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10361837-DS-16 | 10,361,837 | 27,515,984 | DS | 16 | 2130-03-06 00:00:00 | 2130-03-06 17:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / Ace Inhibitors
Attending: ___.
Chief Complaint:
dyspnea x 2 days
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
___ who was recently discharged on ___ with
shortness of breath on the ___ service for heart failure,
presenting again with shortness of breath.
Patient was recently discharged 1 week prior for presumed heart
failure exacerbation due to medication noncompliance. He was
diuresed with IV diuretics and discharged on furosemide 40mg
daily. He had ___ services set up and states that he has been
taking his medication as directed. He was doing well until 2
days ago when he woke up short of breath. The night prior he had
gone to a ball and only had 1 alcoholic drink. He does not think
he had a lot of salty food either. He has difficulty stating
whether he has it more on exertion or if he has been gaining
weight. He denies orthopnea, PND, worsening edema. He has a dry
cough with occasional blood streaks. He was also hospitalized at
___ in the last month for a pneumonia. Consolidation and nodules
seen on imaging on last admission were presumed to be resolving
infection.
In the ED, initial vitals were: 97.3 71 154/85 18 88 RA%
- Labs were significant for BNP 8000
- Imaging revealed Multifocal opacities right greater than left
concerning for pneumonia.
- The patient was given 40mg IV lasix
Upon arrival to the floor, he is sitting comfortably in the
chair and does not feel short of breath. He has not yet tried to
walk around.
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 PHYSICAL EXAM:
Vitals:97.5 114/67 66 97%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: fine crackles at mid and lower lung fields bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: chronic venous stasis changes. 1+pitting edema to level of
knee
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
PHYSICAL EXAM:
Vitals: 98 150s/80s-90s RA ___ 19 95 RA
I/Os: 1600 (120) / ___
Weight: 94.5 today, 94.8 kg /98 kg on admission/dry weight
thought 95 kg
General: Alert, oriented, pleasant man, breathing comfortably on
RA
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP just above clavicle, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, midline
sternotomy incision well healed
Lungs: crackles at left base
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: chronic venous stasis changes, trace pitting edema to
level of knee
Pertinent Results:
ADMISSION LABS
___ 06:15PM BLOOD WBC-4.7 RBC-3.58* Hgb-10.8* Hct-32.8*
MCV-92 MCH-30.2 MCHC-32.9 RDW-15.7* RDWSD-52.4* Plt ___
___ 06:15PM BLOOD ___ PTT-31.3 ___
___ 06:15PM BLOOD Glucose-178* UreaN-20 Creat-1.4* Na-129*
K-5.0 Cl-97 HCO3-22 AnGap-15
___ 06:15PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-8276*
___ 06:00AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.4*
___ 06:40PM BLOOD ___ pO2-58* pCO2-35 pH-7.42
calTCO2-23 Base XS-0
___ 06:40PM BLOOD Lactate-1.3
PERTINENT LABS
___ 06:00AM BLOOD WBC-3.4* RBC-3.37* Hgb-10.1* Hct-31.0*
MCV-92 MCH-30.0 MCHC-32.6 RDW-15.9* RDWSD-52.9* Plt ___
___ 06:00AM BLOOD WBC-3.3* RBC-3.80* Hgb-11.3* Hct-34.9*
MCV-92 MCH-29.7 MCHC-32.4 RDW-15.6* RDWSD-52.3* Plt ___
___ 06:10AM BLOOD WBC-3.0* RBC-3.60* Hgb-10.8* Hct-33.1*
MCV-92 MCH-30.0 MCHC-32.6 RDW-15.4 RDWSD-51.2* Plt ___
___ 09:07AM BLOOD Glucose-290* UreaN-31* Creat-2.3* Na-130*
K-4.0 Cl-95* HCO3-22 AnGap-17
___ 02:40PM BLOOD Glucose-250* UreaN-35* Creat-2.5* Na-131*
K-4.6 Cl-96 HCO3-24 AnGap-16
___ 06:10AM BLOOD Glucose-204* UreaN-37* Creat-2.4* Na-133
K-4.0 Cl-97 HCO3-25 AnGap-15
___ 01:27PM BLOOD Glucose-305* UreaN-37* Creat-2.7* Na-131*
K-5.2* Cl-95* HCO3-24 AnGap-17
___ 09:35AM BLOOD Glucose-268* UreaN-34* Creat-2.3* Na-134
K-4.3 Cl-99 HCO3-25 AnGap-14
___ 03:01PM BLOOD Glucose-346* UreaN-36* Creat-2.3* Na-133
K-4.9 Cl-98 HCO3-24 AnGap-16
TACRO:
___ 06:00AM BLOOD tacroFK-8.6
___ 06:00AM BLOOD tacroFK-9.3
___ 09:07AM BLOOD tacroFK-9.0
___ 06:10AM BLOOD tacroFK-14.1
___ 09:35AM BLOOD tacroFK-8.8
___ 04:20AM BLOOD tacroFK-12.3
DISCHARGE LABS
___ 04:20AM BLOOD WBC-2.7* RBC-3.42* Hgb-10.3* Hct-31.9*
MCV-93 MCH-30.1 MCHC-32.3 RDW-15.6* RDWSD-53.5* Plt Ct-99*
___ 04:20AM BLOOD Glucose-201* UreaN-35* Creat-2.1* Na-135
K-4.1 Cl-98 HCO3-26 AnGap-15
___ 04:20AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8
STUDIES
___ CXR: AP portable upright view of the chest. Midline
sternotomy wires and mediastinal clips are noted. There is
increasing consolidation in the lower lungs, right greater than
left. There is relative sparing of the left upper lung.
