCH-30.5 MCHC-33.0 RDW-13.6 Plt ___
___ 02:55PM BLOOD ___ PTT-26.8 ___
___ 02:55PM BLOOD Glucose-263* UreaN-28* Creat-0.7 Na-132*
K-4.6 Cl-90* HCO3-29 AnGap-18
___ 02:55PM BLOOD CK(CPK)-604*
___ 02:55PM BLOOD CK-MB-2
___ 02:55PM BLOOD cTropnT-0.05*
___ 02:52AM BLOOD cTropnT-0.03*
___ 06:45AM BLOOD Calcium-7.5* Phos-2.3* Mg-2.0
___ 02:55PM BLOOD Digoxin-0.9
___ 03:17PM BLOOD Lactate-2.3*
HEMATOCRIT TREND DURING BLEEDING:
___ 02:55PM BLOOD WBC-9.1 RBC-3.70* Hgb-11.3* Hct-34.2*
MCV-92 MCH-30.5 MCHC-33.0 RDW-13.6 Plt ___
___ 06:45AM BLOOD WBC-6.3 RBC-3.18* Hgb-9.6* Hct-29.2*
MCV-92 MCH-30.2 MCHC-32.8 RDW-13.7 Plt ___
___ 10:17AM BLOOD WBC-5.9 RBC-2.92* Hgb-9.0* Hct-26.7*
MCV-92 MCH-30.9 MCHC-33.7 RDW-13.7 Plt ___
___ 12:23PM BLOOD WBC-8.8 RBC-2.87* Hgb-8.8* Hct-26.3*
MCV-92 MCH-30.8 MCHC-33.6 RDW-13.8 Plt ___
___ 09:50PM BLOOD WBC-15.6*# RBC-3.92*# Hgb-12.0#
Hct-34.7*# MCV-89 MCH-30.7 MCHC-34.7 RDW-15.0 Plt ___
___ 2:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-7.5 RBC-3.73* Hgb-11.5* Hct-33.1*
MCV-89 MCH-30.7 MCHC-34.7 RDW-14.9 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-234* UreaN-8 Creat-0.4 Na-133
K-3.4 Cl-96 HCO3-23 AnGap-17
___ 07:15AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.6
___ 07:15AM BLOOD Digoxin-0.4*
IMAGING:
___ CT HEAD: IMPRESSION:
1. Continued evolution of the right middle cerebral artery
territorial
infarct. No evidence of a new large vascular territory infarct
or hemorrhage.
2. Chronic infarcts within the frontal lobes bilaterally, right
occipital
lobe, and left cerebellar hemisphere.
3. Unchanged chronic small vessel ischemic disease.
___ CTA ABD AND PELVIS:
IMPRESSION:
1. Active arterial bleeding at the anorectal junction.
2. There is significant pre-sacral edema and enlarged arteries
feeding the
rectum; these findings may be be due to a coinciding
inflammatory process.
The findings of active bleed were conveyed to Dr. ___
MICU on the ___ at 3: 37pm, ten minutes after discovery
of the findings. The findings of active bleed were also
discussed with Dr. ___
Gastroenterology on ___ at 3:40pm.
___ CXR: FINDINGS: As compared to the previous radiograph, the
patient has been intubated. The tip of the endotracheal tube
projects 2.3 cm above the carina. There is no evidence of
complications, notably no pneumothorax. Size of the cardiac
silhouette remains relatively large, pacemaker wires are in
unchanged position. There is no pleural effusion, pulmonary
edema, or pneumonia.
Brief Hospital Course:
Ms. ___ is an ___ year old female with history of multiple CVAs on
aspirin who was admitted for urinary tract infection and then
developed arterial bleeding from an ulcer at her anorectal
junction requiring transfusion of 4 units of RBCs and surgical
repair.
Active diagnoses:
# Anorectal ulcer: On HOD #1 she developed frequent bleeding per
rectum. She was having about 1 bowel movement per hour which
was frank blood with clots, about 200 cc volume each time. She
became hypotensive with BP ___ and was transferred to the
MICU for blood transfusions. Overall, she recieved 4 units of
RBCs, 1 unit of platelets, and one unit of FFP. She underwent a
CTA which showed arterial bleeding from teh anorectal junction.
GI performed a flexible sigmoidoscopy but were unable to ligate
the artery so she went to the operating room. They found an
ulcer and repaired this with resolution of her bleeding. Area
was packed with surgicel. On HOD3 she had ~50cc mixed
blood/stool, examined with anoscope without active bleeding.
Area was repacked with surgicel, and she remained stable during
the rest of the hospitalization.
# Urinary tract infection: T > 101 at nursing facility, and up
to 102.8 in emergency room. Source was unclear but she was
treated empirically with aztreonam for a 2 days until the urine
culture returned with only yeast. Other possible culprit was
right apical lung opacity concerning for aspiration although
this is chronic vs abdominal soft tissue infection (pus at
G-tube site). She was initiated on iv aztreoname, vanc and
flagyl. These were d/c'ed on HOD2, and she remained afebrile
throughout the rest of the hospitalization which minimized
concern for infection.
# Vascular dementia/Recent CVA: Recent stroke ___ (see ___
Neuro note) that was treated at ___ where
she required ___ tube for dysphagia and Foley. She is on tube
feeds and these were continued. She was not on anticoagulation
prior to her CVA. Head CT ___ showed late acute/subacute R MCA
territory infarct as well as chronic infarcts in bilateral
frontal and medial right occipital lobes. Lacunar and embolic
sources likely. Her aspirin was held due to rectal bleeding
above, it was restarted on HOD3. She was restarted on
rosuvastatin. Her anti-HTN medications were held in setting of
bleed, and these were notably held on discharge given patient's
normotensive blood pressures.
Chronic diagnoses:
#HTN: Evidence of white matter infarcts on prior imaging.
Anti-HTN meds were briefly held but restarted after the
hypotension from rectal bleeding had stabilized. Amlodipine 5
mg was not continued on discharge, although she may need to be
restarted on this medication if she becomes hypertensive. PRN
labetolol continued, though not administered.
#DMII: On last admission patient was discharged on 14u glargine
qHS with SSI. HbA1c was 8.9 on ___. The insulin was held while
the patient was NPO through HOD3. She was restarted on last day
of hospitalization given that she was tolerating her tube feeds.
#Atrial fibrillation: CHADS=4. On full ASA at home but was held
in setting of bleed. She has been rate controlled, with digoxin,
pacer. Metoprolol was held during hospitalization, and it can be
stopped given normotensive pressures. This can be reassessed at
provider's discretion moving forward. Metoprolol succinate 50 mg
held during hospitalization yet pt remained rate-controlled.
This medication may need to be restarted after evaluation by
physician once discharged from hospital.
#HLD: Pt remained clinically stable on home rosuvastatin and
will be monitored at her nursing home facility.
TRANSITIONAL ISSUES:
Patient will be going to ___. Goals of
care should be revisited in the outpatient setting with family.
Pt's son & HCP were called multiple times from the floor but we
were not able to establish contact.
#MEDICATION CHANGE: Patient's anti-hypertensives (amlodipine,
metoprolol) were discontinued given her normotensive pressures
during the hospilization. She also appears to have
rate-controlled A-fib with digoxin and pacer. These may be
restarted at the provider's discretion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN constipation
5. Calcium Carbonate 500 mg PO TID
6. Digoxin 0.125 mg PO DAILY
7. Labetalol 200 mg PO Q6H:PRN BP>180
8. Niacin 250 mg PO BID
9. Ranitidine 150 mg PO DAILY
10. Rosuvastatin Calcium 2.5 mg PO DAILY
11. Senna 1 TAB PO DAILY:PRN constipation
12. Vitamin D 800 UNIT PO DAILY
13. Metoprolol Tartrate 25 mg PO BID
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
15. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
16. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Calcium Carbonate 500 mg PO TID
3. Digoxin 0.125 mg PO DAILY
4. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
5. Niacin 250 mg PO BID
6. Rosuvastatin Calcium 2.5 mg PO DAILY
7. Senna 1 TAB PO DAILY:PRN constipation
8. Vitamin D 800 UNIT PO DAILY
9. Acetaminophen 650 mg PO Q4H:PRN pain
10. Aspirin 325 mg PO DAILY
11. Bisacodyl 10 mg PO DAILY:PRN constipation
12. Labetalol 200 mg PO Q6H:PRN BP>180
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: BRBPR, rectal ulcer
Secondary diagnoses: CVA, Atrial fibrillation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___
___ was a pleasure to take care of you at the ___
___. You were admitted because you were
having fevers and were more confused than usual. While we
started to treat you for a urinary tract infection, you had
significant bleeds from your rectum. You were taken to the
operating room to locate the source of your bleeding, which were
determied to be ulcers in your rectum which were sewn shut.
While you have had a little bit of blood mixed with your stool,
this would be expected. You have not had more significant
bleeds.
Please note that we continued you on your full dose aspirin.
This medication reduces your risk of stroke but unfortunately
increases your risk of bleeding events.
Followup Instructions:
___
|
10359112-DS-6 | 10,359,112 | 20,261,129 | DS | 6 | 2128-09-17 00:00:00 | 2128-09-17 19:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / Penicillins / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Hypertensive urgency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a history of clotting disorder and multiple PE's on
warfarin, CAD s/p CABG, who presents with dull frontal headache
and severe hypertension.
He reported that yesterday he began feeling unwell with a
headache. His wife took his blood pressure and was found to be
elevated 269/77. He is usually good about a low salt diet, but
in the last few days he has had some very salty meals while
eating out.
This morning, he presented to an OSH, where a ___ showed a
thrombosed left cerebellar AVM, so he was referred to ___ for
neurosurgical evaluation. Prior to transfer, he was given
hydralazine and started on a nitro gtt.
In the ED, initial vitals: 98 98 ___ 98%
He was started on nicardepine drip for hypertension given poor
control on nitro gtt.
Neurosurgery evaluated him in the ED and felt that the AVM was
an incidental finding, and recommended admission to the MICU for
ongoing management of hypertension. they did recommend an MRI
for further characterization.
Past Medical History:
- CAD, s/p CABG in ___, MI in ___, ?stent
- ?blood clotting disorder
- h/o pulmonary emboli
- s/p thyroidectomy for tumor
- s/p cholecystectomy
Social History:
___
Family History:
noncontributory
Physical Exam:
ON ADMISSION:
Vitals- 99.5 79 188/78 17 96%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, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes or excoriations
NEURO: AO x3 CN ___ grossly intact. ___ strength in upper and
lower extremities
ON DISCHARGE:
Vitals-VS 97.7, BP 154/53, P51, R20, O2 100 RA
GENERAL: Alert, oriented, no acute distress
HEENT: PERRL, EOMI, 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 murmur heart
best at left upper sternal border, no rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes or excoriations
NEURO: AO x3, CN ___ intact. ___ strength in upper and lower
extremities, no focal neurologic deficit
Pertinent Results:
ON ADMISSION:
___ 04:50PM BLOOD WBC-6.7 RBC-3.77* Hgb-12.2* Hct-36.1*
MCV-96 MCH-32.4* MCHC-33.8 RDW-14.3 Plt ___
___ 01:58AM BLOOD WBC-6.3 RBC-3.26* Hgb-10.9* Hct-31.3*
MCV-96 MCH-33.3* MCHC-34.7 RDW-14.5 Plt ___
___ 04:50PM BLOOD ___ PTT-39.9* ___
___ 04:50PM BLOOD Glucose-124* UreaN-20 Creat-1.2 Na-140
K-4.5 Cl-106 HCO3-26 AnGap-13
___ 01:58AM BLOOD Glucose-97 UreaN-20 Creat-1.2 Na-141
K-4.4 Cl-108 HCO3-25 AnGap-12
___ 04:50PM BLOOD CK(CPK)-30*
___ 04:50PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:58AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:58AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
___ 04:57PM BLOOD Lactate-1.5
ON DISCHARGE:
___ 12:02AM BLOOD WBC-4.9 RBC-3.35* Hgb-10.8* Hct-31.9*
MCV-95 MCH-32.2* MCHC-33.9 RDW-14.2 Plt ___
___ 08:50AM BLOOD ___
___ 02:09PM BLOOD Glucose-109* UreaN-32* Creat-1.4* Na-140
K-4.7 Cl-105 HCO3-26 AnGap-14
___ 12:02AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.2
IMAGING:
CXR ___:
The patient is status post median sternotomy and CABG. The heart
size is top normal. The mediastinal and hilar contours are
unremarkable. Bilateral calcified pleural plaques are seen
diffusely which limits assessment of the underlying pulmonary
parenchyma. No focal consolidation, pleural effusion or
pneumothorax is clearly demonstrated. There are no acute osseous
abnormalities.
___ MR/MRA Brain:
1. No evidence of acute intracranial hemorrhage or acute
ischemia.
2. Punctate foci of gradient signal hypointensity with
corresponding isointense T1/T2 signal within the left
cerebellopontine angle cistern, near the left flocculo-nodular
region, which could represent a vascular anomaly, such as
thrombosed AVM, given lack of flow voids on T2 imaging.
3. Occlusion or high-grade stenosis of the right middle cerebral
artery within the M1 segment.
Brief Hospital Course:
Mr. ___ is an ___ year old man with a history of clotting
disorder and multiple PE's on warfarin, CAD s/p CABG, HTN, who
presented with headaches to an outside hospital, found to have
hypertensive urgency with SBP~240's thought to be due to dietary
indiscretion.
# HYPERTENSIVE URGENCY: Patient presented to an outside hospital
for severe hypertension and headache. A non contrast head CT was
performed to look for end organ damage showed a thrombosed left
cerebellar AVM, so he was referred to ___ for neurosurgical
evaluation. Prior to transfer, he was given hydralazine and
started on a nitro drip. On arrival to ___, his BP was 202/75,
and he was transferred to the ICU and placed on a Nicardipine
drip. His blood pressure improved and he was transitioned to his
home medication regimen: amlodipine, hydralazine, losartan,
metoprolol. Blood pressure remained stable in the 150s/60s and
he was safe for discharge.
# Elevated Cr: Cr on admission 1.2, today up to 1.4. Concern for
___ in setting of hypertensive urgency vs hypovolemia. Given 1L
NS and repeat Cr 1.4. No other electrolyte abnormalities.
# Left Cerebral AVM; Incidental finding on non contrast head CT.
He had no neurologic symptoms thoughout hospitalization and
neurologic exam intact. Repeat MRI/MRA showed possible
thrombosed cerebral AVM. Per neurosurgery, no intervention
needed.
CHRONIC ISSUES:
#Hypercoagulable disorder: history of PE. No further history
available but is on chronic warfarin and INR within goal.
Continued home dose warfarin. INR at discharge 2.0.
#CAD s/p CABG: Asymptomatic since CABG many years ago . Not on
ASA. Continued Metoprolol.
#BPH: Continue finasteride and tamsulosin
#Hypothyroidism: Continue levothyroxine
=========================================================
TRANSITIONAL ISSUES:
- BP at discharge 154/53
- No change made to home blood pressure regimen: Amlodipine 10mg
daily, hydralazine 10mg TID, losartan 100mg daily, metoprolol
tartrate 25mg BID
- Would consider adding thiazide diuretic to anti-hypertensive
regimen given etiology of hypertensive urgency crisis was
dietary indiscretion.
- Cr slightly elevated at 1.4, stable. Would recommend repeating
Chem 7 at followup PCP visit to trend Creatinine.
- CT/MRI/MRA of head showed incidental finding of possible
thrombosed cerebral AVM, no surgical intervention needed.
- Chest XRAY showed pleural plaques. Patient is asymptomatic.
Has worked in ___, possibly representing asbestosis.
Recommend outpatient pulmonology follow up.
- INR at time of discharge 2.0
- Patient reported intermittent gross hematuria to the health
care team during this admission. Urinalysis during this
hospitalization with 1 RBC. Patient reports ongoing work-up with
Urology for these complaints. Would recommend continued work-up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. HydrALAzine 10 mg PO TID
4. Metoprolol Tartrate 25 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Warfarin 4 mg PO 5X/WEEK (___)
7. Tamsulosin 0.4 mg PO QHS
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Lovastatin 10 mg oral DAILY
10. Niacin 500 mg PO BID
11. Magnesium Oxide 400 mg PO BID
12. Warfarin 3 mg PO 2X/WEEK (___)
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. HydrALAzine 10 mg PO TID
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Niacin 500 mg PO BID
8. Tamsulosin 0.4 mg PO QHS
9. Warfarin 4 mg PO 5X/WEEK (___)
10. Warfarin 3 mg PO 2X/WEEK (___)
11. Lovastatin 10 mg ORAL DAILY
12. Magnesium Oxide 400 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Hypertensive urgency
Left Cerebral Arterio-venous malformation
SECONDARY DIAGNOSIS:
hypercoagulable state
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
transferred from a another hospital for very high blood
pressure. We think your blood pressure went up because you were
eating salty food. You were admitted to the ICU and placed on IV
blood pressure medication. Your blood pressure came down to your
normal range of 150s/60s and you were started on your home
medications.
Your blood pressure remained stable and you were discharged on
your home blood pressure medications.
While you were in the hospital, you had an MRI that showed an
incidenetal finding of a venous malformation. A Chest XRAY also
showed some abnormalities that should be followed up as an
outpatient. Please talk with your primary care provider about
this.
Please make sure to follow your low salt diet.
Sincerely,
Your medical team at ___
Followup Instructions:
___
|
10359443-DS-16 | 10,359,443 | 24,308,293 | DS | 16 | 2140-01-27 00:00:00 | 2140-01-27 16:26:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Pre-syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o CAD s/p PCI in ___ on Plavix and recent diagnosis of
lymphoma presents with presyncope and hematemesis.
Over the last month, the patient had been noting increased
fatigue and developed mild chest pain 2 weeks ago. This prompted
a CT scan which showed a hiatal hernia. This was followed up by
an EGD which showed multiple ulcers with biopsies c/w lymphoma.
Yesterday, the patient had undergone a PET scan and then went to
___ for a wine tour. When she came home, she felt weak
and nauseated. She then had an episode of diaphoresis and
presyncope and was brought to the emergency room. She was then
transferred from an outside hospital to BI where here Hgb was
6.4. She was hemodynamically stable in the emergency room and
had 2 episodes of hematemesis. She also had an episode of large
brown stool, unknown if it was guiac positive.
Patient is DNR/DNI and denied central line placement in the ED.
In the ED, initial vitals: 97.7 96 104/65 22 100% RA
On transfer, vitals were: 97.4 96 125/68 15 99% RA
On arrival to the MICU, she was hemodynamically stable and
complaining of nausea.
Review of systems: No chest pain or dyspnea. No lightheadedness
but +fatigue. +nausea. No abdominal pain. Review of remaining
systems otherwise negative.