Findings are concerning for pneumonia. No large effusion is
seen. Heart remains enlarged. Mediastinal contour is unchanged.
Bony structures are intact.
IMPRESSION: Multifocal opacities right greater than left
concerning for pneumonia.
****
MICROBIOLOGY
___ Blood culture: Negative
___ Legionella urinary antigen: Negative
Brief Hospital Course:
___ yo M with h/o diastolic CHF (EF 50-55%), CAD s/p 4 vessel
CABG, ESRD s/p kidney transplant x2 ___ and ___, HIV, HTN,
DM2, who is here with 3 days worsening shortness of breath and
productive cough.
#Dyspnea/hypoxemia: Patient presented with dyspnea, volume
overload, O2 sat 88% on admission. He also had productive cough,
immunocompromised state, and CXR concerning for pneumonia. ID
were consulted as they had seen him during prior admission. He
was diuresed with excellent improvement in dyspnea and
hypoxemia, and was able to come off supplemental O2. He was also
treated with a 7 day course of levaquin for possible CAP. Given
smoking history he was also given nebs for possible COPD,
although does nto have this diagnosis. Sputum culture was
attempted but only showed contaminants. Upon discharge he was
satting well on RA and ambulating comfortably.
#Community acquired pneumonia: Treated with 7 day course of
levaquin as above.
#Acute on chronic diastolic heart failure: Patient presented
with mild crackles on exam, volume overload, hypoxemia as above.
Precipitant unclear although concern for infection/underlying
pulmonary process as above. He may also have been on inadequate
dose of maintenance outpatient diuretic. He was diuresed. Home
metoprolol continued. TTE was deferred as this was done very
recently prior to admission.
#CAD s/p MI and CABG: Continued ASA, metoprolol and pravastatin.
#ESRD s/p renal transplant x2: Followed outpatient by Dr.
___. Previous Cr 1.0 at last visit in ___ but now with
worsening renal function beginning with prior admission,
suggestive of new baseline. He was continued on azathrioprine,
prednisone. Tacrolimus level was adjusted. He continued bactrim
prophylaxis. Renal transplant followed in house.
#HIV: Last CD4 264 and HIV VL undetecatble during prior
admission. He continued triumeq.
#Possible parkinsonism: Previously diagnosed at ___, possibly
related to tacro, although neurology here did not find
parkinsonian symptoms on exam during prior admission. He
continued carbidopa/levodopa and ropinirole. He may benefit from
outpatient follow up for further evaluation and medical
management.
#Prior CVA: Likely subacute infarct identified on MRI
previously. He was continued on pravastatin, ASA as above.
#Diabetes: Recently started on glargine 30u AM. Home glipizide
was adjusted. He was given glargine and humalog sliding scale in
house.
TRANSITIONAL ISSUES:
-7 day course of levofloxacin, dosed at 750 mg every other day
given renal function, to end with last dose on ___
-Patient discharged on diuretic regimen: torsemide 40 mg PO
daily.
-WBC on day of discharge was 2.7. Please recheck CBC as an
outpatient.
-discharged on 3 mg BID tacrolimus. Please check tacro level and
adjust as indicated.