Past Medical History:
CAD s/p PCI in ___
Lymphoma
Depression
Hypothyroidism
HTN
?CKD
Social History:
___
Family History:
No known history of lymphoma per her recollection.
Physical Exam:
=======================
ADMISSION EXAM
=======================
Vitals: T:
GEN: Fatigued
HEENT: sclerae anicteric, dry mucous membranes
___: Regular, no murmurs
RESP: No increased WOB, no wheezing or crackles
ABD: NTND, NABS
EXT: warm no edema
Neuro: CN ___ grossly intact, moving all 4 extremeties
=======================
DISCHARGE EXAM
=======================
Vitals: 99.0, 70s-110s, 115-127/46-76, 16, 100% on RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c, trace nonpitting edema, 2+ peripheral
pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
======================
ADMISSION LABS
======================
___ 03:30AM BLOOD WBC-8.0# RBC-2.17*# Hgb-6.4*# Hct-21.4*#
MCV-99*# MCH-29.5 MCHC-29.9*# RDW-16.6* RDWSD-57.8* Plt ___
___ 03:30AM BLOOD Neuts-85.9* Lymphs-9.8* Monos-3.4*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.90* AbsLymp-0.79*
AbsMono-0.27 AbsEos-0.01* AbsBaso-0.01
___ 04:10AM BLOOD ___ PTT-25.6 ___
___ 03:30AM BLOOD Glucose-237* UreaN-60* Creat-1.2* Na-131*
K-5.6* Cl-97 HCO3-20* AnGap-20
___ 04:25PM BLOOD ALT-27 AST-36 AlkPhos-58 TotBili-1.1
___ 04:25PM BLOOD Calcium-8.3* Phos-4.4 Mg-2.2
___ 03:52AM BLOOD Lactate-5.3*
___ 04:25PM BLOOD cTropnT-<0.01
======================
MICROBIOLOGY
======================
None
======================
IMAGING/STUDIES
======================
KUB (___): Severe degenerative changes and scoliosis of the
lower lumbar spine. No evidence of free air or of bowel
obstruction
======================
DISCHARGE LABS
======================
___ 07:55AM BLOOD WBC-6.3 RBC-3.03* Hgb-8.7* Hct-27.6*
MCV-91 MCH-28.7 MCHC-31.5* RDW-18.6* RDWSD-60.3* Plt ___
___ 07:55AM BLOOD ___ PTT-26.2 ___
___ 07:55AM BLOOD Glucose-98 UreaN-30* Creat-1.0 Na-136
K-4.3 Cl-103 HCO3-25 AnGap-12
___ 07:55AM BLOOD Calcium-8.2* Phos-1.9* Mg-2.2
___ 02:57PM BLOOD Lactate-1.8
Brief Hospital Course:
Ms. ___ is an ___ woman with a recent diagnosis of
diffuse B cell lymphoma who was admitted for acute blood loss
anemia in the setting of known esophageal/stomach secondary to
lymphoma.
=====================
ACTIVE ISSUES
=====================
# Acute blood loss anemia, Gastrointestinal bleeding: Hg on
admission was 6.4 and patient reported presyncopal symptoms
though she remained hemodynamically stable. She was admitted to
the MICU for close monitoring. She was transfused 2 units pRBCs
with appropriate increase in Hg. Likely source of UGIB is known
lesions in esophagus/stomach secondary to her lymphoma. GI was
consulted and recommended against EGD as her bleeding resolved
on its own and the lymphoma lesions are not amenable to
endoscopic treatment. After discussion with patient's
cardiologist, Plavix was discontinued. Aspirin was continued. Hg
on discharge was 8.7.
# Elevated creatinine, unknown baseline: Cr 1.2 on admission,
which improved to 1.0 after pRBC and IVF administration.
Valsartan was held and was not restarted at discharge given
normotension. In the setting of ___, K was 5.6. This normalized
with improvement in renal function.
# Hyponatremia: Na 131 on admission, likely hypovolemia given
resolution after pRBC and IVF administration.
# Elevated lactate: Lactate 5.3 on admission without anion gap.
Likely due to end organ perfusion though no recorded episodes of
hypotension. Lactate normalized after IVF.
=====================
CHRONIC ISSUES
=====================
# CAD s/p DES in ___: Aspirin and Plavix were initially held
in setting of active GI bleed. After bleeding resolved and after
discussion with her cardiologist, only aspirin was continued.
Plavix was discontinued indefinitely due to high risk of rebleed
in the setting of known lymphoma lesions.
# Hypertension: Valsartan, amlodipine, and atenolol held
initially in the setting of active GI bleed. After resolution of
bleed, atenolol and amlodipine was resumed. Valsartan held on
discharge given normotension. Patient will monitor her BP at
home and will follow-up with PCP ___: resuming valsartan.
# Large B cell lymphoma: This is a recent diagnosis. Patient has
a follow-up visit with her oncologist tomorrow for further
evaluation, which would include a bone marrow biopsy.
=========================
TRANSITIONAL ISSUES
=========================
-Discharged on omeprazole 40 mg bid given known ulcers.
-Valsartan held on discharge given normotension. Patient advised
to check her blood pressure at home and follow-up with PCP (as
scheduled) regarding resuming valsartan.
-After discussion with patient's cardiologist, Plavix was
discontinued (DES placed ___. If patient has further GI
bleeds despite discontinuation of Plavix, consider a
risk-benefit discussion regarding stopping aspirin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO QHS
2. Levothyroxine Sodium 50 mcg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Valsartan 320 mg PO DAILY
5. Clopidogrel 50 mg PO DAILY
6. Escitalopram Oxalate 20 mg PO DAILY
7. Nortriptyline 10 mg PO QHS
8. Aspirin 81 mg PO QHS
Discharge Medications:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO QHS
4. Atenolol 25 mg PO QHS
5. Escitalopram Oxalate 20 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Nortriptyline 10 mg PO QHS
8. HELD- Valsartan 320 mg PO DAILY This medication was held. Do
not restart Valsartan until you see your primary care physician.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Upper GI Bleed
Secondary diagnoses:
Diffuse large B-cell lymphoma
Coronary artery disease (CAD)
Hypertension, controlled
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted for lightheadedness
and episodes of bloody vomit. You received two blood
transfusions and were monitored in the ICU. You were also seen
by the gastroenterology team, who did not think that a repeat
endoscopy was needed. The cause of your bleed was thought to be
related to the lymphoma in your stomach. We started you on a new
medication called omeprazole to help reduce the amount of acid
your stomach makes. After discussion with your cardiologist, we
also stopped your Plavix to help reduce the risk of another
bleed. We held your valsartan on discharge; you should check
your blood pressure at home and follow-up with your primary care
physician as scheduled. She will decide when/if you need to
resume valsartan.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10359479-DS-19 | 10,359,479 | 28,433,266 | DS | 19 | 2148-05-23 00:00:00 | 2148-05-23 11:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
morphene
Attending: ___.
Chief Complaint:
Brain Mass
Major Surgical or Invasive Procedure:
___ L craniotomy for frontal tumor resection
History of Present Illness:
This is a ___ year old female with a history of breast
cancer, uterine cancer presenting from OSH after a syncopal
episode found to have a left frontal mass. The patient was at
home this morning after returning from breakfast with her
friend,
she suddenly became aphasic, went to stand up then experienced a
syncopal episode striking her ___. She was taken to OSH where
___ CT scan showed left frontal 5cm lesion with surrounding
edema and 1.4 cm of midline shift. She received mannitol 25g and
zofran prior to transport. On arrival to BI the patient is
oriented x2, MAE. Denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies focal weakness,
numbness, parasthesiae. Denies chest pain, shortness of breath.
According to the patient's daughter since ___ the patient has
experienced gait instability and expressive aphasia. She has not
seen her PCP since ___.
Past Medical History:
PMHx:
Breast Cancer
Uterine cancer
DM
Dyslipidemia
All:Morphine
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T: 97 BP: 137/70 HR:97 R 18 98% O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: atruamatic, normocephalic Pupils: 3-2mm bilaterally
EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
3-2 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
EXAM on DISCHARGE
Awake, alert, oriented, full motor
Pertinent Results:
___: MR ___ with contrast
IMPRESSION:
Enhancing left frontal extra-axial mass with significant
associated mass
effect and rightward midline shift and medialization of the left
temporal
lobe. Differential consideration remains aggressive meningioma
versus
hemangiopericytoma or dural metastasis.
___ ___
IMPRESSION:
S/p left frontal extra-axial mass resection. Resolution of left
temporal
vasogenic edema and left uncal herniation. Unchanged 15 mm
rightward shift of septum pellucidum due to persistent left
frontal vasogenic edema and extensive left extraaxial
pneumocephalus.
___ MRI with and out contrast
IMPRESSION:
1. S/p left frontal extra-axial mass resection without definite
evidence for residual tumor. Linear enhancement medial to the
superior aspect of the surgical bed is most likely located
within a sulcus. Recommend continued follow-up after blood
products in the operative bed resolve.
2. Persistent vasogenic edema in the left frontal lobe with
only minimal
decrease in rightward shift of midline structures.
Brief Hospital Course:
Mrs. ___ was admitted to the hospital under the neurosurgery
service after her ___ CT revealed a large left frontal mass.
She was placed on steroids and admitted to the ICU. She
underwent a CT of the Torso and CTA for operative planning.
Her pre-operative ICU stay was uncomplicated.
___ went ot OR last night for Frontal tumor resection,
extubated this morning O2 sats 97% on face tent. Post op ___ CT
showed resolution of L temporal vasogenic edema & L uncal
herniation. Unchanged mid line shift from previous scan. Post op
MRI showed normal post op changes with minimal enhacement around
surgical bed. On exam this morning pt is A&O X3 voice hoarsed,
speech difficutl to understand, MAE, limited strenght testing
and EOMs ___ pt very sleepy, PEERL, and follows commands.
___ Pt out of bed in chair, on room air 02 sats 97%, neuro
intact, flagged to floor today, dressing off incision to left
crani C/D/I with staples. On ___ she remained stable and was
seen by ___ which recommended rehab. On ___ she was discharge
to rehab.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Atorvastatin 20 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Levothyroxine Sodium 125 mcg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN prn
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
7. LeVETiracetam 500 mg PO BID
8. Miconazole Powder 2% 1 Appl TP TID
9. Docusate Sodium 100 mg PO BID
10. Famotidine 20 mg PO BID
11. Heparin 5000 UNIT SC TID
12. Senna 1 TAB PO BID:PRN constipation
13. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
14. Dexamethasone 3 mg PO Q8H Duration: 6 Doses
Then taper to 2mg Q8 for 6 doses then 2mg Q12 and continue until
follow-up
Tapered dose - DOWN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left frontal brain mass
Cerebral edema
Expressive aphasia
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:
Craniotomy for Tumor Excision
Dr. ___
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Dressing may be removed on Day 2 after surgery.
Your wound was closed with staples then you must wait until
after they are removed to wash your hair. You may shower before
this time using a shower cap to cover your ___.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace) &
Senna while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home.
Followup Instructions:
___
|
10359708-DS-19 | 10,359,708 | 28,528,489 | DS | 19 | 2161-06-22 00:00:00 | 2161-06-22 20:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ after fall
Major Surgical or Invasive Procedure:
___ - Right MMA embolization w/ coils
___ - Right 2-burr hole evacuation of hematoma
History of Present Illness:
___ is a ___ female who presents to ___ on
___ with a moderate TBI, with history of atrial
fibrillation on coumadin. She presents from OSH with noncontrast
head CT revealing 1.5cm right mixed density SDH with 15mm of
midline shift. Per husband/OSH reports, 5 days ago patient was
walking
with her walker which got caught on her bedspread causing her to
fall to her left side, hitting her head. She did not want to go
to the hospital, but today saw her PCP for progressive weakness
in her left arm, who referred her to the ED. She was transferred
to ___ for neurosurgical evaluation.
Past Medical History:
AFib on coumadin
Gait disturbance
LBP, with lumbar stenosis
Colon CA (adenocarcinoma)
Breast CA
HTN
Borderline DM
Pseudogout
Carotid bruit
HLD
Peripheral vascular disease
Insomnia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
-------------
O: T: 98.5 BP: 198/72 HR: 80 RR:16 O2 Sat:99%RA
GCS at the scene: ___unknown__
GCS upon Neurosurgery Evaluation: 14 Time of evaluation: 1600
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[x]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: atraumatic
Neck: supple
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date (month/year,
wrong day).
Language: Speech is slowed but not dysarthric, with good
comprehension.
If Intubated:
[ ]Cough [ ]Gag [ ]Over breathing the vent
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. RUE/BLE 4+/5. LUE appears contracted, although grip
4+/5, bi ___, tri ___, unable to abduct at shoulder.
Sensation: Intact to light touch
-------------
ON DISCHARGE:
-------------
Exam:
Lethargic, just moved from bed to chair with nursing
Opens eyes: [ ]Spontaneous [x]To voice [ ]To noxious
Orientation: [x]Person [x]Place [x]Time
Hard of hearing, requires speak loud into ear.
This AM, does not respond verbally, nods yes/no appropriately
Follows commands: [x]Simple [ ]Complex [ ]None
With a lot of encouragement and prompting
Pupils: PERRL
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [ ]No - will not cooperate
Speech Fluent: [ ]Yes [ ]No - no verbal output during NSG eval
minimal verbal output per husband
___ intact: [x]Yes [ ]No
Motor:
Antigravity x 4 with motivation
Wound:
[x]Clean, dry, intact
[x]Staples
Pertinent Results:
Please see OMR for pertinent results.
Brief Hospital Course:
#___
___ who presented ___ with right mixed density SDH with 1.5
cm midline shift. She was started on Keppra. On arrival her INR
was 2.2, she received K-centra to reverse INR. On arrival her
GCS was 14, so she was taken for MMA embolization with coils
with Dr. ___ on ___. Please see operative report in OMR for
more information. Post-op, she remained intubated and exam was
poor. She subsequently went for burr hole evacuation of the ___
on ___ with subgaleal JP drain placement. Please see separate
operative reports by Dr. ___ more information. Post-op CT
showed decrease size of SDH and improvement in midline shift. On
___, the subgaleal drain was removed. On ___, a CT of the
head was performed which was stable. She was given keppra for
seizure ppx x7 days which ended ___, but was resumed ___ for
possible seizure (L gaze deviation, non verbal and not following
commands < 5 min). EEG was negative and discontinued. Her level
of alertness continued to wax and wane, but her overall neuro
exam remained stable while on the floor. She was discharged to
acute rehab on ___.
#Dysphagia
She passed a bedside swallow, and was started on puree/honey
thick liquid diet on ___ with 1:1 supervision.
#Acute respiratory insufficiency with hypoxemia
Patient remained intubated post-operatively. She was found to
have pulmonary edema and received a dose of Lasix on ___. She
was extubated ___ and placed on high flow oxygen face mask. She
received 6mg IV Decadron x1 then started on 4mg q6h for 2 days.
She was reintubated on ___ and started on Solumedrol for
airway edema. On ___, the patient self extubated. She remained
stable on room air.
#Afib
Coumadin was held given SDH. She was continued on home digoxin
and lopressor. She was started on Aspirin 81 mg.
#Hypertension
Patients blood pressure was titrated to goal SBP <140 post-op
and then liberalized to SBP <160 on post-op day 1. She was
maintained on a nicardipine drip intermittently for blood
pressure control while in the ICU, which was weaned off as she
resumed her home BP meds.
#Hyperglycemia
Patient labs consistently had elevated blood sugars. Hemaglobin
A1c was sent and elevated. ___ was consulted and adjustments
were made to insulin per their recommendations. She was started
on lantus, which was discontinued and she was started on
glipizide (5mg qAM and 2.5mg with dinner).
#Leukocytosis
WBC was rising, she remained afebrile. CXRs were monitored given
concern for potential aspiration, but remained negative.
#High stool output
Patient was noted to have high liquid stool output on ___.
Flexiseal was placed and stool sample was sent for C.diff which
was negative. She continued to have loose stools requiring
flexiseal; C.diff was again sent which negative. Banana flakes
were added per nutrition's recommendations.
#Perianal/gluteal irritation
Associated with the high stool output, irritation, she developed
some perianal gluteal fold skin irritation and was started on
hydrocortisone 1% ointment.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. amLODIPine 10 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Digoxin 0.125 mg PO DAILY
6. HydrALAZINE 50 mg PO BID
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Warfarin Dose is Unknown PO DAILY16
10. Gabapentin 300 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. GlipiZIDE 5 mg PO QAM
5. GlipiZIDE 2.5 mg PO DINNER
6. Hydrocortisone Cream 1% 1 Appl TP QID
7. LevETIRAcetam 500 mg PO Q12H Duration: 1 Week
8. Nystatin Oral Suspension 5 mL PO QID Duration: 1 Week
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Allopurinol ___ mg PO DAILY
11. amLODIPine 10 mg PO DAILY
12. Atorvastatin 20 mg PO QPM
13. Digoxin 0.125 mg PO DAILY
14. Gabapentin 300 mg PO DAILY
15. HydrALAZINE 50 mg PO BID
16. Hydrochlorothiazide 12.5 mg PO DAILY
17. Losartan Potassium 100 mg PO DAILY
18. Metoprolol Tartrate 25 mg PO BID
19. HELD- Warfarin Dose is Unknown PO DAILY16 This medication
was held. Do not restart Warfarin until cleared to do so by your
neurosurgeon at follow-up.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Mental Status: Clear and coherent.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Surgery
You underwent a procedure called MMA embolization to prevent
further accumulation of subdural blood.
You underwent a surgery called a burr hole evacuation to have
blood removed from your brain.
Please keep your sutures or staples along your incision dry
until they are removed.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Care of the Puncture Site
You will have a small bandage over the site.
Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
Keep the site clean with soap and water and dry it carefully.
You may use a band-aid if you wish.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Ibuprofen,
Plavix, Coumadin) until cleared by the neurosurgeon.
You were started on Aspirin 81 mg daily to decrease
stroke risk in the setting of your diagnosed atrial
fibrillation. Please continue to hold your Coumadin (Warfarin)
at least until seen by your neurosurgeon in follow-up. At this
time, you may be advised to stop this medication indefinitely.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
Hyperglycemia
You were started on an oral medication for high blood
pressures during this admission. Please continue Glipizide 5mg
qAM and Glipizide 2.5mg with dinner. Please continue to check
your blood sugar before meals and before bed.
What You ___ Experience:
Mild tenderness and bruising at the puncture site (groin).
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
or puncture sites.
Fever greater than 101.5 degrees Fahrenheit
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10360069-DS-15 | 10,360,069 | 20,338,764 | DS | 15 | 2112-04-29 00:00:00 | 2112-04-29 12:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with coronary artery disease s/p CABG x 4 in
___ in ___ who presented to ___ ED with one day
history of left-sided chest, shoulder and wrist tingling.