-DISCHARGE WEIGHT: 94.5 kg
# CODE STATUS: Full
# CONTACT: Dr. ___
Relationship: friend
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
2. Azathioprine 125 mg PO DAILY
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Amlodipine 10 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Metoprolol Succinate XL 200 mg PO DAILY
7. oxyCODONE-acetaminophen 7.5-325 mg oral Q6H:PRN
8. Pravastatin 40 mg PO QPM
9. PredniSONE 5 mg PO DAILY
10. Ropinirole 4 mg PO QPM
11. Sertraline 200 mg PO DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus 5 mg PO Q12H
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
15. Milk of Magnesia 30 mL PO PRN constipation
16. Bisacodyl ___AILY:PRN constipation
17. Aspirin 81 mg PO DAILY
18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
19. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
20. Nystatin Cream 1 Appl TP BID:PRN rash
21. Diphenoxylate-Atropine 2 TAB PO BID:PRN diarrhea
22. Furosemide 40 mg PO DAILY
23. GlipiZIDE XL 10 mg PO DAILY
24. Simethicone 80 mg PO Q8H:PRN gas pain
25. Acetaminophen 650 mg PO Q6H:PRN pain
26. Glargine 30 Units Bedtime
27. Guaifenesin 5 mL PO Q4H:PRN cough
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Azathioprine 125 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
9. Metoprolol Succinate XL 200 mg PO DAILY
10. Milk of Magnesia 30 mL PO PRN constipation
11. Nystatin Cream 1 Appl TP BID:PRN rash
12. Pravastatin 40 mg PO QPM
13. PredniSONE 5 mg PO DAILY
14. Ropinirole 4 mg PO QPM
15. Sertraline 200 mg PO DAILY
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
18. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*1 Tablet Refills:*0
19. Diphenoxylate-Atropine 2 TAB PO BID:PRN diarrhea
20. GlipiZIDE XL 10 mg PO DAILY
21. Guaifenesin 5 mL PO Q4H:PRN cough
22. oxyCODONE-acetaminophen 7.5-325 mg oral Q6H:PRN
23. Simethicone 80 mg PO Q8H:PRN gas pain
24. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
25. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
26. Glargine 30 Units Bedtime
27. Tacrolimus 3 mg PO Q12H
RX *tacrolimus 1 mg 3 capsule(s) by mouth every 12 hours Disp
#*90 Capsule Refills:*0
28. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Hypoxemia
Acute on chronic diastolic heart failure
Community acquired pneumonia
Secondary
CAD s/p MI and CABG
ESRD s/p renal transplant
HIV
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you awoke with
difficulty breathing and were found to be in mild heart failure
exacerbation. You received diuretic medications (which make you
urinate off extra fluid) by IV (through your arm). We also
treated you for a pneumonia with antibiotics. Your breathing
improved and you stopped requiring oxygen. You were seen by the
infectious disease team and we started you on an antibiotic for
pneumonia. You need to take your last dose of this medicine
(called levaquin) tomorrow (___).
We also gave you IV diuretic medications to remove fluid from
your lungs. It is very important that you weigh yourself every
morning, and call your doctor if your weight goes up more than 3
lbs in 1 day or 5 lbs in 1 week.
It is important that you attend your follow up appointment with
your kidney transplant doctors.
___ was a pleasure taking care of you during your stay in the
hospital.
Very best wishes,
Your ___ Team
Followup Instructions:
___
|
10361837-DS-18 | 10,361,837 | 28,911,641 | DS | 18 | 2130-04-16 00:00:00 | 2130-04-16 21:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / lisinopril / Ace Inhibitors
Attending: ___
Chief Complaint:
Left arm weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per Dr. ___ is a ___ left handed man with
extensive PMH including prior strokes, HIV, s/p renal transplant
who presented after a transient episode of left arm weakness.
The patient is a very poor historian but what he recalls is that
around 3am he woke up with the need to urinate. He was sleeping
curled up on his left side. When he rolled over onto his back he
found that his left arm "didn't feel right". He said that it was
not numb and he does not recall any pins and needles but it
wasn't moving normally. He was able to get it off the bed and
move it around in the air. He cant say if there was a pattern to
the weakness. He got up and went to the bathroom - able to
ambulate without trouble. He looked into the mirror and his face
looked normal. He went to sit down in his favorite chair and
tried to "shake off" the problem, at which time it slowly
resolved. The entire event lasted about 10 minutes.
The following day the patient talked to a friend who recommended
that he present to the ED for TIA evaluation.
Of note: he was in the hospital from ___ to ___ for
heart failure found to have an NSTEMI and was taken to cardiac
cath on ___ for a balloon angioplasty. The patient notes that
since DC his ___ has not been coming in so he has been managing
his medications on his own. He finds this to be very challenging
but does not think that he misses meds (though he can not name
any medications he takes).
Of note: The patient was also hospitalized on ___ - ___
for CAP. ___ - ___ for acute on chronic CHF. Also
admissions to ___ in ___.
On neuro ROS: the pt denies headache, loss of vision, blurred
vision, diplopia, oscilopsia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. No bowel or
bladder incontinence or retention. Denies difficulty with gait.