He reports his anginal equivalent is GERD symptoms noticed
during his last MI in ___. He has had intermittent chest
tingling lasting for seconds similar to his symptoms today after
his CABG. He usually plays two sets of doubles tennis without
any symptoms.
He flew to ___ one week ago for vacation and stayed there for two
days. Over the past week, they have been traveling around
___ --> ___ and now ___ through car. He
does report history of intermittent calf pain in the past though
has had two episodes this week. No history of shortness of
breath or syncopal event.
In the ED, initial vitals are as follows: 98.4 79 117/84 18 99%
RA. Labs notable for normal CBC, Chem10 and initial set of
negative tropoinin. EKG showed inferolateral T-wave inversion.
He was given SL nitro to get chest pain free which dropped his
SBP to ___ which improved with IVF. He was subsequently admitted
to cardiology service for futher evaluation and management.
Currently, he is chest pain free.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
CABG x 4 (___)
EF of 30% on TTE in ___
Social History:
___
Family History:
Dad, living in his ___. Had CABG
Physical Exam:
Vitals - 98.0 103/70 63 18 99%RA Wt: 69.8 kg
GENERAL: Male in no acute distress
HEENT: NC/NT/Anicteric. MMM. PERRLA. EOMI. OP clear
CARDIAC: Regular rate and rhythm. No murmurs or gallops
appreciated
LUNG: CTAB
ABDOMEN: Soft, nontender and nondistended
EXT: No edema. No rash
NEURO: CN ___ intact.
DERM: No rash
Pertinent Results:
Admission:
___ 07:00PM BLOOD WBC-8.6 RBC-5.46 Hgb-17.1 Hct-50.1 MCV-92
MCH-31.2 MCHC-34.0 RDW-12.3 Plt Ct-UNABLE TO
___ 07:00PM BLOOD Neuts-77* Bands-0 Lymphs-11* Monos-7
Eos-3 Baso-1 Atyps-1* ___ Myelos-0
___ 07:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:00PM BLOOD ___ PTT-32.2 ___
___ 07:00PM BLOOD Glucose-104* UreaN-19 Creat-1.0 Na-136
K-3.8 Cl-99 HCO3-24 AnGap-17
___ 06:35AM BLOOD CK-MB-6 cTropnT-<0.01
___ 07:00PM BLOOD cTropnT-<0.01
___ 07:00PM BLOOD CK-MB-8
INDICATION: ___ man with chest pain and leg cramps in
setting of a long flight and long car race. Assess for DVT.
COMPARISONS: None.
FINDINGS: Grayscale and color Doppler sonography was performed
of the
bilateral lower extremities. Normal compressibility and flow was
seen in the common femoral, superficial feINDICATION: Chest
pain.
COMPARISON: None.
.
PA AND LATERAL VIEWS OF THE CHEST:
The patient is status post median sternotomy, coronary artery
stenting, and CABG. The heart is mildly enlarged with a left
ventricular predominance. The mediastinal and hilar contours
are normal. The lungs are clear. No pleural effusion or
pneumothorax is identified. No acute osseous abnormality is
seen.
IMPRESSION: No acute cardiopulmonary abnormality.
moral, popliteal, peroneal and posterior tibial veins
bilaterally.
IMPRESSION: No evidence of lower extremity deep venous
thrombosis.
.
No results pending at discharge.
Brief Hospital Course:
___ year old man who is 6 months s/p CABG who presents without
dynamic EKG changes, negative troponins x2, episodes of chest,
lumbar, and left shoulder discomfort lasting for several second.
Chest discomfort: Patient's pain is non-exertional. It lasts for
"seconds." The patient otherwise feels well. Pain not associated
with nausea, diaphoresis, palpitations, and not improved with
rest. The patient is very active at baseline. He plays tennis
several times a week and has been carrying around "a lot of
luggage while being on vacation in ___ Outside records from
___, show no dynamic EKG changes concerning for ischemia.
His troponins and MB were flat. He was discharged and told to
follow up with his cardiologist in ___.
Medication changes:
1. Decrease aspirin 325 from BID to Qd
Pending at discharge: None
Medications on Admission:
1. aspirin 325 mg Tablet Sig: One (1) Tablet BID DAILY (Daily).
2. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Non-cardiac chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for chest pain. We believe that your chest
pain is not cardiac in origin. Your cardiac enzymes which are a
very sensitive marker for heart attack were negative. This means
you did not have a recent heart attack. Also, your EKG changes
when compared to your prior EKGs in ___ were not concerning.
Please be sure to follow up with your Cardiologist upon to
return ___. We are making the following changes to your
medications.
1. Please take aspirin 325mg ONCE a day.
Please continue all of your normal home medications. If you
experience any of the danger signs listed below please go to the
nearest emergency department.
Followup Instructions:
___
|
10360477-DS-16 | 10,360,477 | 21,976,288 | DS | 16 | 2147-05-04 00:00:00 | 2147-05-05 16:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending: ___
Chief Complaint:
Neutropenic Fever
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy
History of Present Illness:
___ yo M with hx ESRD s/p LRRT x 2 (___) treated with
rituximab for chronic allograft rejection. Patient presented
to ED with ___ days of drenching night sweats and fever. He was
taking tylenol to supress fever but became concerned because his
doctor had told him weeks ago that he had a low white blood cell
count and should look out for infection. He checked his temp
this morning and it was 101.7. He called the transplant
department this morning, and was advised to come to the ED for
further evaluation.
He reports few other localizing symptoms. He does note a sore
throat over the past week and a severe tooth ache last week that
has subsided. He did not have any dental procedures. He denies
health care setting exposure or sick contacts other than his two
young children who go to day care. One child had an ear
infection recently and the other had a sore throat. He denies
cough, sputum, production, abdominal pain, nausea, vomiting,
diarrhea, constipation, dysuria, hematuria, urinary
urgency/frequency, rash, skin breakdown, ulcers, wounds, or
tooth pain.
Initial vitals in the ED were 98 90 145/73 18 96%RA. Patient
reported taking acetaminophen prior to arrival. His labs are
notable for WBC count 1.9K (repeat 2.3K), with zero percent
neutrophils x2. BUN/creatinine were ___. Lactate 0.7. U/A had
mild proteinuria but no pyuria or bacteriuria. CXR was clear. He
was given vancomycin and cefepime.
Full 10-system review otherwise negative except as noted above
Past Medical History:
S/p R nephrectomy ___ age ___, with reimplantation of L ureter
Developed proteinuria at age ___
ESRD ___ renal atrophy and IgA nephropathy s/p LRRT x2
-LRRT from mother on ___ failed due to IgA nephropathy in
transplanted kidney
-LRRT from sister on ___ found to have progressive
transplant glomerulopathy on ___ biopsy
-Rituximab x2 doses in ___ for presence of anti-donor antibody
Secondary Hyperparthyroidism/Renal Osteodystrophy
Hx of perforated duodenal ulcer ___, status post surgery
s/p right tonsillectomy
s/p mediastinal schwannoma removal ___ c/b Horner's syndrome
hypertension
admitted in ___ for evidence of herpes zoster
anxiety/depression
dyslipidemia
Social History:
___
Family History:
no hx of renal disease, mother is adopted but healthy and
paternal grandmother with cerebral aneurysm rupture.
Sister with multiple spleens.
Physical Exam:
ON ADMISSION:
Vitals: 98.6, 124/80, 99, 18, 99% RA
General: awake, alert, well-nourished, NAD
HEENT: no conjunctival icterus, injection or pallor, MMM, OP
clear, no exudate
Neck: supple, no JVD
Lymph: no cervical, axillary, inguinal lymphadenopathy
Lungs: CTAB no rales, wheezes or rhonchi
CV: RRR, normal S1/S2, no M/R/G
Abdomen: soft, NT/ND, +BS througout, no organomegaly
Ext: warm, symmetric 2+ pedal/radial pulses bilaterally
ON DISCHARGE:
Afebrile with stable vital signs
General: awake, alert, well-nourished, NAD
HEENT: no conjunctival icterus, injection or pallor, MMM, OP
clear, no exudate
Neck: supple, no JVD
Lymph: no cervical, axillary, inguinal lymphadenopathy
Lungs: CTAB no rales, wheezes or rhonchi
CV: RRR, normal S1/S2, no M/R/G
Abdomen: soft, NT/ND, +BS througout, no organomegaly
Ext: warm, symmetric 2+ pedal/radial pulses bilaterally
Pertinent Results:
ADMISSION:
___ 09:25PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:25PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:25PM URINE MUCOUS-RARE
___ 11:20AM tacroFK-6.1
___ 11:20AM WBC-2.3* RBC-4.51* HGB-12.7* HCT-37.8* MCV-84
MCH-28.2 MCHC-33.6 RDW-13.1
___ 11:20AM NEUTS-0 BANDS-0 LYMPHS-81* MONOS-18* EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0
___ 11:20AM I-HOS-AVAILABLE
___ 11:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 11:20AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 11:20AM URINE HYALINE-44*
___ 11:20AM URINE MUCOUS-RARE
___ 09:49AM LACTATE-0.7
___ 09:40AM GLUCOSE-111* UREA N-25* CREAT-1.3* SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
___ 09:40AM estGFR-Using this
___ 09:40AM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-1.9 URIC
ACID-9.2*
___ 09:40AM WBC-1.9* RBC-4.26* HGB-11.9* HCT-35.2* MCV-83
MCH-28.0 MCHC-33.9 RDW-13.0
___ 09:40AM NEUTS-0 BANDS-0 LYMPHS-54* MONOS-42* EOS-0
BASOS-0 ATYPS-4* ___ MYELOS-0
___ 09:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 09:40AM PLT SMR-NORMAL PLT COUNT-273
INTERIM:
___ 08:09AM BLOOD WBC-1.6* RBC-3.83* Hgb-10.8* Hct-32.1*
MCV-84 MCH-28.1 MCHC-33.6 RDW-12.9 Plt ___
___ 08:09AM BLOOD Neuts-2* Bands-0 Lymphs-77* Monos-17*
Eos-1 Baso-0 Atyps-3* ___ Myelos-0
___ 05:50AM BLOOD WBC-1.7* RBC-3.68* Hgb-10.4* Hct-30.6*
MCV-83 MCH-28.3 MCHC-34.1 RDW-12.9 Plt ___
___ 05:50AM BLOOD Neuts-3* Bands-1 Lymphs-60* Monos-22*
Eos-2 Baso-2 Atyps-10* ___ Myelos-0
___ 06:49AM BLOOD WBC-1.9* RBC-3.51* Hgb-10.0* Hct-29.6*
MCV-84 MCH-28.4 MCHC-33.7 RDW-12.8 Plt ___
___ 06:49AM BLOOD Neuts-0 Bands-0 Lymphs-67* Monos-9 Eos-2
Baso-0 Atyps-12* Metas-3* Myelos-7*
___ 10:21AM BLOOD WBC-1.4* RBC-3.91* Hgb-10.8* Hct-32.3*
MCV-83 MCH-27.7 MCHC-33.5 RDW-12.9 Plt ___
___ 10:21AM BLOOD Neuts-4* Bands-0 Lymphs-54* Monos-25*
Eos-8* Baso-1 Atyps-8* ___ Myelos-0
DISCHARGE:
___ 06:00AM BLOOD WBC-4.4# RBC-3.76* Hgb-10.5* Hct-31.2*
MCV-83 MCH-28.0 MCHC-33.7 RDW-13.2 Plt ___
___ 06:00AM BLOOD Neuts-27* Bands-0 ___ Monos-35*
Eos-3 Baso-0 ___ Myelos-0 Other-0
___ 06:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
___ 06:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:00AM BLOOD Glucose-84 UreaN-18 Creat-1.4* Na-140
K-4.7 Cl-106 HCO3-26 AnGap-13
___ 06:00AM BLOOD tacroFK-9.1
MICRO:
___ 11:20 URINE CULTURE (Final ___: NO GROWTH.
-___ 8:09 am Blood (CMV AB)
CMV IgG ANTIBODY (Final ___: Negative
CMV IgM ANTIBODY (Final ___: Negative
-___ 8:09 am Blood (EBV)
___ VIRUS VCA-IgG AB (Final ___: canceled due to
prior EBV panel
-___ 8:09 am Immunology (CMV)
CMV Viral Load (Final ___: CMV DNA not detected.
-___ 2:45 pm BONE MARROW
GRAM STAIN (Final ___: NO MICROORGANISMS SEEN.
PATHOLOLGY:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
HYPOCELLULAR LEFT-SHIFTED, MARKEDLY ERYTHROID DOMINANT BONE
MARROW WITH APOPTOTIC CELLS AND DEBRIS-LADEN MACROPHAGES, SEE
NOTE.
Note: The findings are most compatible with granulocytopenia due
to toxic/metabolic, drug or infection-related injury. Clinical
correlation is recommended.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation. Erythrocytes are slightly
decreased, normochromic, and normocytic with no significant
anisopoikilocytosis. The white blood cell count is decreased.
Neutrophils are scant. Atypical lymphocytes are noted, as well
as many with "uropods" suggestive of an activated T cell
phenotype. The platelet count appears normal. Rare large
platelets are seen. A differential shows 1% bands, 77%
lymphocytes, 20% monocytes, 1% eospinophils, 1% basophil.
Aspirate Smear:
The aspirate material is adequate for evaluation and consists of
multiple cellular spicules. M:E ratio is 0.7:1. Erythroid
precursors are proportionately increased in number and exhibit
normoblastic maturation. Myeloid precursors are proportionately
decreased in number and show left-shifted maturation.
Megakaryocytes are normal. A 300 cell manual differential
shows: 1% Blasts, 5% Promyelocytes, 8% Myelocytes, 3%
Metamyelocytes, 6% Bands/Neutrophils, 10% eosinophils, 49%
erythroids, 16% lymphocytes, 2% plasma cells.
Clot Section and Biopsy Slides:
The core biopsy material is adequate for evaluation. It
consists of a 1.0 cm core biopsy of trabecular marrow and
cortical bone and periosteum with a cellularity of ___. The
M:E ratio estimate is decreased. Erythroid precursors are
proportionately increased in number, and have overall
normoblastic maturation. Myeloid precursors are proportionately
decreased in number with left-shifted maturation.
Megakaryocytes are normal in number, with focal loose and tight
clustering. There is one small juxtatrabecular lymphoid
aggregate composed of small mature lymphocytes occupying <5% of
marrow cellularity. There are conspicuous apoptotic cells, as
well as debris-laden macrophages.
Final reports on:
Immunophenotyping - BM => Pending at discharge
BONE MARROW - CYTOGENETICS => Pending at discharge
IMAGING:
___ Radiology CHEST (PA & LAT)
FINDINGS: Frontal and lateral views of the chest were obtained.
No focal
consolidation, pleural effusion or evidence of pneumothorax is
seen. The
cardiac, mediastinal, and hilar contours are unremarkable.
IMPRESSION: No acute cardiopulmonary process
___BD & PELVIS W/O CON
CT OF THE CHEST: The thyroid gland appears homogeneous. No
supraclavicular, axillary, mediastinal, or hilar lymphadenopathy
is seen. The airways are patent to the subsegmental level. The
lungs are clear. No pleural effusion.
The heart, pericardium, and great vessels are within normal
limits.
CT OF THE ABDOMEN: The liver appears homogeneous without focal
lesions or intrahepatic biliary dilatation. The gallbladder is
unremarkable. The spleen, pancreas, and adrenal glands are
unremarkable. Left native kidney is very atrophic. Right
native kidney is not visualized. Severely atrophic right lower
quadrant transplant noted. The transplanted kidney on the left
lower quadrant demonstrates a vague area of hypodensity within
the interpolar region that is subtle and difficult to
characterize. There is no hydronephrosis. The stomach, small
bowel and colon appear unremarkable with no wall thickening or
signs of obstruction.
CT OF THE PELVIS: The urinary bladder, prostate gland and
seminal vesicles are unremarkable. No inguinal or pelvic
lymphadenopathy and no pelvic free fluid.
No suspicious bony lesions are seen.
IMPRESSION:
A vague area of hypodensity is seen within the interpolar region
of the
transplanted kidney in the left lower quadrant that is too
subtle to
characterize on this study. Ultrasound is recommended for
further followup.
___ Radiology TEETH (PANOREX FOR DENT
Review Panorex image. The image would indicate a healthy
dentition. The wisdom teeth appear to have been previously
removed. The remaining dentition is intact. There is no
indication of gross decay or infection. The bone levels appear
to be good. There is little to suggest the patient has had much
in the way of dental treatment.
Brief Hospital Course:
# Neutropenia: Patient presented with neutropenia with ANC 0.
Differential diagnosis broadly included infection, malignancy,
and medication effect. A complete infectious work up was done
without any localizing source of infection. A CT torso did not
show any localizing source of infection, CXR clear, UA no
growth, BM aspirate negative gram stain. Further evaluation CMV
viral load,negative. Blood cultures negative. Hematology
oncology was consulted for possible malignant etiology. A CT
Torso did not show any lymphadenopathy, further peripheral blood
smear without any abnormal cells. A bone marrow biopsy was
performed and pathology noted "The findings are most compatible
with granulocytopenia due to toxic/metabolic, drug or
infection-related injury." Final cytogenics and
immunophenotyping still pending. Medication side effect
ultimately decided to be most likely cause of neutropenia.
Further the patient received Rituximab in the past few months.
Other possible medications include Bactrim. The patient's
absolute neutrophil count improved to >1000 after receiving
neupogen and he was discharged off Cellcept and Bactrim with
instructions for followup.
# Fever: No clear source of infection; patient does not endorse
localizing symptoms aside from dental pain and mildly sore
throat. Infectious disease work up was negative including
urinalysis, CMV, chest x-ray, dental x-ray. Blood cultures
negative. Patient started initially on vancomycin, cefepime and
flagyl. Flagyl was started for possible oral etiology and
discontinued after dental x-ray negative. Vancomycin was
continued until ___ when patient had been afebrile for
multiple days and blood cultures had failed to grow anything.
# S/P Renal Transplant: History of ESRD s/p LRRT x2 with
presence of donor antibodies treated with rituximab in early
___, now presenting with febrile neutropenia. Patient admitted
to nephrology transplant attending. Creatninine was trended and
improved with hydration. Patient was continued on tacrolimus at
home dose with monitoring of tacrolimus level. He was also
continued on prednisone at home dose. Mycophenolate mofetil and
bactrim prophylaxis were held due to marrow suppressive
properties. Patient discharged on Prednisone and Tacrolimus for
immunosupression.
# Acute renal failure: Creatinine improved with IVF but remained
slightly elevated at discharge. Likely secondary to dehydration
from insensible losses.
CHRONIC ISSUES
# Anxiety/Depression: Continued Citalopram 10 mg PO DAILY
#Hypertension: Held Metoprolol Tartrate 25 mg PO BID but
restarted at discharge
TRANSITIONAL ISSUES
1) Final reports on Immunophenotyping and cytogenics of Bone
Marrow were Pending at discharge
2) Patient was instructed to STOP his Cellcept and his Bactrim
and otherwise continue/resume his other home medications
(including Tacrolimus/Prednisone). Care connections was working
on scheduling an appointment with Dr. ___ in the next 4
weeks.
3) Patient was given outside lab Rx for CBC with Diff and Chem 7
on ___ or ___ to be faxed to Dr. ___.
4) HBV vaccine will be needed
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
2. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg calcium- 400 unit Oral daily
3. Mycophenolate Mofetil 500 mg PO BID
4. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250 mcg
Oral daily
5. Pravastatin 10 mg PO DAILY
6. Citalopram 10 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
8. PredniSONE 5 mg PO DAILY
9. Tacrolimus 2 mg PO Q12H
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Pravastatin 10 mg PO DAILY
3. PredniSONE 5 mg PO DAILY
4. Tacrolimus 2 mg PO Q12H
5. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg calcium- 400 unit Oral daily
6. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 400-250 mcg
Oral daily
7. Metoprolol Tartrate 25 mg PO BID
8. Outpatient Lab Work
Draw on ___ or ___: CBC with Differential, Chem-7.
ICD-9: 288.00 (Neutropenia)
Please send results to Dr. ___ (Phone#: ___
Fax#: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: neutropenic fever
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 ___ at ___
___ were admitted with a fever and very low
white blood cell count. ___ were treated with antibiotics and a
medication to increase your white cell count. A bone marrow
biopsy was performed and preliminary results were not consistent
with a malignant process.
Please have labs drawn on ___ or ___ (next week) to be
followed by Dr. ___.
Medication changes:
Please note that ___ should STOP your Cellcept (mycophenolate
mofetil) and STOP your Bactrim (sulfamethoxazole-trimethoprim)
until advised by your outpatient doctors.
___ may resume your other medications as previously prescribed.
Followup Instructions:
___
|
10360824-DS-4 | 10,360,824 | 28,333,632 | DS | 4 | 2132-12-11 00:00:00 | 2132-12-14 05:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right upper quadrant abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy
History of Present Illness:
___ yo F w/ no PMH who yesterday started having vague abdominal
pain, continued to eat normally. Later last night, she started
having worse pain and had some n/v (NBNB), and then the pain
localized to RLQ. Denies fevers, chills, sweats, SOB, dysuria,
radiation of pain, ovarian problems, or any other symptoms. She
denies any prior sexually transmitted infections or PID, and she
is currently on her period.
Past Medical History:
PMH: none
PSH: none
Meds: OCP
Social History:
___
Family History:
FH: no history of UC or crohn's
Physical Exam:
VS
98.5 73 101/52 18 100RA
Gen: AAOx3
HEENT: NCAT, PERRLA, EOMI, mucosa pink, no LAD
CV: RRR no mrg
Pulm: CTA ___, no w/r/c
Abd: s/nt/nd; bsx4; inc: c/d/i
ext: no c/c/e; +2 pulses
Pertinent Results:
___ 09:23AM ___ PTT-27.8 ___
___ 06:30AM GLUCOSE-96 UREA N-7 CREAT-0.8 SODIUM-139
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-17
___ 06:30AM estGFR-Using this
___ 06:30AM ALT(SGPT)-24 AST(SGOT)-23 ALK PHOS-54 TOT
BILI-0.7
___ 06:30AM LIPASE-28
___ 06:30AM ALBUMIN-5.1
___ 06:30AM URINE HOURS-RANDOM
___ 06:30AM URINE UCG-NEGATIVE
___ 06:30AM WBC-18.0* RBC-4.91 HGB-15.0 HCT-44.9 MCV-91
MCH-30.5 MCHC-33.4 RDW-11.7 RDWSD-38.8
___ 06:30AM NEUTS-87.1* LYMPHS-6.0* MONOS-6.1 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-15.63* AbsLymp-1.07* AbsMono-1.10*
AbsEos-0.02* AbsBaso-0.06
___ 06:30AM PLT COUNT-283
___ 06:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 06:30AM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-4 TRANS EPI-<1
___ 06:30AM URINE MUCOUS-RARE
Brief Hospital Course:
___ p/w RUQ pain underwent lap appy ___. pt tolerated
procedure well and was brought back to the floor after an
uneventful stay at the PACU. For details of the procedure,
please refer to the operative note. pt was AAOx3 throughout
hospitalization. pain was initially managed with IV meds but
transitioned to po oxycodone. Cardiovascular functions were
monitored routinely noninvasively and pt was hemodynamically
stable. Pulmonary toilet was encouraged with early oob/amb and
IS. pt tolerated regular diet immediately. Her fluid balance was
recorded and electrolytes were repleted appropriately. pt was
afebrile throughout hospitalization. She was given cipro/flagyl
for 1 day. DVT ppx was given as HSQ.
Upon d/c, pt was doing well, afebrile, and hemodynamically
stable wnl. pt received discharge instructions and teaching,
along with follow up instructions. pt verbalizes agreement and
understanding of discharge plans.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours
Disp #*50 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home 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.
Followup Instructions:
___
|
10361115-DS-8 | 10,361,115 | 29,397,231 | DS | 8 | 2170-07-02 00:00:00 | 2170-07-03 00:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
exertional cp/sob
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ PMH DM (medically managed), hypertension,
dyslipidemia, who was referred by PCP to stress lab for work-up
of increasing chest pain and shortness of breath with exertion.
He reported he was in his usual state of health until
approximately 2 months ago when he started experiencing
intermittent chest pain and shortness of breath. The chest pain
would occur on exertion as well as at rest, last 30 seconds to
one minute, and spontaneously resolve. The chest pain is
retrosternal, non-radiating, not associated with nausea,
vomiting, or sweating but associated with shortness of breath.
He denies shortness of breath otherwise and also denies
orthopnea, PND, and lower extremity edema. He visited his PCP ___
___ who requested a stress test. Patient was alerted en route
while traveling from his home in ___ that the
treadmill at ___ had broken, and was referred to the ___
lab instead.
During testing, he developed chest pain and shortness of breath,
as well as 3-3.___levation in lead V2, 1-1.5 mm STE
elevation V1, V3, and aVr. These resolved with 2 min rest.
Patient was then given full dose aspirin and referred to the
___ ED.
In the ED initial vitals were: 97.9 80 181/94 18 98% RA
EKG: <1 mm STE V1, <1 mm ST F. Read as no significant change
from ___ EKG in atrius system.
Labs/studies notable for: normal cbc, coags, chem 7 (except
for elevated glucose in 200s), trop < 0.01
Patient was given: full dose aspirin in stress lab prior to
transfer, no other intervention
Vitals on transfer: 98.2 80 146/82 16 100% RA
On the floor, the patient was comfortable and in no pain. He
confirmed the history detailed above.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations,
syncope, or presyncope.
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 exertional
buttock or calf pain. Denies recent fevers, chills or rigors.
All of the other review of systems were negative.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
-Obstructive Sleep Apnea
-Diverticulosis
-History of lyme disease
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Dementia in father.
Mother dies at age ___ in a skiing accident.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.2 80 146/82 16 100% RA
GENERAL: WDWN, 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, no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAMINATION
VS: 97.7, 125/77, 77, 48, 95%RA
GENERAL: WDWN, in NAD. Oriented. Mood, affect appropriate.
HEENT: NCAT. Oral mucosa moist
NECK: Supple, no JVD.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. BS+
EXTREMITIES: No edema, nontender
Pertinent Results:
ADMISSION LABS
___ 04:16PM BLOOD WBC-6.6 RBC-5.02 Hgb-15.1 Hct-42.8 MCV-85
MCH-30.1 MCHC-35.3 RDW-12.5 RDWSD-38.0 Plt ___
___ 04:16PM BLOOD Glucose-213* UreaN-18 Creat-0.8 Na-137
K-3.7 Cl-96 HCO3-25 AnGap-20
___ 04:16PM BLOOD ___ PTT-25.6 ___
___ 04:16PM BLOOD cTropnT-<0.01
___ 05:28AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.1
PERTINENT/DISCHARGE LABS
___ 05:28AM BLOOD WBC-5.3 RBC-4.71 Hgb-14.0 Hct-40.5 MCV-86
MCH-29.7 MCHC-34.6 RDW-12.4 RDWSD-38.9 Plt ___
___ 05:28AM BLOOD Glucose-257* UreaN-16 Creat-0.9 Na-137
K-3.7 Cl-97 HCO3-29 AnGap-15
___ 05:28AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:28AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.1
STUDIES/IMAGING:
Cardiac stress test
INTERPRETATION: This ___ year old NIDDM man with h/o HTN, HL and
OSA
was referred to the lab for evaluation of exertional chest
discomfort.
He exercised for 6 minutes on modified ___ protocol and the
test
stopped due to ST elevation in the anterior leads and chest
discomfort.
That represents a poor exercise tolerance with ___ METs. At 3
minute on
exercise the patient reported a progressive ___ central chest
discomfort, which became ___ near peak exercise and resolved by
1.5
minue post-exercise. At peak exercise a 3-3.___levation
noticed in
lead V2, 1-1.___levation in leads V1, V3 and aVR as well
as a
1.5-2 mm upsloping ST segment depression in the inferolateral
leads.
These ST changes resolved by 2 minutes post-exercise. Rhythm was
sinus
with occasional isolated VPBs near peak exercise and rare
ventricular
couplets. There was a transient dropping in systolic blood
pressure at
the second stage of exercise then stayed blunted. Blunted HR
response
to exercise. ASA 325 mg given to the patient to chew one minute
post
exercise. Patient transferred to the ED by the ambulance for
further
evaluation.
IMPRESSION : Marked ST elevation with anginal symptoms to the
low
achieved workload. Nuclear report sent separately.
Cardiac Perfusion
FINDINGS: Left ventricular cavity size is normal during rest
with mild
reversible left ventricular cavity dilatation with stress.
Resting and stress perfusion images reveal a severe reversible
perfusion defect in the apex, mid and distal anterior wall, and
anteroseptal wall.
Gated images reveal akinesis in areas of perfusion defect
post-stress and normal wall motion at rest. The calculated left
ventricular ejection fraction is 60% at rest and 49% post
stress.
IMPRESSION: 1. Reversible perfusion defect in the apex,
mid-and distal
anterior wall, and anteroseptal wall with akinesis during stress
but normal wall motion during rest.
2. Mild reversible left ventricular cavity dilatation with EF
60% at rest and EF 49% with stress.
CXR
FINDINGS:
PA and lateral views the chest provided. There is no focal
consolidation or signs of edema. Hila appear mildly congested.
The cardiomediastinal
silhouette is normal. Bony structures are intact.
Brief Hospital Course:
___ PMH DM (medically managed), hypertension, dyslipidemia, who
was referred by PCP to stress lab for work-up of increasing
chest pain and shortness of breath with exertion for two months.
During testing, he developed chest pain and shortness of breath,
as well as 3-3.___levation in lead V2, 1-1.5 mm STE
elevation V1, V3, and aVr. These resolved with 2 min rest.
Patient was then given full dose aspirin and referred to the
___ ED. In the ED, his vitals were stable, a repeat EKG showed
<1 mm STE V1, <1 mm ST F, and he had two negative troponins.
Given the stress test was concerning for a high risk lesion in
the LAD, the patient was admitted for evaluation for cardiac
catheterization. Patient was started on metoprolol 50mg XL, his
atorvastatin was increased to 80mg daily, and he was continued
on Losartan and Chlorthalidone. Patient's blood glucose was in
the 200s--per patient he had been previously trying to manage
with diet alone and was just starting to discuss medical
management w/ PCP--patient was not started on oral hypoglycemics
nor insulin while admitted. It was determined that the patient
did not need an urgent catheter the day following (on the
weekend), and a cardiac catheterization on ___ was
recommended. Given the patient has been hemodynamically stable
without recurrent symptoms and desired to wait outpatient for
the catheterization, the patient was advised of the risks of
going home to ___ (where there is not a cardiac
catheter lab) with a likely high risk lesion. The patient
verbalized acceptance of the risk, and a cardiac catheterization
was planned for ___ or ___, with continued
optimal medical management (Aspirin, Atorvastatin, Metoprolol,
and Losartan).
SEE DETAILS BELOW BY PROBLEM
# Chest Pain: The symptoms of patient are suggestive of stable
angina, given short duration and self-resolution. Stress MIBI
showed reversible perfusion defect in the apex, mid-and distal
anterior wall, and anteroseptal wall with akinesis during stress
but normal wall motion during rest, highly suggestive of an LAD
lesion. Trops negative. Based on history, there is no concern
for unstable angina. Patient was managed medically on aspirin
81 mg, atorvastatin to 80, carvedilol 3.125 BID (switched to
metoprolol prior to discharge). It was determined that the
patient did not need an urgent catheter the day following (on
the weekend), and a cardiac catheterization on ___ was
recommended. Given the patient has been hemodynamically stable
without recurrent symptoms and desired to wait outpatient for
the catheterization, the patient was advised of the risks of
going home to ___ (where there is not a cardiac
catheter lab) with a likely high risk lesion. The patient
verbalized acceptance of the risk, and a cardiac catheterization
was planned for ___ or ___, with continued
optimal medical management
# DM:
blood glucose was in the 200s--per patient he had been
previously trying to manage with diet alone and was just
starting to discuss medical management w/ PCP--patient was not
started on oral hypoglycemics nor insulin while admitted
# HTN:
Well controlled during admission on home losartan and
chlorthalidone
NEW MEDICATIONS
Metoprolol 50mg XL daily
Nitroglycerin SL 0.3mg SL q5min PRN for chest pain
CHANGED MEDICATIONS
Atorvastatin 80mg daily
TRANSITIONAL ISSUES
===================
- Patient to be scheduled for cardiac catheterization on ___
or ___, and is to stay NPO from midnight the night before.
- Ensure patient continues to take medicines as prescribed (see
above)
- Monitor blood pressure and titration medications as needed
(given addition of beta ___ consider trial of removing
chlorthalidone to minimize number of medications for patient
- Minimize other cardiac risk factors, ie hyperlipidemia and
diabetes, with medication, diet, and exercise
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Losartan Potassium 100 mg PO DAILY
3. Chlorthalidone 12.5 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Chlorthalidone 12.5 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Angina, suspected Coronary artery disease
Secondary: Hypertension, Hyperlipidemia, Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at the ___
___!
Why were you admitted to the hospital?
======================================
-You had a cardiac stress test that showed you likely have
blocked arteries, and that you are at risk for having a heart
attack
What happened while you were here?
==================================
- You had blood tests and an electrocardiogram which showed you
were not having a heart attack.
- You were started on medication to help prevent a heart attack
(metoprolol)
- You were seen by a Cardiologist, who determined you did not
need an emergent cardiac catherization to evaluate your blocked
arteries (ie this weekend), but that you should get one very
___ or ___ the artery in your heart that
is likely blocked is an artery that is at higher risk for a
severe heart attack.
- In discussion with the Cardiologist of the above risks,
including the risk of going home to ___, where
there is not a cardiac catherization lab close, should you have
an emergency, and you verbalized that you accepted these risks
and agreed to return for the cardiac catherization on ___ or
___
What should you do when you leave?
==================================
- Expect to hear from scheduling ___ night or ___ morning.
If you do not hear from them, please call ___, and ask
if you are scheduled in the cardiac catheter lab.
- Do not eat or drink anything from ___ night at midnight
until your cardiac cath.
- If you have chest pain, sit down to rest and take one
nitroglycerin tablet. If continue to have pain after 5 minutes,
take another one. If you still have pain after two or three
call an ambulance.
- Continue to eat a hearty healthy and diabetic diet
- See your primary care doctor ___ endocrinologist as you
discussed) to start on medication for your diabetes
- Continue to take your medications as prescribed:
NEW MEDICATIONS
Metoprolol 50mg XL daily
CHANGED MEDICATIONS
Atorvastatin 80mg daily
We wish you all the best in your recovery!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10361120-DS-14 | 10,361,120 | 22,299,216 | DS | 14 | 2180-11-26 00:00:00 | 2180-11-26 21:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cor angio ___
History of Present Illness:
Patient is ___ gentleman with hx of CAD status post LAD
stent in ___ at ___, as well as ongoing tobacco and EtOH use,
who presented to urgent care today with chest tightness, and was
transferred to our emergency department due to concerning EKG
changes.
Patient reports that he has been having substernal chest
tightness for the last week. He states that it is on and off. He
states that often times it is triggered when he eats food. He is
not someone who normally gets reflux. The pain is located in the
substernal area, feels like pressure, is worse with eating, but
it also worse with exertion. It is not associated with
diaphoresis nausea or vomiting or shortness of breath. He states
it "feels different than his last heart attack". He does note
that if he has the pain that he walks up a set of stairs the
pain
increases in intensity. He also notes that when he was shoveling
earlier this week the pain also increased in intensity. He was
seen at urgent care where he had an EKG done and was sent here
for further evaluation. He did take 1 baby aspirin today. He has
not had any chest tightness while in the ED or up on the floor.
He denies SOB, DOE, cough, ___ edema, orthopnea, PND. He also
denies odynophagia, dysphagia, choking sensation when swallowing
liquids or solids. No unintentional weight loss.
He still smokes, although he states less than a pack a day.
Denies any posterior chest pain. Denies any palpitations or
dizziness.
In ___, patient was experiencing chest pain (which he
characterizes as less painful then his current episode) has a
positive stress test which showed nonsustained ventricular
tachycardia and ST elevations anteriorly. He was found to have
an
ostial LAD lesion which was stented with a drug-eluting stent.
ED spoke with Dr. ___ atrius cardiology. He said no
immediate cath as long as patient is pain-free. Continue on
heparin. Will cath in the morning.
Past Medical History:
1. CARDIAC RISK FACTORS
- Dyslipidemia
- Tobacco use
2. CARDIAC HISTORY
- CABG: None
- PCI: DES to ___ LAD in ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- CAD s/p PCI ___ w DES to LAD
- Basal cell carcinoma
- Hemorrhoids, internal
- Hypercholesteremia
- BPH (benign prostatic hyperplasia)
Social History:
___
Family History:
Denies any family history of cardiac disease.