On general ROS: the pt denies recent fever or chills. No night
sweats or recent weight loss or gain. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
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:
VS: Tm 98.0 T 97.1 110s-140s/60s-70s ___ ___
96-100RA FSBG 1811-415
Gen: AOx3, NAD
Pulm: breathing comfortably
Neruo: nonfocal, full strength in bilateral upper extremities,
steady gait with use of cane
Pertinent Results:
ADMISSION LABS:
___ 01:45PM BLOOD WBC-3.2* RBC-3.25* Hgb-9.8* Hct-30.7*
MCV-95 MCH-30.2 MCHC-31.9* RDW-14.8 RDWSD-51.4* Plt ___
___ 01:45PM BLOOD Neuts-50.8 ___ Monos-10.3 Eos-6.3
Baso-1.0 Im ___ AbsNeut-1.53* AbsLymp-0.93* AbsMono-0.31
AbsEos-0.19 AbsBaso-0.03
___ 01:45PM BLOOD Glucose-389* UreaN-27* Creat-1.5* Na-131*
K-4.3 Cl-96 HCO3-22 AnGap-17
___ 01:45PM BLOOD ALT-17 AST-21 AlkPhos-122 TotBili-0.3
___ 01:45PM BLOOD cTropnT-0.04*
___ 06:45AM BLOOD cTropnT-0.04*
___ 01:45PM BLOOD Albumin-3.0*
___ 02:08PM BLOOD Lactate-1.6
PERTINENT LABS:
___ 06:45AM BLOOD %HbA1c-8.6* eAG-200*
___ 06:45AM BLOOD Triglyc-152* HDL-62 CHOL/HD-2.6
LDLcalc-68
DISCHARGE LABS:
___ 09:08AM BLOOD WBC-3.4* RBC-3.41* Hgb-10.4* Hct-32.5*
MCV-95 MCH-30.5 MCHC-32.0 RDW-14.6 RDWSD-50.7* Plt ___
___ 09:08AM BLOOD Glucose-300* UreaN-32* Creat-1.7* Na-129*
K-4.6 Cl-98 HCO3-20* AnGap-16
IMAGING:
___ CTA Head
Head CT: No evidence of intracranial hemorrhage. Hypodensity
involving the
left basal ganglia consistent with chronic infarcts.
CTA: Right middle cerebral artery is occluded, similar
appearance to prior
head MRA from ___. Right vertebral artery is hypoplastic
with non
visualization of the V4 segment. Severe atherosclerotic disease
of the
bilateral carotid bifurcations with approximately 50 to 75%
percent stenosis of the right internal carotid artery. Severe
atherosclerotic disease of the cavernous carotids. Cardiomegaly.
Severe Coronary artery calcifications. Final read pending 3D
reformats.
___ MRI Head
The evaluation is markedly limited given the acquisition of only
diffusion-weighted and sagittal T1 weighted imaging since the
study had to be aborted in between because of patient
discomfort. No acute intracranial infarct. A repeat study can
be performed at a later date as clinically indicated.
Brief Hospital Course:
___ with PMH of stroke, HIV, s/p renal transplant x2 who
presented to ED with L arm weakness. CTA head without evidence
of hemorrhage, MRI head without evidence of infarct. Diagnosis
likely nerve compression, however TIA cannot be ruled out.
Patient is already on dual anti-platelet and atorvastatin 80.
Concern for patient taking home medications, social work and
case management consulted and determined patient is capable of
administering medications himself.
Of note, patient's blood glucose was elevated. His SSI was
adjusted while in house, and he was instructed to follow-up with
his PCP and endocrinologist for ongoing management.
Additionally, patient's sodium was mildly low. He chronically
has lower values, and recommend trending this value with his
PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Azathioprine 125 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Guaifenesin 5 mL PO Q4H:PRN cough
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
10. PredniSONE 5 mg PO DAILY
11. Ropinirole 4 mg PO QPM
12. Sertraline 200 mg PO DAILY
13. Simethicone 80 mg PO Q8H:PRN gas pain
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Tacrolimus 3 mg PO Q12H
16. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
17. GlipiZIDE XL 10 mg PO DAILY
18. Lantus (insulin glargine) 30 units subcutaneous QHS
19. Metoprolol Succinate XL 200 mg PO DAILY
20. Milk of Magnesia 30 mL PO PRN constipation
21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
22. Nystatin Cream 1 Appl TP BID:PRN rash
23. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
24. oxyCODONE-acetaminophen 7.5-325 mg oral Q6H:PRN
25. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
26. Clopidogrel 75 mg PO DAILY
27. Atorvastatin 80 mg PO QPM
28. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
29. Torsemide 60 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Azathioprine 125 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Metoprolol Succinate XL 200 mg PO DAILY
11. oxyCODONE-acetaminophen 7.5-325 mg oral Q6H:PRN
12. PredniSONE 5 mg PO DAILY
13. Sertraline 200 mg PO DAILY
14. Simethicone 80 mg PO Q8H:PRN gas pain
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
16. Tacrolimus 3 mg PO Q12H
17. Torsemide 60 mg PO DAILY
18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itch
19. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
20. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
21. Ropinirole 4 mg PO QPM
22. Nystatin Cream 1 Appl TP BID:PRN rash
23. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
24. Milk of Magnesia 30 mL PO PRN constipation
25. Bisacodyl ___AILY:PRN constipation
26. Carbidopa-Levodopa (___) 1 TAB PO TID
27. GlipiZIDE XL 10 mg PO DAILY
28. Guaifenesin 5 mL PO Q4H:PRN cough
29. Lantus (insulin glargine) 30 units subcutaneous QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Nerve compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with left arm weakness. The imaging
of you brain did not show evidence of a stroke. It is likely
that your symptoms were caused by compression of the nerves in
your left arm. You are being discharged home. You should
follow-up with the neurology team in the next ___ weeks (see
below). Please continue to take all your home medications and
contact your PCP with any concerns regarding these prescriptions
or need for refills, as it is very important that you take your
aspirin, amlodipine, metoprolol, and atorvastatin to prevent
future stokes.