Father w hx of esophageal CA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Temp: 98.5 PO BP: 137/75 L Lying HR: 68 RR: 18 O2 sat:
94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: well developed, well nourished in NAD
HEENT: sclera anicteric, MMM, OP clear
NECK: JVP at at level of clavicle, no LAD
CARDIAC: heart sounds distant, rrr, no mrg
LUNGS: CTABL, no wheezes, rales, or rhonchi, normal WOB on room
air
ABDOMEN: soft, non-tender, non-distended, bowel sounds present
GU: No foley
EXTREMITIES: warm, well perfused, no cyanosis or edema
NEURO: AOx3, face symmetric, moving all extremities antigravity
DISCHARGE PHYSICAL EXAM:
___ ___ Temp: 98.5 PO BP: 115/70 R Lying HR: 59 RR: 16 O2
sat: 93% O2 delivery: Ra
General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid upstroke and amplitude without
bruits
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time
Pertinent Results:
ADMISSION LABS:
================================
___ 03:32PM BLOOD WBC-6.8 RBC-5.04 Hgb-14.9 Hct-47.9 MCV-95
MCH-29.6 MCHC-31.1* RDW-13.7 RDWSD-47.5* Plt ___
___ 03:32PM BLOOD Neuts-67.6 ___ Monos-10.3
Eos-0.9* Baso-0.4 Im ___ AbsNeut-4.57 AbsLymp-1.37
AbsMono-0.70 AbsEos-0.06 AbsBaso-0.03
___ 03:32PM BLOOD ___ PTT-28.4 ___
___ 03:32PM BLOOD Glucose-93 UreaN-18 Creat-1.0 Na-139
K-5.1 Cl-104 HCO3-23 AnGap-12
___ 06:08PM BLOOD CK(CPK)-527*
___ 03:32PM BLOOD CK-MB-45*
___ 03:32PM BLOOD cTropnT-0.88*
___ 07:29AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.0 Mg-1.9
DISCHARGE LABS:
================================
___ 07:38AM BLOOD WBC-5.6 RBC-4.35* Hgb-13.2* Hct-41.4
MCV-95 MCH-30.3 MCHC-31.9* RDW-13.6 RDWSD-47.7* Plt ___
___ 07:38AM BLOOD ___ PTT-26.7 ___
___ 07:38AM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-139
K-4.6 Cl-108 HCO3-23 AnGap-8*
___ 07:38AM BLOOD proBNP-350*
___ 07:38AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1
OTHER PERTINENT LABS:
================================
___ 07:29AM BLOOD ALT-25 AST-40 LD(LDH)-319* CK(CPK)-374*
AlkPhos-104 TotBili-1.0
___ 06:08PM BLOOD CK-MB-39* MB Indx-7.4*
___ 06:08PM BLOOD cTropnT-0.84*
___ 11:25PM BLOOD CK-MB-31* MB Indx-7.4* cTropnT-0.94*
___ 07:29AM BLOOD CK-MB-24* MB Indx-6.4* cTropnT-0.81*
MICROBIOLOGY:
================================
None
IMAGING:
================================
___ (PA & LAT)
FINDINGS:
Lungs are slightly hyperinflated though clear without
consolidation, effusion,
or edema. Cardiomediastinal silhouette is within normal limits.
No acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
___
CONCLUSION: The left atrial volume index is mildly 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
regional left ventricular systolic dysfunction with hypokinesis
of the mid half of the inferolateral wall (see schematic) and
preserved/normal contractility of the remaining segments.
Quantitative 3D volumetric left ventricular ejection fraction is
54 %. Left ventricular cardiac index is normal (>2.5 L/ min/m2).
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with normal free wall
motion. Tricuspid annular plane systolic excursion (TAPSE) is
normal. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is mild [1+] tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is high normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction most consistent with single
vessel coronary artery disease (LCX/OM distribution). No
valvular pathology or pathologic flow identified. Normal
pulmonary artery systolic pressure.
OTHER DIAGNOSTIC:
================================
___ CARDIAC CATH
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel and is normal. This vessel bifurcates into the
Left Anterior Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. Previously deployed stent in
proximal segment is widely patent. The Septal Perforator,
arising from the proximal segment, is a small caliber vessel.
The Diagonal, arising from the proximal segment, is a medium
caliber vessel.30% stenosis in proximal segment.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. The ___ Obtuse Marginal, arising from the
proximal segment, is a large caliber vessel. There is a 100%
stenosis with evident thromnbus in the proximal and mid
segments. Right to left collaterals to distal segment. The ___
Obtuse Marginal, arising from the mid segment, is a medium
caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a 30% stenosis in the mid
segment. The Acute Marginal, arising from the proximal segment,
is a small caliber vessel. The Right Posterolateral Artery,
arising from the distal segment, is a medium caliber vessel. The
Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
Percutaneous Coronary Intervention: Percutaneous coronary
intervention (PCI) was performed on an ad hoc basis based on the
coronary angiographic findings from the diagnostic portion of
this procedure. A 6 ___ EBU3.5 guide provided adequate
support. Occluded segment OM1 crossed with a Roadrunner wire
whaich was passed into the distal segment. Predilated with a 2.0
mm balloon and then deployed a 2.5 mm x 28 mm Promus Elite DES.
Postdilated at high pressure using a 2.75 mm balloon. Final
angiography revealed normal flow, no dissection and 0% residual
stenosis.
Brief Hospital Course:
HOSPITAL COURSE
======================================================
Mr. ___ is a ___ gentleman w hx CAD s/p DES to LAD (___),
ongoing tobacco and EtOH use, presenting w/ several weeks of
chest pain/pressure with eating and exertion. Found to have
NSTEMI w/ rising enzymes, underwent cor angio ___ with 99% ___
s/p DES.
ACUTE ISSUES
======================================================
# ACS
Pt presented with intermittent substernal chest pain for 2
weeks, worse in the past few days. Presented with EKG changes
including ST depressions in V2-3, tall R wave in V1, mild STE in
V5-6. Trop and CK-MB elevated. Posterior EKG without ischemic
changes. Risk
factors CAD, active smoker, ETOH use. Trop peaked at 0.94. Cor
angio ___ with 99% ___ s/p DES. Discharged on ASA 81, atorva
80, losartan 25, metop 25.
# Borderline reduced EF
TTE showing EF 54%, LVH, mild regional systolic dysfunction c/w
single-vessel disease in LCx/OM distribution. Medications as
above.
# Chest pain w eating
Could be related to ACS vs. GERD vs. esophageal cancer (risk
factors of smoking, drinking, family hx). Improved after cath.
Consider starting pantoprazole outpatient if persistent.
CHRONIC ISSUES
======================================================
# Smoking
- Nicotine patch provided
# Etoh use
- Counseled about risks of ETOH use
TRANSITIONAL ISSUES
======================================================
[] Follow up with PCP and cardiology
[] PCP to work up pain with eating if persistent, consider PPi
New medications
- Started Atorvastatin 80 mg PO QPM
- Started Clopidogrel 75 mg PO DAILY
- Started Losartan Potassium 25 mg PO DAILY
- Started Nicotine Patch 14 mg/day TD DAILY
- Stopped Pravastatin 20 mg PO QPM
# Contact/HCP: ___, wife, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 20 mg PO QPM
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Nicotine Patch 14 mg/day TD DAILY
RX *nicotine 14 mg/24 hour Daily Disp #*30 Patch Refills:*0
5. Aspirin 81 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute coronary syndrome
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 a myocardial infarction
(heart attack). We performed a cardiac catheterization and found
a blockage in one of the arteries around your heart. We placed a
stent to open up this artery and improve blood flow.
You will need to be on several medications after this procedure,
including aspirin and Plavix. It is VERY important that you take
these medications every day, as there is a risk the artery could
close back up if you miss ___ dose.
It was a privilege to care for you in the hospital, and we wish
you all the best.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
10361129-DS-5 | 10,361,129 | 28,928,966 | DS | 5 | 2144-02-11 00:00:00 | 2144-02-11 17:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Accupril / celecoxib
Attending: ___.
Chief Complaint:
Fever, chills, myalgias, loose stools
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old elementary school ___ with a
PMHx of PMR on daily prednisone, OA, gout, HTN who presents
with myalgias, chills, and loose stool for 2 days.
The patient was in his usual state of health until ___ at 10:00
am when he developed acute onset joint aches in his shoulders
and hips b/l. He also reported associated chills, dark urine,
and several episodes of watery diarrhea for two days. Due to his
body aches he took an extra dose of prednisone overnight. He
reports fever which began this morning prompting presentation to
___. He reports that he had a skin biopsy with
cryotherapy that he was dressing daily with neosporin. He noted
worsening erythema and significant edema
of the LUE over the past two days.
He denies any chest pain, dyspnea, cough, blurry vision, HA, jaw
claudication, abdominal pain, dysuria.
He presented to ___ who referred him where CXR not
consistent with pneumonia. Outside labs notable for
hyponatremia at 132, creatinine of 1.28, magnesium of 1.47, AST
of 85, ALT of 78, T bili of 1.16, white blood cell count of 15.1
with 94.9% neutrophils, CRP of 310, ESR of 25, UA with 25 leuks,
negative nitrites, ___ white blood cells, trace bacteria. Flu
A/B neg.
In the ED:
- Initial vitals:
T 98.0 HR 89 BP 129/62 RR 18 SPO2 96% RA
- Exam notable for:
General: Patient lying in bed, pleasant, no apparent distress,
awake aware and oriented ×3
HEENT: Atraumatic, Moist mucous membranes, pupils equal and
reactive bilaterally, no JVD
Cardiovascular: Regular rate and rhythm no murmurs rubs or
gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft nontender nondistended, no rebound or guarding
Extremities: 2+ pulses bilaterally
Neuro: ___ strength bilaterally in UE and ___. SLTIT.
Rectal: Brown stool, heme positive
L hand: 2 x 3 cm area of cellulitis surrounding an area of loose
area of skin. No fluctuance. No signs of flexor tenosynovitis
- Labs notable for:
CBC: WBC 12.1 Hb 13.2 , CHEM 7: K 3.9 BUN/Cr ___, Lactate:
2.6 - > 1.4, CRP: >300, LFTs: ALT 87 AST 74, UA: few bact. 30
prot
- Imaging notable for:
+ Hand PA, Lat, Oblique
IMPRESSION:
No gas found in soft tissues. No evidence of acute bony
abnormality.
+ Liver U/S
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
2. Splenomegaly measuring up to 14.2 cm
- Pt given:
IV CefTRIAXone 1 g, LR 1000 mL, IV Vancomycin 1000 mg
- Vitals prior to transfer:
T 100.1 HR 102 BP 150/84 RR 18 SPO2 97% RA
Upon arrival to the floor, the patient reports pain in hips and
shoulders that started two days ago, loose stool up to twice
daily, and the development of fevers and chills today. He
reports that five days ago he had a skin biopsy that he thought
was concerning for a BCC likely treated by ED&C. He has been
putting neosporin on lesion and dressing it with gauze daily. He
notes
worsening erythema, pain and edema of the entire dorsum of his
hand. He has had no abdominal pain. No nausea or vomiting. He
reports dark "orange" colored urine. No dysuria.
Past Medical History:
Polymyalgia rhematica
Hyperlipidemia
Hypertension
L Knee Osteoarthritis
Gout
Cervical spine pain
Obstructive sleep apnea
Social History:
___
Family History:
Mother: ___
Father: MI
___ Ca
Sister: CVA
Physical ___:
Admission Physical Exam
========================
VITALS: ___ 0020 Temp: 102.4 PO BP: 158/83 L Lying HR: 115
RR: 18 O2 sat: 95% O2 delivery: ra
General: Alert, oriented, in no acute distress.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not measured secondary to habitus, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
Abdomen: Normoactive bowel sounds. Obese. Soft, non-tender,
non-distended, no rebound or guarding, no masses.
Ext: WWP. LUE with 1+ edema of hand, wrist. Palpable radial
pulse. L hand with limited extension and flexion of MCP/PIP/DIP
and ___ swelling. Sensation grossly in tact in the LUE.
Skin: Skin type II. LUE with 2x2cm blister on dorsum of hand
filled with clear fluid, with mild surrounding erythema. Minimal
tenderness surrounding blister; no tenderness of the upper arm,
forearm or palmar spaces. No crepitus. R thigh with dessicated
lesion with surrounding pink erythema. Scaly, erythematous
papules on face/hands c/w AK.
Neuro: A&O x3. No gross focal deficits.
Discharge Physical Exam
========================
24 HR Data (last updated ___ @ 812)
Temp: 98.9 (Tm 99.6), BP: 165/83 (132-165/76-83), HR: 75
(75-89), RR: 18, O2 sat: 96% (95-96), Wt: 243.8 lb/110.59 kg
General: Alert, oriented, in no acute distress.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not measured secondary to habitus, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
Abdomen: Normoactive bowel sounds. Obese. Soft, non-tender,
non-distended, no rebound or guarding, no masses.
Ext: WWP. Palpable radial pulse. L hand with in tact extension
and flexion of MCP/PIP/DIP, with minimal swelling. Sensation
grossly in tact in the LUE.
Skin: Skin type II. LUE with 2x2cm blister on dorsum of hand,
drained, with mild surrounding erythema. Minimal tenderness
surrounding blister; no tenderness of the upper arm, forearm or
palmar spaces. No crepitus. R thigh with dessicated lesion with
surrounding pink erythema. Scaly, erythematous papules on
face/hands c/w AK.
Neuro: A&O x3. No gross focal deficits.
Pertinent Results:
ADMISSION LABS
___ 03:57PM BLOOD WBC-12.1* RBC-4.53* Hgb-13.2* Hct-39.8*
MCV-88 MCH-29.1 MCHC-33.2 RDW-12.9 RDWSD-41.1 Plt ___
___ 03:57PM BLOOD Neuts-93.9* Lymphs-1.2* Monos-1.8*
Eos-2.2 Baso-0.2 Im ___ AbsNeut-11.32* AbsLymp-0.15*
AbsMono-0.22 AbsEos-0.27 AbsBaso-0.02
___ 03:57PM BLOOD Glucose-121* UreaN-31* Creat-1.6* Na-138
K-3.9 Cl-98 HCO3-25 AnGap-15
___ 03:57PM BLOOD ALT-87* AST-74* AlkPhos-73 TotBili-1.1
___ 03:57PM BLOOD Albumin-3.9 Calcium-8.4 Phos-3.6 Mg-2.1
___ 03:57PM BLOOD CRP-GREATHER T
___ 04:27PM BLOOD Lactate-2.6*
CULTURES AND SEROLOGIES
___ 01:28AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
IgM HAV-NEG
___ 01:28AM BLOOD HCV Ab-NEG
IMAGING
XRay - Left Hand (___)
Soft tissues are swollen, but no gas is found. There is no
evidence for
fracture, dislocation or lysis.
RUQ Ultrasound (___)
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
2. Splenomegaly measuring up to 14.2 cm.
CT Left Upper Extremity (___)
2.2 x 0.6 x 1.8 cm raise lesion extending from the skin surface
of the dorsum of the hand without a deep component. Associated
moderate edema and skin thickening about the dorsum of the hand.
No deep fluid collection or subcutaneous gas. No bony erosion
or evidence of osteomyelitis.
LUE Venous Ultrasound (___)
No evidence of deep vein thrombosis in the left upper extremity.
C. difficile PCR (Final ___:
NEGATIVE.
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS
___ 06:06AM BLOOD WBC-9.8 RBC-4.00* Hgb-11.7* Hct-34.8*
MCV-87 MCH-29.3 MCHC-33.6 RDW-12.8 RDWSD-40.9 Plt ___
___ 06:06AM BLOOD ___
___ 06:06AM BLOOD Glucose-167* UreaN-11 Creat-0.8 Na-141
K-3.3* Cl-103 HCO3-24 AnGap-14
___ 06:06AM BLOOD ALT-268* AST-124* AlkPhos-135*
TotBili-1.7*
___ 06:06AM BLOOD Calcium-8.6 Phos-1.7* Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ year old man with PMHx of PMR, cervical
stenosis, HTN, HLD, OA, gout presenting with myalgias and LUE
swelling and blistering after recent cryotherapy, with concern
for sepsis.
ACUTE/ACTIVE PROBLEMS:
======================
#Concern for viral infection vs. left hand complicated SSTI
Patient initially presented with sepsis with a WBC 15.1, fever
to 102, and tachycardia. He additionally had a CRP>300,
hyponatremia, ___, anemia, thrombocytopenia, and a mild
transaminitis. He was placed on a broad antibiotic regimen of
vanc/ceftriaxone/flagyl. Initially, presentation was thought to
be secondary to left hand SSTI following recent cryotherapy -
given the blistering, erythema, and swelling of his L hand as
seen on exam. However, LUE CT and US were unconcerning for an
acute, necrotizing infection; in addition, hand surgery and
dermatology did not believe that his hand findings were likely
the cause of his sepsis - as they more likely consistent with
post-cryotherapy changes. Other etiologies of his sepsis that
were examined included a PMR flare, which rheumatology deemed
unlikely, as well as a bacterial gastroenteritis, which resulted
in negative c.diff and stool cultures. In addition, hepatitis
panels and flu test was negative. Due to lack of concern of an
overt bacterial infection, patient was taken off of antibiotics.
He improved clinically off of antibiotics. Given the negative
findings of his extensive hospital work-up, his presentation was
thought to be likely due to a viral illness.
#Transaminitis
Patient has acute transaminitis that gradually worsened
throughout his hosptialization. Additionally, he was found to
have liver steatosis and splenomegaly on Abd US. Hepatitis labs
were negative. The etiology of his transaminitis is likely
secondary to his acute viral illness. He will follow-up with
LFTs and a PCP visit as an outpatient to trend his
transaminitis.
#Thrombocytopenia
Patient had acute thrombocytopenia that improved throughout his
hospitalization. This was likely secondary to his acute viral
illness, but could additionally be due to new liver pathology in
the setting of liver steatosis and splenomegaly found on
ultrasound. He will follow-up with CBC and a PCP visit as an
outpatient.
# ___
Patient had an acute ___, with Cr elevated to 1.6 from baseline
~1. Following IVF, his ___ improved. This was likely pre-renal
in the setting of diarrhea and poor PO intake. His Cr at
discharge was 0.8.
# Hyponatremia
Patient was hyponatremic to Na 132 on presentation to
___. Following IVF, his hyponatremia resolved. This was
likely secondary to dehydration in the setting of diarrhea and
poor PO intake. His Na at discharge was 141.
# PMR
Patient has symptoms of hip/shoulder pain that is consistent
with a PMR flare. He also had an elevated CRP >300. He was
continued on prednisone 9mg daily and hydroxychloroquine. On
___, patient's prednisone was increased to 15mg daily, and his
hydroxychloroquine was discontinued in the setting of his
transaminitis.
CHRONIC/STABLE PROBLEMS
=======================
# HLD: Patient's home simvastatin was initially held in the
setting of his transaminitis. It was restarted at time of
discharge.
# HTN: Patient's home anti-hypertensives were initially held in
the setting of sepsis. These were restarted at time of
discharge.
Transitional Issues
===================
[] Patient will need CBC, BMP, LFT trended after discharge in
the next ___ days with outpatient follow-up with his PCP, he was
provided with a prescription for this.
[] Patient will need follow up with a
gastroenterologist/hepatologist given his splenomegaly and
thrombocytopenia. He may benefit from a fibroscan.
[] Patient will need to follow up with his PCP regarding need
for ___ vaccines.
[] Patient will continue current prednisone 15 mg daily regimen
until he sees his outpatient rheumatologist
Medications on Admission:
1. PredniSONE 9 mg PO DAILY
2. valsartan-hydrochlorothiazide 320-25 mg oral DAILY
3. Allopurinol ___ mg PO DAILY
4. Alendronate Sodium 70 mg PO Frequency is Unknown
5. amLODIPine 5 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
8. Hydroxychloroquine Sulfate 200 mg PO BID
Discharge Medications:
1. PredniSONE 15 mg PO DAILY
RX *prednisone 5 mg 3 tablet(s) by mouth once a day Disp #*84
Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral BID
5. Simvastatin 20 mg PO QPM
6. valsartan-hydrochlorothiazide 320-25 mg oral DAILY
7. HELD- Hydroxychloroquine Sulfate 200 mg PO BID This
medication was held. Do not restart Hydroxychloroquine Sulfate
until you see your rheumatologist
8.Outpatient Lab Work
ICD: D69.6, N17.9, R74.0
CBC, Cr/BUN, AST, ALT, Alk phos, T bili
Fax results to: ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
Acute viral infection c/b SIRS, ___, Thrombocytopenia, and
Hepatitis
SECONDARY DIAGNOSES:
====================
Polymyalgia Rheumatica
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 being involved in your care.
Why you were hospitalized:
==========================
- You had fevers, muscle aches, and lab abnormalities concerning
for an infection.
What happened in the hospital:
==============================
- You were given IV antibiotics.
- You were seen by hand surgery and dermatology, who felt that
your recent hand procedure was not causing your illness.
- Your antibiotics were stopped.
- You became better with time, suggesting that you had a viral
illness.
What to do when you leave the hospital:
=======================================
- Take all of your medications as described below.
- Attend all of your follow-up appointments.
We wish you the best!
Your ___ Team
Followup Instructions:
___
|
10361310-DS-7 | 10,361,310 | 23,864,255 | DS | 7 | 2133-07-18 00:00:00 | 2133-07-18 13:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Clindamycin
Attending: ___
Chief Complaint:
___ yo man s/p fall and resultant intracranial hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year-old right-handed man with a PMHx of
HTN
who presents after a fall with a right SDH and small amount of
midline SAH. Per his report he was trying to rip the cardboard
off of a washing machine box and fell three feet and hit the
back
of his head against a pickup truck. His wife, who was with him
says he looked unconsicous for a few seconds, but then was awake
and not confused. Patient denies LOC.
The patient was able to get up and finish watching the washing
machine be installed however complained of unsteady gait and
dizzy thus reason for seeking medical attention. Patient
presented to ___ where they did a ___ which
showed a right SDH and small amount of midline SAH. Patient was
placed in a c-collar due to complaints of bilateral finger
tingling. Patient was transfered to ___ for further evaluation
and care.
Past Medical History:
-HTN
-depression
-s/p motorcycle accident in ___ w/ resultant arthritis in
shoulders and nerve damage at the shoulders. He his his head,
but denies brain injury.
- s/p right first finger amputation from necrotizing fascitis in
___
-OSA on CPAP
- Prior Substance abuse - cocaine, heroin, clonazepam,
oxycodone.
- Necrotizing fasciitis s/p injury at work to finger, admitted
___. Complicated by TSS/DIC with GAS, ARDS, multiorgan failure
- Bipolar disorder
- MRSA colonization
Social History:
___
Family History:
Diabetes. Cancer in father. ___ and depression.
Physical Exam:
UPON DISCHARGE:
Alert and oriented x 3. PEARL 2 brisk. EOM intact. Speech clear
and appropriate, no dysarthria or aphasia noted. Patient follows
commands, ___ strengths in all muscle groups bilaterally. Face
symmetric, no drift, tongue midline. Sensory intact. No
tingling/numbness.
Pertinent Results:
CT HEAD W/O CONTRAST ___ 8:26 AM:
IMPRESSION:
1. Interval development of bifrontal intraparenchymal
hemorrhage, right
greater than left, with mild local mass effect.
2. Unchanged subdural hematoma along the right frontoparietal
convexity and falx.
3. Stable, mild left midline shift without evidence for
impending downward herniation.
CT HEAD: ___ 9 ___
IMPRESSION:
1. Slight interval increase in right subdural hematoma as
described.
2. Stable 3 mm right to left midline shift.
3. Stable right and left frontal intraparenchymal and left
frontal subdural hemorrhages.
4. No new hemorrhages identified.
5. Grossly stable, approximate 1 cm pineal cyst.
MRI OF HEAD W CONTRAST: ___
IMPRESSION:
1. Unchanged appearance of 5 cm right frontal and 1.5 cm left
frontal
parenchymal hemorrhages. Right hemispheric subdural hematoma
measure
approximately 3 mm greatest thickness is also unchanged. No new
hemorrhages are identified.
2. Unchanged mass effect on surrounding structures from the
right frontal lobe hemorrhage.
3. There are periventricular and subcortical T2/FLAIR white
matter
hyperintensities which are nonspecific, but commonly seen in
setting chronic microangiopathy.
4. There is no underlying enhancement within the parenchymal
hemorrhage to suggests mass.
MRI OF CERVICAL SPINE: w/o CONTRAST
1. No significant spinal canal or neural foraminal narrowing.
2. No evidence for ligamentous injury, prevertebral or epidural
hematoma.
Brief Hospital Course:
On ___, the patient was transferred to ___ from an outside
hospital due to a right SDH and small amount of midline SAH
after a fall. The patient was admitted to the ICU for medical
management and stabilization. He was extubated later in the
evening and neurologically intact.
On ___, the patient remained neurologically and hemodynamically
intact. An MRI of head and cervical spine was ordered which
showed no canal, neural foraminal narrowing or ligamentous
injury; stable hemorrhage, no mass. His blood pressure was in
the high 150's and was given labetalol, hydralazine and
enalapril prn. He was re-started on his home antihypertensives.
His blood pressure was liberalized to less than 160. His collar
was maintained until after the MRI of the cervical spine, his
paraesthesia's to bilateral upper fingers were improving. He was
written for transfer to the floor.
On ___, patient complained of nausea but resolved with
medication. It was noted that when the patient is sleeping, the
patients HR HR dipping into ___. Cardiology consult was
completed and recommended continue telemetry as an inpatient and
to have the patient follow up with PCP/Cardiology as an
outpatient for a Holter Monitor. Neck MRI negative for spinal
canal, neural foraminal narrowing or ligamentous injury and
Brain MRIs negative for mass, stable hemorrhages. Collar d/c'd.
On ___, patient continued to be neurologically stable. Patient
continued to complain of headache with minimal relief from
oxycodone - patient was started on Fiorcet with good effect.
On ___, patient continues to be neurologcially stable. Physical
Therapy saw the patient and cleared the patient to go home with
supervision with stairs.
Medications on Admission:
- lisinopril ? dose QD
- amlodipine 10mg QD
- citalopram 60mg QD
- buspirone 2 tabs (? dose) TID
- neurontin 100mg TID
- ibuprofen PRN (about every other day) 800mg
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN HA
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every six (6) hours Disp #*40 Tablet
Refills:*0
2. Amlodipine 10 mg PO DAILY
3. BusPIRone 10 mg PO TID
4. Citalopram 60 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Gabapentin 100 mg PO TID
7. Hydrochlorothiazide 25 mg PO DAILY
8. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Lisinopril 20 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right Frontal IPH. Right parietal SDH. Traumatic Brain Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptoms after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
10361825-DS-18 | 10,361,825 | 29,197,528 | DS | 18 | 2113-03-18 00:00:00 | 2113-03-21 20:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / Lovenox
Attending: ___.
Chief Complaint:
Hemetemesis
Major Surgical or Invasive Procedure:
Endoscopy ___
History of Present Illness:
Pt is a ___ yo M with PMH of EtOH cirrhosis c/b grade I varices
and encephalopathy, mech AVR on warfarin, CAD, HTN, h/o CVA,
ventral hernia s/p multiple repairs, PBC vs. sclerosing
cholangitis, and ___ fistula, who presents with
complaint of hemoptysis/hematemesis.
Pt reports spitting up blood X 2 days, unable to quantify amt or
whether he feels he is coughing or vomiting. On day before
presentation he was noted to have a hct drop to 19 from 25 on
___. Has been supratherapeutic to 4.8 on ___, 4.7 on ___. Pt
denies any chest pain or fevers. Pt states he has had similar
episodes before due to dry sinuses.
Of note, pt has complicated colocutaneous fistula ___ infected
hematoma s/p hernia surgery. Originally managed w/ wound vac,
now w/ wet-to-drys. On TPN through PICC for bowel rest. Had bcxs
drawn ___ for unclear reasons that grew out MRSA, PICC d/c'd and
tip cxed w/ also grew MRSA. Has been treated w/ 1250 vancomycin
Q24H since that time, PICC reinserted.
Vitals in the ED: 97.0 67 121/64 18 95%. Labs were notable for:
Hgb 8.6 Hct 25.8 AP 413 Tbili 1.8 Alb 2.1 INR 2.5 PTT 44.3 ___
27.2. He was given vancomycin, azithromycin, and ceftriaxone.
On arrival to the MICU, pt was c/o pain, no specific site. VSS.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
Chronic Diverticulosis
Cardiomyopathy
h/o stroke
h/o brain aneurysm
Ventral hernia s/p repair c/b infection and enterocutaneous
fistula, open abdominal wound
DM2
Mechanical Aortic Valve Replacement in ___
CAD with LAD stent x 2
HL
HTN
Anemia
RP bleed (spontaneous)
CCY
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T: 98.9 BP: 121/52 P: 65 R: 28 O2: 99% on RA
General- Alert, oriented, no acute distress. 1 TBsp clot in
basin.
HEENT- Sclera anicteric, MMM, oropharynx clear. Neck- supple,
JVP not elevated, no LAD
Lungs- Poor exam ___ pt reluctance to cooperate, clear to
auscultation anteriorly.
CV- Regular rate and rhythm, S2>S1, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, dressings on abdominal
wound c/d/i.
GU- no foley
Ext- warm, well perfused, no cyanosis or edema. R PICC in place.
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals- Tmax 98.7 Tc 98 BP 103-120/55-67 HR 54-65 RR
18 sat 98-100% on 2L NC
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM
Neck- supple, no LAD
Lungs- Clear to auscultation bilaterally in anterior lung
fields, unable to position pt to auscultate posterior lung
fields
CV- Regular rate and rhythm, with loud mechanical click
throughout precordium
Abdomen- soft, mildly tender especially around dressing on
belly, non-distended, hypoactive bowel sounds, no rebound
tenderness or guarding, C/D/I
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
no asterixis
Neuro- CNs2-12 grossly intact, motor function grossly normal
Skin: no telangectasias or stigmata of liver disease noted
Pertinent Results:
ADMISSION LABS
___ 05:25PM BLOOD WBC-6.5 RBC-3.24* Hgb-8.6* Hct-25.8*
MCV-80* MCH-26.5*# MCHC-33.2 RDW-18.3* Plt ___
___ 05:25PM BLOOD Neuts-82.9* Lymphs-9.6* Monos-4.7 Eos-2.5
Baso-0.3
___ 05:25PM BLOOD ___ PTT-44.3* ___
___ 05:25PM BLOOD Glucose-110* UreaN-33* Creat-0.8 Na-141
K-3.5 Cl-111* HCO3-22 AnGap-12
___ 05:25PM BLOOD ALT-12 AST-30 AlkPhos-413* TotBili-1.8*
___ 05:25PM BLOOD ___
___ 05:25PM BLOOD Lipase-80*
___ 03:47AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.0
___ 05:25PM BLOOD Albumin-2.1*
___ 08:09PM BLOOD Lactate-0.9
Relevant labs:
___ 05:25PM BLOOD ___
___ 06:13AM BLOOD cTropnT-<0.01
___ 02:02PM BLOOD cTropnT-<0.01
___ 10:01AM BLOOD ___ PTT-55.2* ___
___ 06:30AM BLOOD Vanco-29.1* (After this trough drawn,
vanc decreased to current dose of 1250 Q24h)
___ 06:08AM BLOOD Triglyc-121 (TPN)
Discharge labs:
___ 06:08AM BLOOD WBC-3.3* RBC-2.82* Hgb-7.9* Hct-23.6*
MCV-84 MCH-27.9 MCHC-33.4 RDW-18.2* Plt ___
___ 01:45PM BLOOD Hct-23.7*
___ 06:08AM BLOOD ___ PTT-50.5* ___
___ 06:08AM BLOOD Glucose-86 UreaN-22* Creat-0.8 Na-135
K-4.3 Cl-106 HCO3-25 AnGap-8
___ 06:08AM BLOOD ALT-10 AST-31 AlkPhos-352* TotBili-0.8
___ 06:08AM BLOOD Calcium-8.6 Phos-2.2* Mg-1.9
CXR ___:
FINDINGS: The patient is status post median sternotomy and
aortic valve
replacement. The PICC tip terminates within the SVC. The heart
remains
moderately enlarged. Mediastinal widening is unchanged. There is
new mild
pulmonary edema. No pleural effusion or pneumothorax is
identified. There are no acute osseous abnormalities. Patient
is also status post CABG.
___ EGD:
Esophagus:
The endoscope was advanced into the esophagus. At the level of
the mid esophagus old blood clot was seen that was flushed with
saline. Behind the clot from the mid to distal esophagus was
deep linear ulceration with old blood. No varices were
visualized in the esophagus.
Stomach:
Mucosa: Erythematous mosaic pattern of the stomach mucosa in the
body of the stomach consistent with moderate portal hypertension
gastropathy. No evidence of active bleeding was visualized. No
varices were noted on retroflexion.
Duodenum:
Mucosa: Normal mucosa was noted in the whole duodenum.
Impression: At the level of the mid esophagus old blood clot was
seen that was flushed with saline. Behind the clot from the mid
to distal esophagus was deep linear ulceration with old blood
consistent with severe erosive esophagitis.
Moderate portal gastropathy
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: High dose protonix iv bid
Carafate suspension 1gm QID
Monitor CBC closely
TTE ___:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
moderate cavity dilation and regional systolic dysfunction c/w
CAD. Well-seated and normally functioning aortic bileaflet
prosthesis. Mild-to-moderate mitral regurgitation. No
echocardiographic evidence of valvular vegetations. However, if
clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
CT chest abdomen and pelvis ___:
CT CHEST: Right-sided PICC tip terminates at the cavoatrial
junction. Prior aortic valve replacement is noted along with
coronary artery and mitral valve calcifications. The heart is
mildly enlarged. The great vessels are unremarkable. There are
no pathologically enlarged supraclavicular, axillary, or hilar
lymph nodes by size criteria. Multiple enlarged paratracheal
lymph nodes measure up to 12 mm (2:18). The esophagus contains
a small amount of fluid. Dependent atelectasis is noted with a
small pleural effusion on the left and a trace effusion on the
right. Right upper lobe peribronchial opacities are worrisome
for infection. Wedge-shaped opacity in the right apex is more
likely atelectasis (601B:40). The airways are patent to the
subsegmental level.
CT ABDOMEN: Mesenteric hematoma is smaller than on ___. It now
measures 8.4 x 4.8 cm compared to 11.1 x 5.0 cm on ___
(2:88). 4.3 x 2.0 cm gastrocolic nodule is unchanged dating
back to ___ (2:61). Multiple nodules along the distal
transverse colon are also unchanged (2:72,81).
The liver enhances homogenously and there is no focal liver
lesion. Hepatic nodularity, hypertrophy of the left lobe of the
liver, and splenomegaly suggest cirrhosis. The hepatic and
portal veins are patent. The gallbladder is absent. 9 mm
hypodensity in the spleen is of doubtful clinical significance.
The pancreas and adrenals are normal. The kidneys enhance
symmetrically and excrete contrast without evidence of
hydronephrosis or mass. 2.5 cm simple cyst is noted in the left
kidney. The stomach is normal.
CT PELVIS: The pigtail catheter above the bladder has been
removed and a
tract is now seen, representing the colocutaneous fistula
(602B:27).
Thickening of the bladder dome is still present. Oral contrast
passes freely through the stomach, small bowel, and colon to the
rectum without obstruction or extravsation. There is no pelvic
lymphadenopathy or free fluid. The seminal vesicles and
prostate are unremarkable. Surgical material is again noted in
the right lower quadrant. The previously described filling
defect in the small bowel is no longer seen and probably
represented post-surgical edema (601B:27).
OSSEOUS STRUCTURES: Compression fracture of T11 is unchanged
from multiple priors. There is no lytic or blastic lesion
worrisome for malignancy.
IMPRESSION:
1. Right upper lobe pneumonia. Mediastinal lymphadenopathy may
be reactive. Nonspecific small bilateral pleural effusions.
2. Interval decrease in size of mesenteric hematoma, now
measuring 8.5 cm compared to 11.1 cm on ___. Supravesicular pigtail catheter has been removed with
residual
colocutaneous tract.
4. Evidence of cirrhosis disease as described above.
5. Filling defect described in the small bowel on ___
is no longer seen.
___ ECG:
Sinus bradycardia. Possible left atrial abnormality. Possible
anterior
myocardial infarction, age undetermined and possible lateral
myocardial
infarction, age undetermined. Non-specific repolarization
abnormality.
Compared to the previous tracing of ___ the T wave
inversions in the
anterior precordial leads are less prominent. Otherwise, no
diagnostic change.
MICROBIOLOGY:
All blood cultures negative
Brief Hospital Course:
Pt is a ___ yo M with PMH of EtOH cirrhosis c/b grade I varices,
mechanical AV on warfarin, CAD, HTN, h/o CVA, who presents w/
hemoptysis vs. hematemesis. He was felt more likely to have
hematemesis and had dark tarry guaiac positive bowel movements
during his stay. An EGD revealed severe erosive esophagitis as
well as a significant linear ulceration with an old blood clot
that may have been source of prior bleeding. There was no
active bleeding and there were no procedures that were performed
that could limit bleeding in the future. This is complicated by
the need to anticoagulate the patient given his mechanical
aortic valve.