Of note, your blood sugars (blood glucose) were high during your
hospital admission. Please contact your PCP ___
endocrinologist (diabetes doctor) to further evaluate your
insulin and diabetes medications.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Sincerely,
You ___ Care Team
Followup Instructions:
___
|
10362003-DS-20 | 10,362,003 | 20,121,113 | DS | 20 | 2171-06-02 00:00:00 | 2171-06-02 20:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Chest tube placement and thoracentesis ___
History of Present Illness:
___ with hx only of hip replacement and arthritis who presents
with progressive SOB and R sided chest pain. She has not seen ___
MD for many years but has ___ NP ___) who visits her
at home. Patient states that she has had a cough for years but
has had worsening SOB over the past several weeks to 1 month.
She had a CXR performed yesterday and was given an abx for PNA,
however when she developed worsening SOB, her visiting nurse
called her and suggested that she call ___ and present to the
ED. Reports that her pain is right sided and radiates to her
neck and is worse with inspiration and does not seems to
associated with activity.
ROS + for 50lb wt loss over past year, chills. She denies any
N/V, belly pain, diarrhea. Increased urinary frequency which has
been controlled recently. She also reports intermittent
constipation which is currently controlled with a "pill." She
reports decreased appetite over the past several months as well
but recently had new dentures made and has had issues with
swallowing and chewing.
In the ED, initial vitals notable for ___ pain, T 97.6, HR 122,
BP 123/78, RR 22, 96% on NC. No documented exam. Labs notable
for Na 146, K 5.2, Cr 0.9. WBC 11.7, Hgb 14.6, Plt 328. CXR
showed large R sided effusion. Patient given 1L NS and then
developed Afib with RVR and received 10mg IV dilt with
improvement in HR. IP was consulted and placed R sided chest
tube which drained 1700cc. Patient also then given ASA 324mg,
750mg Levoflox and 2.5mg PO Oxycodone. Patient also underwent
CTA to rule out PE which was negative for PE, however noted an
obstructive hilar mass. After placement of chest tube, HR and RR
and sats improved, however patient admitted to ICU given
previous tachycardia.
On transfer, vitals were 98.5, 86, 129/55, RR 26, 96% NC. On
arrival to the MICU, patient resting comfortably in bed. VSS.
Past Medical History:
- Hip Replacement
- R Leg Surgery
- Low Blood Pressure
- ? Overactive bladder
- R pleural effusion
- R-sided thoracic mass
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PE:
Vitals: Afebrile. HR ___ BP 124/70; RR ___ 98% on 2L NC
GENERAL: Alert, oriented, no acute distress. Cachectic female.
HEENT: Sclera anicteric, dry MM, oropharynx clear
NECK: supple, JVP not elevated, no cervical supraclavicular
adenopathy
LUNGS: reduced BS at R base. Crackles at L base. no wheezes,
rales, rhonchi
CV: irregularly irregular, 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, bilateral pitting edema
NEURO: A&Ox3. Moving all extremities with purpose
DISCHARGE PE:
Vitals: 97.9 119-131/50-54 52-68 ___ 95% on 4L NC
GENERAL: Alert, oriented, no acute distress. Cachectic female.
Pleasant.