# Hemoptysis/hematemesis. Pt described hemoptysis vs hemetemesis
X 2 days in setting of elevated INR. Endorsed nausea, difficulty
keeping fluids down, denied fevers, long term cough. Vital signs
stable at presentation, admitted to the ICU due to concern for
active bleeding. Records sent w/ patient revealed pt had falling
hct requiring 2 units PRBCs at his rehab on the day before
admission. In ICU, bleed thought likely upper GI in origin given
nausea, black stool in vault, unlikely variceal bleed given
grade I lesions. Pt was typed and crossed, adequate access
obtained. Pt seen by GI, who recommended IV pantoprazole and
octreotide gtts. Also on CTX x3 days. Pt was kept NPO and
monitored on telemetry overnight. Underwent EGD on HD1, revealed
portal gastropathy and severe erosive esophogitis as well as
deep linear ulceration with clotted blood overlying, but no
active bleeding. No further intervention was recommended for
his esophagitism, there was no intervenable lesion, and the
cause of this ulceration and esophagitis remains unclear. It
was recommended that the patient continue high dose IV PPI BID,
sucralfate QID, and decrease ursodiol to 600 BID given its
propensity to induce reflux.
The patient continues to have guiac positive stool. He is s/p 3
units of PRBC while here. His last transfusion was on ___.
His HCT has remained stable with BID HCT draws. His last HCT on
___ was 23.7.
Patient remained stable and subsequently transferred to the
floor. However on ___ was found to be coughing blood actively.
This was thought secondary to his recent epistaxis. IP was
consulted and a CT chest ordered which showed incidental
pneumonia but no evidence of blood in lungs or mass lesion in
lung or airway. The hemoptysis has resolved.
The patient's anticoagulation is being carefully managed. His
INRs fluctated dramatically ___ to lack of nutrition as the
patient remained NPO and did not have TPN ordered for the first
several days of his hospitalization. He started on 2.5 mg
warfarin on ___. He is on a heparin bridge with warfarin for a
target INR of 2.5-3.0 to promote healing and limit further
bleeding. His target PTT should be 60-80.
The patient has follow up with hepatology, transplant surgery,
and interventional pulmonology for his hematemesis and
hemoptysis.
#MRSA bacteremia. Blood cxs from ___ drawn at ___ rehab
returned ___ bottles MRSA, PICC removed at that time, tip also
reportedly grew MRSA. Pt admited w/ new PICC in place, on
vancomycin since ___, had not had TTE. Surveillance cxs were
monitored, which grew nothing on this hospitalization.
Vancomycin was continued. TTE revealed no vegetation. Patient
has mechanical valve and would normally receive TEE to r/o
endocarditis, but given the patients severe esophagitis with
ulceration and GI bleeding, it was felt by hepatology and
cardiology that TEE would be too risky. Infectious disease
agreed with this and recommended total 4 week antibiotic course
with vancomycin.
- Continue vancomycin for total 4 week course from ___
- Pt has follow up with transplant ID on ___.
- Vanc trough should be drawn on ___ or ___
#Hospital acquired pneumonia: Pt without cough or symptoms
suggestive of pneumonia but CT chest revealed right upper lobe
pneumonia with mediastinal lymphadenopathy. Pt was initially
started on cefepime for healthcare associated pneumonia on ___.
Pt remained stable without any pneumonia symptoms. This was
deescalated on ___ to ceftriaxone. He should continue
ceftriaxone through ___ (last dose ___.
# Mechanical valve on coumadin. Pt had been supratherapeutic to
4.8 in days leading up to admission; 2.5 at admission. Pt's INR
1.8 on HD1, and given his mechanical valve w/ INR goal 2.5-3.5,
he was started on heparin gtt. Warfarin held initially pending
resolution of bleeding, restarted on ___ at 3mg (half home
dose). But INR continued to rise due to lack of nutrition.
Pt's warfarin dose was changed several times and ultimately his
INR was 1.4 on discharge and on heparin bridge. He has received
2.5 mg warfarin on ___ and ___.
- Continue on heparin bridge until INR therapeutic. Would aim
for INR 2.5-3.0.
#Cirrhosis c/b grade I varices, encephalopathy. Etiology thought
to be alcohol + PBC versus PSC: Ceftriaxone 1g Q24 started
given suspicion for GIB, continued for 3 days. Nadolol continued
initially but halved to 10mg daily given bradycardia and
relative hypotension. He was also continued on lactulose TID.
His ursodiol was decreased to 600 BID from 600 and 900 for
concern of reflux.
- Pt will follow up with hepatology.
#CAD. Continued aspirin. Echo was performed while in the unit
that revealed anterior focal wall motion abnormalities, and
there were some ST changes in the anterior leads concerning for
active ischemia. Troponins remained negative however and
regarding cardiac sxs, the patient only complained of baseline
left chest and shoulder pain with some tenderness to palpation
which was attributed to a previous mechanical injury. Pt not on
statin given concern for PBC.
# Pain. Pt w/ chronic pain secondary to abdominal wounds.
Morphine IV ___ mg Q4H prn pain started initially, then switched
to pt's home oxycontin/oxycodone regimen when pt able to take PO
medications.
#Abdominal wound/fistula. Wound care consulted, who requestioned
surgery recommendations as they were able to see the mesh. Per
transplant surgery mesh is biologic and will resorb over
time--granulation tissue overlying wound looks good. Pt needs to
continue on bowel rest as previously planned. Transplant surgery
agreed that okay for patient to take sips for comfort. CT
revealed continued presence of colocutaneous fistula. ___
require intervention in future which will be discussed as
outpatient. No further inpatient intervention. Hematoma
resolving.
- Follow up with Dr. ___ in transplant surgery clinic.
# Pulmonary edema. CXR on admission read as overload, BNP of
10829 supported this diagnosis. Initially unknown EF or h/o
heart failure; TTE revealed hypokinesis of mid to distal septum
and anterior wall, EF 40-45%. Pt satting in mid ___ on room air.
Pt diuresed several liters but became transiently hypotensive to
the ___ and so needed some fluid repleted. Pt's pulmonary
status remained stable and satting 100% on 2L.
# Nutrition: Sips for comfort. On TPN. Please see attached
sheet for our nutritionists' TPN recommendations.
Code status: Full
Transitional:
- Continue vanco through ___, needs trough on ___ or ___.
- Continue CTX through ___
- Monitor HCT and have active type and screen available
- If patient demonstrates signs of active bleeding and not just
oozing, may need rescope
- Continue PPI and sulcrafate
- Heparin bridge to warfarin
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amitriptyline 10 mg PO HS
2. Calcium Carbonate 500 mg PO BID
3. Lactulose 30 mL PO TID
4. Nadolol 20 mg PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
7. Pantoprazole 40 mg PO Q24H
8. Sodium Chloride Nasal ___ SPRY NU BID
9. Ursodiol 600 mg PO QAM
10. Ursodiol 900 mg PO QPM
11. Vitamin A 10,000 UNIT PO DAILY
12. Zinc Sulfate 220 mg PO TID
13. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
14. Warfarin 6 mg PO/NG DAILY16
15. Senna 1 TAB PO BID:PRN constipation
16. Miconazole Powder 2% 1 Appl TP QID
17. Aspirin 81 mg PO DAILY
18. Ondansetron 4 mg IV Q6H:PRN nausea
19. Vancomycin 1500 mg IV Q 24H
20. Cyclobenzaprine 10 mg PO Q6H:PRN pain
21. Clotrimazole Cream 1 Appl TP BID
22. Betamethasone Valerate 0.1% Cream 1 Appl TP BID
23. Citalopram 40 mg PO DAILY
Discharge Medications:
1. Amitriptyline 10 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Citalopram 40 mg PO DAILY
4. Clotrimazole Cream 1 Appl TP BID
5. Cyclobenzaprine 10 mg PO Q6H:PRN pain
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
7. Lactulose 30 mL PO TID
8. Miconazole Powder 2% 1 Appl TP QID
9. Ondansetron 4 mg IV Q6H:PRN nausea
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
12. Sodium Chloride Nasal ___ SPRY NU BID
13. Ursodiol 600 mg PO BID
14. Vancomycin 1250 mg IV Q 24H Duration: 4 Weeks
15. Warfarin 2.5 mg PO DAILY
16. Nadolol 10 mg PO DAILY
17. CeftriaXONE 1 gm IV Q24H Duration: 4 Days
Last dose should be given ___ to complete ___. Heparin IV Sliding Scale
No Initial Bolus
Initial Infusion Rate: 1000 units/hr
Target PTT: 60 - 100 seconds
19. Sucralfate 1 gm PO QID
20. Betamethasone Valerate 0.1% Cream 1 Appl TP BID
21. Calcium Carbonate 500 mg PO BID
22. Pantoprazole 40 mg PO Q24H
23. Senna 1 TAB PO BID:PRN constipation
24. Vitamin A 10,000 UNIT PO DAILY
25. Zinc Sulfate 220 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: MRSA bacteremia, GI bleed, pneumonia
Secondary: cirrhosis, colocutaneous fistula, mechanical AVR on
coumadin
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 ___. You were
admitted with a blood infection which was treated with an IV
antibiotic called vancomycin. You will need to complete a 4
week course of vancomycin (last day will be ___.
You also had pneumonia, which is being treated with antibiotics.
You should complete an 8 day course of the antibiotic
ceftriaxone (last day will be ___.
Additionally, you experienced some bleeding from your
gastrointestinal tract (gut). An endoscopy showed damage to
your esophagus, the tube that leads from your mouth to your
stomach. Please continue taking carafate, nadolol and
pantoprazole to treat this problem.
You were followed by transplant surgery and colorectal surgery
for the abdominal fistula. You will have follow-up appointments
with transplant surgery. Transplant surgery recommends that you
not eat or drink large amounts of fluids yet, as this will delay
healing of the fistula. Your nutrition will be provided by TPN
and you may take small sips of fluids for comfort.
For your liver disease, please continue taking ursodiol and
lactulose.
Because you have a mechanical heart valve, you will need to
continue taking warfarin. This medication should be monitored
and adjusted at the care facility.
Followup Instructions:
___
|
10361833-DS-15 | 10,361,833 | 26,265,087 | DS | 15 | 2119-06-01 00:00:00 | 2119-06-03 07:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pelvic pain
Major Surgical or Invasive Procedure:
transvaginal drainage of left fallopian tube
History of Present Illness:
Ms. ___ is a ___ year-old G2P0 who presents as a transfer
from ___ for 1 week of pelvic pain, fever, and n/v
concerning for ___.
She reports that for the past week, she has had gradual
worsening of pelvic pain, which she describes mostly as pressure
"in my tubes" with occasional periods of sharp knife-like pain,
similar to the pain she has had in the past when treated for
PID. She denies any sudden acute exacerbation of pain. She has
been taking naproxen with minimal relief. She has also had
persistent nausea and vomiting for the past few days. Two days
ago, she reports a fever to 104 at home as well as chills. She
has had more watery vaginal discharge in the past week as well
as vaginal spotting a few days ago. Her LMP was ___. Denies
dysuria or hematuria. Had been constipated but took a powder
(miralax?) and had a loose BM today. She has also been having
nonproductive cough but denies any SOB/CP. She has been taking
nyquil and theraflu for this.
She presented to ___ today for evaluation. She was afebrile
98.4F. She had a negative CXR and a CT abd/pelvis which was
negative (normal lung bases, liver, gallbladder, pancreas,
spleen, adrenals, kidneys, small and large bowel, and appendix)
except for dominant cystic lesions in pelvis, measuring 5.5cm on
the left and 8.4cm on the right. She had GC/Ch and pelvic exam
by Dr. ___ with scan vaginal discharge but moderate R > L
adnexal tenderness and CMT.
Labs were:
139 | 106 | 10
---------------< 80
3.9 | 26 | 0.6
9.6 > 15.0 / 43.9 < 272
UCG neg, UA neg leuk/nitr
They were unable to obtain an ultrasound because (per the pt)
the ultrasound department had left for the night. Given the
cystic pelvic masses and tenderness on exam, she received 500mg
PO cipro, 500mg IV flagyl, and 1g ceftriaxone prior to transfer
to ___.
Currently, she continues to endorse the same bilateral pelvic
pain which is improved with dilaudid. Has not had any emesis
here.
Past Medical History:
Obstetric History: G2P0, SAB x 2
Gynecologic History:
- Menses generally monthly, lasting ___ days
- h/o chlamydia and hospitalized for PID in ___ at ___, and
reports having had transgluteal drains placed in her tubes at
___
- reports that her primary gynecologist has been recommending
laparoscopic salpingectomy to her
Past Medical History:
- asthma
- depression/bipolar disorder
- PTSD
Past Surgical History:
- tonsillectomy
- ___ drains into TOAs
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
Vitals in ED: 98.6 82 122/67 24 97% RA
General: intermittently tearful obese Caucasian woman, NAD, AxO
CV: RRR, no murmur
Resp: CTAB, no crackles
Abd: +BS, soft, obese, nondistended, tender to deep palpation in
lower abdomen and mild RUQ tenderness, no rebound or guarding
Pelvic: normal external genitalia without lesions, smooth
vaginal walls without lesions, minimal physiologic discharge,
cervix without lesions. On bimanual exam, which is limited by
pt's body habitus, she has +CMT as well as tenderness in the
bilateral adnexa (R > L). Unable to palpate any distinct adnexal
masses although there is fullness bilaterally
Ext: no calf tenderness
On discharge:
T98.2 HR 68 BP 115/75 RR 22 O2 96% RA
General: NAD, comfortable, appears drowsy
CV: RRR
Lungs: CTAB
Abdomen: Soft, nondistended, no rebound or guarding
Extremities: No TTP, Bilateral ___ edema in all extremities,
nonpitting
Pertinent Results:
___ 01:20AM BLOOD WBC-12.6*# RBC-4.83 Hgb-14.4 Hct-43.3
MCV-90# MCH-29.7 MCHC-33.2 RDW-13.3 Plt ___
___ 07:30AM BLOOD WBC-8.2 RBC-4.22 Hgb-12.7 Hct-38.4 MCV-91
MCH-30.1 MCHC-33.1 RDW-13.4 Plt ___
___ 01:20AM BLOOD Neuts-88.3* Lymphs-10.2* Monos-0.6*
Eos-0.8 Baso-0.2
___ 07:30AM BLOOD Neuts-56.5 ___ Monos-3.0 Eos-0.9
Baso-0.4
___ 01:20AM BLOOD ___ PTT-32.4 ___
___ 01:20AM BLOOD ESR-14
___ 01:20AM BLOOD Glucose-167* UreaN-12 Creat-0.5 Na-135
K-4.0 Cl-104 HCO3-18* AnGap-17
___ 01:20AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8
___ 01:20AM BLOOD HCG-<5
___ 01:20AM BLOOD CRP-10.8*
___ 07:30AM BLOOD HIV Ab-NEGATIVE
___ 08:58PM BLOOD Genta-0.3*
___ 01:20AM BLOOD Lithium-LESS THAN Valproa-<3*
___ 07:30AM BLOOD HCV Ab-PND
___ 01:26AM BLOOD Lactate-3.3*
___ 03:20AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:20AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:20AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
___ 03:20AM URINE UCG-NEGATIVE
___ 1:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:15 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 3:42 am SWAB Source: Cervical.
**FINAL REPORT ___
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___: Negative for Chlamydia trachomatis by
___ System,
APTIMA COMBO 2 Assay.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___: Negative for Neisseria gonorrhoeae by
___
System, APTIMA COMBO 2 Assay.
___ 3:42 am SWAB Source: Vaginal.
SMEAR FOR BACTERIAL VAGINOSIS (Final ___:
GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS.
YEAST VAGINITIS CULTURE (Preliminary):
___ 5:00 pm ABSCESS L ADNEXAL FLUID COLLECTION.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): RESULTS PENDING.
ANAEROBIC CULTURE (Preliminary):
Pelvic Ultrasound ___:
1. Bilateral dilated fallopian tubes with internal debris, which
may represent blood or pus. Findings are suggestive of bilateral
___.
2. 4.9 cm right hemorrhagic ovarian cyst. Superinfection of the
cyst cannot be excluded.
3. Normal left ovary. Right ovary only seen in one plane, but
appears unremarkable.
4. Normal uterus and endometrium.
Brief Hospital Course:
Ms. ___ was admitted to the gynecology service secondary to
concern for pelvic inflammatory disease and possible
tubo-ovarian abscess after being transferred from ___
___ where she had presented with pelvic pain. In ___,
she received 1 dose of ceftrixone, cipro and flagyl. On intial
presentation to ___, she was afebrile. On physical examination
she had adnexal tenderness as well as cervical motion
tenderness. Lab evaluation releaved an elevated CRP and mild
leukocytosis. Pelvic ultrasound revealed bilateral dilated
fallopian tubes with internal debris consistent with fluid vs.
pus as well as a 4.9 cm right hemorrhagic ovarian cyst. She was
therefore admitted to the gynecology service for inpatient
management.
She received gentamicin and clindamycin for treatment of PID and
possible tubo-ovarian abscess. She was made NPO for possible
drainage.
On ___ she underwent transvaginal ultrasound-guided
placement of 8 ___ ___ catheter into complex left adnexal
collection, which was thought to be likely a hematosalpinx as 15
cc of serosanguineous fluid was aspirated.
Gonorrhea and chlamydia swabs were sent and negative. Yeast
culture was negative, BV is still pending. Gram stain from the
drained fluid was negative. Culture is still pending. A complete
STI panel was sent and negative to date, although some results
are pending.
She remained afebrile. Her leukocytosis improved to 8.2 on
hospital day #2. Given the minimal amount of serosanguinous
drainage, the drain was discontinued. After review of her
course, it was determined that her pelvic pain was likely
secondary to a hemorrhagic ovarian cyst with an incidentally
found left hematosalpinx, and less likely PID.
On hospital day #2, she was afebrile and ambulatory. Pain was
controlled and she tolerated a regular diet. She was discharged
but prior to leaving, on the night of hospital day #2, she had
an episode of pain, which was evaluated with a pelvic ultrasound
and labs which were both stable. She had a reassuring exam and
the pain resolved with NSAIDs.
On hospital day #3, she continued afebrile and ambulatory with
minimal pain. She tolerated a regular diet. She had experienced
persistent wheezing and a productive cough throughout her
hospitalization, and so was discharged home in stable condition
with a prescription for azithromycin to treat a presumed
bacterial upper respiratory infection.
She plans to follow-up with her primary gynecologist Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate 100-200 mg PO QHS
2. Methylphenidate SR 40 mg PO QAM
3. HydrOXYzine 50 mg PO TID:PRN anxiety
4. Divalproex (EXTended Release) 250 mg PO QAM
5. Divalproex (EXTended Release) 1500 mg PO Q ___
Discharge Medications:
1. HydrOXYzine 50 mg PO TID:PRN anxiety
2. Methylphenidate SR 40 mg PO QAM
3. Divalproex (EXTended Release) 250 mg PO QAM
4. Divalproex (EXTended Release) 1500 mg PO Q ___
5. QUEtiapine Fumarate 100-200 mg PO QHS
6. Azithromycin 250 mg PO DAILY
Take two pills first day, then one pill each day until
prescription finished.