HEENT: NCAT
NECK: supple
LUNGS: reduced BS on R, no wheezes, rales, rhonchi
Chest: R chest tube removed
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, no rebound tenderness or
guarding
EXT: Warm, well perfused, trace edema
NEURO: A&Ox3. Moving all extremities with purpose
Pertinent Results:
ADMISSION LABS:
___:55AM BLOOD WBC-11.7*# RBC-4.91 Hgb-14.6 Hct-47.4*
MCV-97 MCH-29.7 MCHC-30.8*# RDW-13.9 RDWSD-48.9* Plt ___
___ 11:55AM BLOOD Neuts-90.1* Lymphs-2.4* Monos-6.7
Eos-0.0* Baso-0.3 Im ___ AbsNeut-10.53* AbsLymp-0.28*
AbsMono-0.78 AbsEos-0.00* AbsBaso-0.03
___ 11:55AM BLOOD ___ PTT-30.7 ___
___ 11:55AM BLOOD Glucose-176* UreaN-29* Creat-0.9 Na-146*
K-5.2* Cl-106 HCO3-26 AnGap-19
___ 11:55AM BLOOD LD(LDH)-304*
___ 11:55AM BLOOD cTropnT-0.03*
___ 11:55AM BLOOD TotProt-6.6 Calcium-9.6 Phos-4.1 Mg-2.4
___ 02:42PM BLOOD pH-7.31* Comment-PLEURAL FL
DISCHARGE LABS:
___ 05:37AM BLOOD WBC-9.6 RBC-4.31 Hgb-12.6 Hct-41.4 MCV-96
MCH-29.2 MCHC-30.4* RDW-13.6 RDWSD-48.2* Plt ___
___ 06:22AM BLOOD ___ PTT-31.0 ___
___ 05:37AM BLOOD Glucose-95 UreaN-16 Creat-0.4 Na-141
K-4.4 Cl-102 HCO3-30 AnGap-13
___ 05:37AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
STUDIES/IMAGING:
___ CXR:
IMPRESSION:
There continues to be a small right apical pneumothorax.
Opacity in the right lower lung is unchanged. The right-sided
effusion slightly smaller. The right pigtail catheter is again
seen. There is small left effusion that is increased compared
to prior. The upper lungs are clear.
___ CXR:
AP upright chest radiograph is compared to radiograph performed
approximately 3 hours prior. There has been placement of a right
basal pigtail chest tube with interval decrease in size of a
right pleural effusion now moderate in volume. No pneumothorax.
Otherwise unchanged.
___ CHEST CTA:
1. No evidence of pulmonary embolism.
2. Large right infrahilar mass which results in subsegmental
atelectasis of the right upper lobe and partial collapse of the
right lower lobe. Secretions are present within the bronchus
supplying the right lower lobe as well as numerous mucoid
impactions within the airways supplying the left lower lobe
inferiorly.
3. Moderate-sized right pneumothorax, a chest tube identified
traversing the right eighth and ninth ribs space. Trace
nonhemorrhagic right pleural effusion.
4. Moderate centrilobular emphysema is apical predominant.
EKG: initial EKG Afib with RVR, repeat EKG, narrow complex
tachycardia
Brief Hospital Course:
___ with minimal PMH who presents with progressive SOB found to
have large R effusion and hilar mass concerning for malignancy.
#SOB/Lung Mass/Pneumothorax: given weight loss, smoking history,
very concerning for malignancy. Effusion consistent with
exudative. Pt also with trapped lung physiology and iatrogenic
pneumo. Chest tube was removed, however a pleurex catheter may
be considered for palliatiation if effusion returns. Pleural
fluid cytology is still pending. The patient has indicated she
would not want further investigation if the cytology is
equivocal. Arrangements were made for hospice care.
#Afib with RVR vs atrial ectopic rhythm: patient with episode of
afib with RVR in the ED that improved with Diltiazem but repeat
EKG appeared to show atrial ectopic rhythm. CHADS2 score 1 so
anticoagulation not indicated and unlikely to be within
patient's goals of care. Also had episode of SVT, resolved with
carotid massage. Her Metoprolol was adjusted to 25mg BID for
goal heart rate of 60.
#Goals of care: Patient has filled out a DNR/DNI/DNH MOLST.
========================
TRANSITIONAL ISSUES:
- Palliative/hospice care per facility
- Consider placement of pleurex catheter for palliative drainage
in case of recurrent effusions
- Enjoys opera and crossword puzzles
Medications on Admission:
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ due to fluid in your lung. You had this
fluid drained with a chest tube, which was then removed. If the
fluid reaccumulates, you may need another chest tube placed
permanently so fluid can be removed as needed.
It was also discovered that you have a large mass in your chest.
___ studies did not definitively identify the cause of your
mass. You have indicated to us that if these tests are
inconclusive, you would not want further invasive studies, such
as a biopsy, for definitive diagnosis.
It was a pleasure taking care of you,
Your ___ team
Followup Instructions:
___
|
10362013-DS-5 | 10,362,013 | 29,355,260 | DS | 5 | 2182-10-21 00:00:00 | 2182-10-21 18:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / Dilaudid
Attending: ___.
Chief Complaint:
back pain
suspicious lesions in the verterbral bodies found on
non-contrast MRI in the ED
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with a PMH significant for
chronic back pain, cervical radiculopathy, reported history of
disc herniation, suspicious lesions in her brain concerning for
MS, and osteopenia who presents with a 4 day history of weakness
in her thighs progressing to ___ back pain in the ___
the spine."