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
7. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
hematosalpinx (blood in tubes)
hemorrhagic ovarian cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for evaluation and treatment of abdominal pain
and dilated fallopian tubes. You were given IV antibiotics in
case the fluid in the tubes was due to an infection. The fluid
in the left tube was drained by radiology and did not show
evidence of infection. Your white blood cell count was normal
after the drainage and you did not have a fever. After
evaluation, it is thought that the pain you experienced was
likely due to accumulation of blood in the fallopian tubes from
a hemorrhagic cyst on your ovary. You do not need to take any
more antibiotics for this problem.
You also experienced a cough and wheezing and are being a given
a prescription to take at home (azithromycin) to help with your
upper respiratory infection. You should take use your inhaler as
well to help with any wheezing.
Please follow these instructions:
*) take all medicines as prescribed
*) Pelvic rest for two weeks after drain removal on ___
(Nothing in vagina: no sex, tampons, douching)
Followup Instructions:
___
|
10361837-DS-15 | 10,361,837 | 22,076,746 | DS | 15 | 2130-02-21 00:00:00 | 2130-02-22 09:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / Ace Inhibitors
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with history of dCHF (EF 50-55%), CAD s/p 4-vessel CABG,
HTN/DM, HIV, ESRD s/p Kidney SCD ___ SCD
___, recent admissions at ___ with stroke and C. diff
colitis, coming in with worsening DOE, orthopena, ___ swelling.
___ found that patient was saturating 90% on room air today.
Patient has long history of medication noncompliance and admits
to forgetting to take his medications frequently.
At baseline, patient poor historian and frequently forgets what
we are discussing and asks me to repeat questions during the
interview. He reports he was "unable to move" this morning
because of shortness of breath and also had associated chest
pressure. He notes gasping for breath in the middle of the
night, which has been occurring intermittently for at least
years. He endorses 4 pillow orthopnea and PND. Denies current
chest pain, nausea, vomiting. No SOB at rest. Does report
increased leg swelling over the past few days. Reports a dry
cough (chronic). Of note, patient was recently hospitalized at
___ for pneumonia.
In the ED, initial vitals were: 16:19 ___ 98.6 HR76 BP146/76
20 97%NC
- Labs were significant for Na130, K5.5 with repeat 5.3 after
intervention below, creat 1.5 (baseline 0.9-1.2), u/a 600
protein, 100 glc, and trop 0.04, h/h 10.7/30.1 (baseline hgb
___
- Imaging revealed CXR with pulmonary edema and renal
ultrasound with normal flow.
- The patient was given 40mg IV Lasix, 2g calcium gluconate,
10U regular insulin, 25gm 50% IV dextrose. UOP 250cc prior to
coming up from ED, patient refused foley.
Vitals prior to transfer were:
Today 19:20 ___ 97.9 75 141/77 24 95% Nasal Cannula
Upon arrival to the floor, patient c/o of chronic arm/leg pain
secondary to his neuropathy. He rates pain as ___.
Past Medical History:
-HIV
-End-Stage Renal Disease s/p Cadaveric transplant x2
-R AVF, HD catheter placements
-Coronary Artery Disease s/p Myocardial Infarction and CABG
-Subacute Basal ganglia stroke (___)
-___ disease (dx at ___ in ___
Hypertension
Hypercholesterolemia
Asthma, not taking meds as directed
GERD
IDDM, uncontrolled
Neuropathy
Lung nodules
Anemia
+VRE in past
s/p Appendectomy
s/p Tonsillectomy
s/p Tracheostomy x 2 secondary to angioedema from lisinopril
h/o Deep Vein Thrombosis
Hyperparathyroidism
HSV
___ HPV
CRT ___
Nephrostomy tube ___
Urinoma pigtail drain ___
Social History:
___
Family History:
CAD in many relatives but not at a young age. Mother with breast
cancer currently in remission at ___. Father is healthy.
Physical Exam:
Admission:
Vitals: T97.4 BP137/72 HR78 RR20 93%2L NC 98.7kg
General: Alert, oriented, no acute distress, yawning frequently
throughout interview
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP at level of tragus, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: crackles in b/l bases
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Lukewarm, well perfused, 2+ pulses, 2+pitting edema
extending up to b/l knees, chronic venous stasis changes b/l
Neuro: CNII-XII intact, ___ strength RLE/LLE/LUE, ___ strength
in RUE, grossly normal sensation, gait deferred.
Discharge:
VS: 97.4 ___ ___ 18 99%RA
I/O: ___
General: Alert, oriented, no acute distress. AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP at level of tragus, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB, no bibasilar crackles.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Lukewarm, well perfused, 2+ pulses, 1+pitting edema
extending up to b/l knees, chronic venous stasis changes b/l
Neuro: CNII-XII intact, ___ strength RLE/LLE/LUE, ___ strength
in RUE, grossly normal sensation, gait deferred.
Pertinent Results:
Admission:
___ 09:50PM GLUCOSE-154* UREA N-19 CREAT-1.5* SODIUM-131*
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-23 ANION GAP-15
___ 08:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-600
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 08:00PM URINE RBC-16* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:00PM URINE GRANULAR-1*
___ 08:00PM URINE MUCOUS-RARE
___:30PM K+-5.3*
___ 07:24PM tacroFK-7.1
___ 07:04PM ___ PTT-34.7 ___
___ 05:34PM GLUCOSE-233* UREA N-19 CREAT-1.5* SODIUM-130*
POTASSIUM-5.5* CHLORIDE-99 TOTAL CO2-23 ANION GAP-14
___ 05:34PM estGFR-Using this
___ 05:34PM LD(___)-212
___ 05:34PM cTropnT-0.04*
___ 05:34PM proBNP-9565*
___ 05:34PM CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-1.7
___ 05:34PM WBC-4.4 RBC-3.58* HGB-10.7*# HCT-33.1* MCV-93
MCH-29.9 MCHC-32.3 RDW-15.2 RDWSD-51.8*
___ 05:34PM NEUTS-76.3* LYMPHS-14.6* MONOS-6.6 EOS-0.9*
BASOS-0.7 IM ___ AbsNeut-3.35 AbsLymp-0.64* AbsMono-0.29
AbsEos-0.04 AbsBaso-0.03
___ 05:34PM PLT COUNT-100*
Discharge:
___ 12:53PM BLOOD WBC-3.4* RBC-3.66* Hgb-10.8* Hct-33.1*
MCV-90 MCH-29.5 MCHC-32.6 RDW-15.0 RDWSD-49.2* Plt ___
___ 04:18AM BLOOD WBC-2.7* RBC-3.56* Hgb-10.7* Hct-32.3*
MCV-91 MCH-30.1 MCHC-33.1 RDW-14.8 RDWSD-49.1* Plt ___
___ 12:53PM BLOOD Plt ___
___ 04:18AM BLOOD Plt ___
___ 04:18AM BLOOD Glucose-173* UreaN-35* Creat-1.8* Na-132*
K-4.4 Cl-99 HCO3-22 AnGap-15
___ 04:20AM BLOOD ALT-8 AST-31 AlkPhos-170* TotBili-0.2
___ 04:18AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.8
___ 04:18AM BLOOD tacroFK-8.3
Imaging:
CXR ___ comparison with the study of ___, the
patient has taken a better inspiration. There are bilateral
pulmonary opacifications consistent with alveolar and
interstitial opacities, that could well represent asymmetric
pulmonary edema. However, this appears low much less prominent
today on the left, raising the possibility of superimposed
pneumonia on the right. On the lateral views, there does not
appear to be substantial pleural effusion.
MRI/MRA brain ___:
1. Small area of slow diffusion is identified in the body and
head of the left caudate nucleus and left basal ganglia, which
is also evident on T2 and FLAIR sequences as described detail
above, suggesting subacute ischemic changes, there is no
evidence of hemorrhagic transformation or mass effect.
2. The left middle cerebral artery is not clearly identified,
probably
artifactual from dental hardware versus due to vascular
occlusion, if clinically warranted correlation with CT of the
head is recommended for
further characterization.
3. Dominance of the left vertebral artery, the right vertebral
artery is not clearly identified.
RECOMMENDATION(S): Point 2. The left middle cerebral artery is
not clearly identified and also the right vertebral artery, if
clinically warranted, correlation with CTA of the head and neck
is recommended for further characterization.
CT chest w/o contrast ___: Asymmetric ground-glass and
peribronchial nodular opacities most pronounced in
the right lung are most suggestive of atypical infection.
Imaging
differential diagnosis includes PCP, ___, or bacterial
infection, given the history of HIV and immunosuppression.
Pulmonary nodules are likely
infectious/inflammatory and can be followed up with CT thorax in
3 months time to ensure resolution. Mild basal predominant
pulmonary edema. Mediastinal lymphadenopathy is likely benign.
This can be reactive to acute infection, or can be related to
HIV or chronic cardiac disease.
CXR ___: As compared to ___ radiograph,
worsening asymmetrically distributed combined alveolar and
interstitial opacities, right greater than left, may be due to
asymmetrical edema, but superimposed infection in the an should
be considered in the appropriate clinical setting. Small to
moderate right pleural effusion has also increased in size. No
other relevant changes.
Echo ___:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. Mild symmetric left ventricular hypertrophy with normal
cavity size, and regional/global systolic function (biplane LVEF
= 66 %). Overall left ventricular systolic function is normal
(LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg).Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valveleaflets (?#) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. No
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function. Moderate pulmonary artery
systolic hypertension. Mildly dilated ascending aorta. Increased
PCWP.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram
is suggested in ___ years.
Micro:
___: Sputum gram stain- negative, culture- pending.
___: stool cultures, O/P x3 negative
___: HIV viral load undetectable
___: BCx: pending x2
___: CMV viral load: undetectable
___: Urine culture
Brief Hospital Course:
Brief Hospital Course:
======================================
___ yo M with history of dCHF (EF 65%), CAD s/p 4-vessel CABG,
HTN/DM, HIV, ESRD s/p Kidney SCD ___ SCD
___, recent admissions at ___ with stroke and C. diff
colitis, coming in with CHF exacerbation, and also underwent
work up for pulmonary nodules, neuro consulted for prior stroke.
Active Issues:
========================================
#Acute on chronic ___ exacerbation: Trigger unclear. Echo
unchanged, no evidence of new ischemic disease. Likely
medication noncompliance as pt was supposed to take Furosemide
40 mg prn for leg swelling which he likely was not doing. Mr.
___ was initially treated with IV diuretics until he was
clinically more euvolemic and eventually transitioned to po
Lasix 40 mg qd for discharge.
___: The patient also developed worsening renal function
(baseline creatinine 1.5, creatinine 1.8 on discharge) likely
due to diuresis. Creatinine peaked at 2.1 but improved by
discharge when switched to po diuretics.
#H/o renal transplant: The patient was seen on the inpatient
renal transplant service. His tacrolimus dose was reduced to 5
mg bid as his levels were elevated while in the hospital. He was
maintained on Prednisone 5 mg qd and Azathioprine 125 mg qd.
#BRBPR: The patient was also found to have a small amount of
blood in a bowel movement on the day of discharge. He told me
that he has a history of hemorrhoids and as his CBC remained
stable throughout the day, we felt that likely this represented
a small hemorrhoid bleed and he was safe for discharge. However,
due to this finding and his age, he should have a colonoscopy as
an outpatient.
#Pulmonary nodules: He was also found to have asymmetrical
opacities on CXR concerning for asymmetric pulmonary edema vs.
resolving pneumonia. As the patient had recently been admitted
to ___ for treatment of pneumonia, we believe that his CXR
findings were most likely consistent with resolving pneumonia.
On a CT chest from ___, bilateral pulmonary nodules and
mediastinal lymphadenopathy were seen. We repeated a CT chest
which revealed similar findings as well as aforementioned
asymmetrical lung consolidations but according to our pulmonary
team they felt that the nodules represented response to recent
intrapulmonary infection rather than malignancy so no further
workup was required. He should have a follow-up CT chest in 3
months. As he was not febrile, did not have leukocytosis, and
symptomatically did not appear to have pneumonia, we did not
feel it necessary to treat with antibiotics. The infectious
disease team also saw the patient and agreed that antibiotics
were not necessary.
#Basal ganglia stroke, Parkinsonism: We also consulted our
neurology team as the patient has new diagnosis of ___
disease and recent subacute stroke seen on MRI brain at ___ and
confirmed on our own imaging. No changes were made in his
management for these issues and he is scheduled to see Dr.
___ as an outpatient.
#Diabetes: Likely secondary to long standing HIV infection and
steroid use. Tacrolimus is also pro-diabetic. He is known to be
nonadherent to his insulin administration at home. Pt was
restarted on insulin glargine 30 units at bedtime and instructed
to check his blood sugar each night prior to insulin
administration. We chose not to restart Humalog sliding scale
due to high copay cost and patient's history of noncompliance
and an attempt to simplify his regimen. Since he had not been
taking this prior to admission, we re-prescribed all his
supplies as well.
# Medication noncompliance: Pt will need close follow up as an
outpatient. He has ___ services at home which should help as
well.
Chronic Issues:
================================
# HIV, ___, abs CD4 count 284, viral load undetectable).
Continued on home HIV medications Triumeq and Bactrim
prophylaxis.
# Mood disorder: Continued on home sertraline
# CAD: Continued on home metoprolol, pravastatin, and aspirin
# Asthma: Continued on advair, albuterol, loratidine.
# Neuropathy: Patient continued on home Percocet.
Transitional Issues:
=================================
-Pt should have a colonoscopy as soon as possible as he is ___
years old and had small amount of blood in stool at the
hospital.
-Restarted insulin glargine 30 units every night. He should
check his finger sticks each evening prior to administering
Glargine and is instructed that if his ___ is <80 or >300 he
should notify his doctor. Please ensure that the patient is
using properly and titrate as required. Due to high copays and
patient noncompliance, we are choosing at this point to not
start him on a sliding scale but this should be considered as an
outpatient.
-consider hemoglobin A1C to monitor
-Please get a follow-up CT chest in ___ (three
months)
-Please check a tacrolimus level within two weeks of discharge
and adjust dose accordingly.
-Please check Elecrolytes and creatinine within 2 weeks of
discharge to assess creatinine levels and sodium/potassium in
setting of diuretic use.
# CODE STATUS: FULL CODE
# CONTACT: HCP Dr. ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azathioprine 125 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Glargine 23 Units Bedtime
Insulin SC Sliding Scale using Novalog InsulinMax Dose Override
Reason: poorly controlled diabetes
4. Metoprolol Succinate XL 200 mg PO DAILY
5. PredniSONE 5 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Ropinirole 4 mg PO QPM
8. Sertraline 200 mg PO DAILY
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 10 mg PO Q12H
11. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
12. Aspirin 81 mg PO DAILY
13. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
14. Dolutegravir 50 mg PO DAILY
15. Simethicone 80 mg PO Q8H:PRN gas pain
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
17. Calcitriol 0.25 mcg PO DAILY
18. Pantoprazole 40 mg PO Q24H
19. Carbidopa-Levodopa (___) 1 TAB PO TID
20. Amlodipine 10 mg PO DAILY
21. Nystatin Cream 1 Appl TP BID:PRN rash
22. Bisacodyl ___AILY:PRN constipation
23. GlipiZIDE XL 10 mg PO DAILY
24. Loratadine 10 mg PO DAILY
25. Milk of Magnesia 30 mL PO PRN constipation
26. Acetaminophen 650 mg PO Q6H:PRN pain
27. Guaifenesin 100 mg PO Q6H:PRN cough/congestion
28. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
29. Diphenoxylate-Atropine 2 TAB PO Q8H:PRN diarrhea
30. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
31. Furosemide 40 mg PO DAILY:PRN leg swelling
32. oxyCODONE-acetaminophen 7.5-325 mg oral Q6H:PRN
Discharge Medications:
1. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
RX *abacavir-dolutegravir-lamivud [Triumeq] 600 mg-50 mg-300 mg
1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
2. Azathioprine 125 mg PO DAILY
RX *azathioprine 50 mg 2.5 tablet(s) by mouth Daily Disp #*75
Tablet Refills:*0
3. Carbidopa-Levodopa (___) 1 TAB PO TID
RX *carbidopa-levodopa 25 mg-100 mg 1 tablet(s) by mouth three
times a day Disp #*90 Tablet Refills:*0
4. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
inh oral twice a day Disp #*1 Disk Refills:*0
6. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. oxyCODONE-acetaminophen 7.5-325 mg oral Q6H:PRN
RX *oxycodone-acetaminophen 7.5 mg-325 mg 1 tablet(s) by mouth
Q6H prn Disp #*20 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Pravastatin 40 mg PO QPM
RX *pravastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
10. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Ropinirole 4 mg PO QPM
RX *ropinirole 4 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Sertraline 200 mg PO DAILY
RX *sertraline 100 mg 2 tablet(s) by mouth Daily Disp #*60
Tablet Refills:*0
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
14. Tacrolimus 5 mg PO Q12H
RX *tacrolimus 1 mg 5 capsule(s) by mouth twice daily Disp #*300
Capsule Refills:*0
15. Simethicone 80 mg PO Q8H:PRN gas pain
16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
17. Loratadine 10 mg PO DAILY
RX *loratadine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
18. Milk of Magnesia 30 mL PO PRN constipation
19. Bisacodyl ___AILY:PRN constipation
20. Aspirin 81 mg PO DAILY
21. Acetaminophen 650 mg PO Q6H:PRN pain
22. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
23. Vitamin D ___ UNIT PO 1X/WEEK (___)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth once a week Disp #*4 Capsule Refills:*0
24. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
25. Nystatin Cream 1 Appl TP BID:PRN rash
26. Diphenoxylate-Atropine 2 TAB PO Q8H:PRN diarrhea
27. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
28. Guaifenesin 100 mg PO Q6H:PRN cough/congestion
29. GlipiZIDE XL 10 mg PO DAILY
RX *glipizide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
30. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using Novalog InsulinMax Dose Override
Reason: poorly controlled diabetes
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: CHF exacerbation, ___
Secondary: Subacute basal ganglia stroke, resolving pulmonary
infection
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 had worsening shortness
of breath in the setting of having too much fluid in your lungs
due to heart failure. Since you also have had a recent admission
at ___ for a new stroke and a new diagnosis of ___
disease, we also had our neurology team see you with Dr.
___ will be your new neurologist. We also saw that you
had a few concerning findings on your CT scan of your chest at
___, but we felt that this was most likely due to a resolving
pneumonia that you had so we will have you follow up with Dr.
___ at ___ on ___ as below. It is very important
that you take all your medications as prescribed in this form
and follow up with ___ and Dr. ___ their office if
you have ANY questions about your medication. You will also be
re-started on insulin so please call with any questions about
this as well.
Sincerely,
Your care team at ___
Followup Instructions:
___
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.