Ms. ___ reports that she was vacuuming on ___ when she
started to feel pain in her back. She reports waking the next
morning with weakness in her thighs. She was still able to
climb stairs and get out of a chair to standing but that it took
her longer than usual. She reports that one day later the
weakness resolved but the pain in her lower back was worsening
and she felt like her "spine was going to snap." She is unsure
of the start of her pain, but believes it gradually worsened
over months. Of note, she was taking care of her mother with
___ disease and was lifting her frequently until her
mother passed away ___ she believes the pain has been
worsening since then. She reports the pain was not present in
the mornings, but worsened throughout the day; it was worst when
sitting and she was unable to drive with the pain. She endorsed
that it improved when lying down and with heat; she denied that
it woke her up at night or that it radiated down her leg. She
also denied weight loss, anorexia, fever, fatigue, recent night
sweats. Her last mammogram was ___ years ago and she has never
had a colonoscopy.
Of note, work up of past back pain found "white spots" on her
brain and C-spine, she is followed by a Neurologist, and has
declined LP for further characterization. She has baseline
chronic back pain as well as muscle spasms but never had
weakness.
In the ED, initial VS were: 5 98.1 74 122/81 16 95%RA. CHEM7 and
CBC were unremarkable. On exam, she was felt to have weakness in
her bilateral IPs, so neurology was consulted. On their
neurological examination, however, this was not present. She had
an MRI L-spine to evaluate for myelopathy ___ showed
multi-level abnormalities on her thoracic spinal MRI concerning
for mets, though needed further characterization with a
gadolinium-enhanced study. She received 1 Percocet and Lorazepam
1mg PO. Was admitted to Medicine for further workup. VS prior to
transfer were ___ 116/60 96% RA pain ___.
On arrival to the floor, vitals were: T 98.1 BP 117/68 HR 68 RR
20 O2sat 97RA with pain at ___. She was upset by the possible
diagnosis of cancer. This morning, she felt that her pain was
adequately controlled at ___ and she was tired because she
didn't have time to sleep. She felt that her pain would be
worse if she sat up. Of note, she denied any desire to hurt
herself or anyone else.
Past Medical History:
- ADD (medicated occasionally with daughter's ___
and amphetamine)
- seasonal allergies
- asthma (uses Fluticasone and salmeterol
- anxiety (Lorazepam 2mg PO Q6H PRN)
- cervical disc dz
- cervical radiculopathy
- depression with hospitalizations for depression and SI
- ? MS, followed by Dr. ___ at ___ in
___ has had multiple MRI's of head and cervical spine
for "white spots", but pt refused LP, so unclear of the
significance
- s/p removal of osteoid osteoma from her R femur in ___
- s/p removal of parathyroid gland at ___ for
hyperparathyroidism
in ___
- s/p CCY in ___
- mltiple asthma and PNA hospitalizations
- routine cancer screening: never had a colonoscopy, last
mammogram was ___ years ago, last Pap smear was ___ years ago
Social History:
___
Family History:
-Home: Living in her cousin's basement in ___.
Divorced ___ years and is on bad terms with her ex. They have 1
daughter and adopted a daughter and a son. One daughter is not
speaking with her.
-Occupation: ___
-Tobacco: Smokes 1.5-2ppd and has done so since ___ (but had
previously quit from ___ to ___, and before ___ had been
smoking 2 pps since ___
-EtOH: Drinks ___ glasses of wine most but not all nights; ~
___ drinks per week
-Illicits: None
Physical Exam:
VITALS: T 98.1 BP 117/68 HR 68 RR 20 O2sat 97RA
GENERAL: calm, non-toxic, non-diaphroetic, no acute distress
lying flat in bed with heating pad on back
HEENT: pinpoint pupils. Very poor dentition with several missing
teeth; one 5 mm numular white plaque on her right buccal mucosa.
NECK: no thyromegaly or palpable thyroid nodules, JVP at 7 cm at
30 degrees.
Lymph nodes: no cervical or axillary lymphadenopathy
LUNGS: bilateral basilar inspiratory and expiratory wheezes; no
rhonchi or rales
BACK: tender at level of L2-L4 with paraspinal tenderness; no
pain with straight leg raise; extreme left sided CVA tenderness
that she associated with muscle spasm
HEART: regular rate and rhythm, normal S1 S2, no murmurs rubs or
gallops
ABDOMEN: Soft, non-tender, non-distended, no organomegaly
EXTREMITIES: 1+ pitting edema at ankles and at sacral spine. no
cyanosis or clubbing
NEUROLOGIC: A+OX3; ___ strength in lower extremities
bilaterally. 2+ reflexes patellar and achilles. normal
sensation intact bilaterally. Vibration sense intact at medial
malleolus. joint position sense intact at toes.
Pertinent Results:
___ 10:50PM GLUCOSE-77 UREA N-15 CREAT-0.6 SODIUM-139
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
___ 10:50PM WBC-7.7 RBC-4.48 HGB-14.2 HCT-42.2 MCV-94
MCH-31.7 MCHC-33.6 RDW-12.6 PLT COUNT-243
___ 10:50PM NEUTS-42.7* LYMPHS-43.1* MONOS-4.7 EOS-9.0*
BASOS-0.5
___ 10:50PM CRP-0.9
___ 10:50PM SED RATE-5
MR THORACIC SPINE W/O CONTRAST ___ FINAL
1. No abnormal signal in the spinal cord to suggest myelopathy.
2. Non specific signal abnormality in the T4, T6, T7, and T10
vertebral bodies
which likely reflect hemangiomas or focal fat deposits.
3. Degenerative changes of the thoracic spine. If there is any
clinical
concern with malignancy, correlation with bone scan is
recommended.
MR ___ SPINE SCAN WITH CONTRAST ___ FINAL:
The previously identified non specific vertebral body lesions
are
non enhancing and may again reflect focal fat or hemangiomas.
If there is any clinical concern with malignancy, correlation
with bone scan is recommended.
CHEST (PA & LAT) ___ UNREAD: Follow up with your PCP about
the results.
Brief Hospital Course:
HOSPITAL COURSE:
Ms. ___ is a ___ year old woman with a past medical history of
chronic back pain, cervical radiculopathy, and history of
lesions in her C-spine and brain suspicious for MS who presented
to the ED due to 4 days of worsened back pain with some proximal
leg weakness and was admitted due to concerns about multi-level
spine lesions seen on MRI. She received an MRI with contrast
which showed verterbral body fat deposits or hemangiomas which
were both BENIGN. She had a chest X ray when there was
suspicion for metastatic cancer which is still pending on
discharge. She has been instructed to follow up with her PCP
about the results of the chest X ray.
ACTIVE ISSUES:
# Back pain: She has a history of chronic back pain; during past
work up an MRI showed findings of "white spots" on her brain and
C-spine on MRI concerning for MS; she also has a family history
of MS. ___ the time, she refused LP and further work up due to
no weakness. She presented to the ED with subjective weakness
(see below) and ___ back pain which she has never experienced
before. MRI without contrast preliminarily showed spine column
lesions concerning for mets per Radiology and she was admitted
for work up. Follow up MRI with contrast preliminary did not
enhance like metastaces and were considered to be fat deposits
or hemangiomas which are both benign. Ms. ___ back pain
was well controlled inpatient with Oxycodone-Acetaminophen
(5mg-325mg) ___ TAB PO/NG Q6H:PRN pain plus her home pain
regimen.
# Leg weakness: The patient reported subjective proximal thigh
weakness but was still able to climb stairs and rise from a
chair. Her neuro exam showed no objective weakness and was
normal with ___ strength bilaterally, 2+ patellar and achilles
reflexes, normal sensation bilaterally, vibration sense at the
medial malleolus and intact joint position sense. The patient
has been counseled to be careful when she feels weak to avoid
falling and to use the handrail when going up and down stairs.
# Family history of breast cancer: The patient's sister had
breast cancer at age ___ and therefore we strongly encouraged her
to get a screening mammography and colonoscopy. Her las
mammogram was ___ years ago with no history of colonoscopy. She
will follow up with her PCP about this.
# Anxiety, depression: Endorses significant depression with
inability to afford prescribed medications. Has many
psychosocial stressors including losing her house, living in her
cousin's basement, losing her mother. She denied any desire to
hurt herself or others. She has a history of passive suicide
ideation in ___ which she was admitted to an ___
hospital for 3 days. She endorses difficulty affording her
medication but was well controlled on Cymbalta in the past. She
was last prescribed Celexa which she doesn't take and cannot
afford. Because she was informed in the ED that she may have
spinal metastaces, she expressed significant distress. In
house, she was reassured that it was not a final diagnosis, that
she was not alone and that her team was here to support her and
to develop an aggressive plan if the results of the MRI with
contrast show cancer. She was promptly informed that she does
not have metastaces to the spine when the MRI with contrast came
back. A social work consult also saw her. We have continued
her home lorazepam and her home trazodone with assistance
through the ___ free pharmacy to receive these. For the
trazedone, we have started with 100mg HS instead of prior 300mg.
INACTIVE ISSUES:
# Asthma: stable but bibasilar inspiratory and expuiratory
wheezes heard on auscultation. Continued home inhalers.
TRANSITIONAL ISSUES:
- NEW primary care physician because her previous doctor retired
(scheduled at ___ Primary Care ___ with Dr. ___ on
___.
- f/u with PCP about results of Chest X ray which were pending
on discharge
- f/u with PCP for scheduling mammogram
- f/u with PCP for scheduling colonoscopy
- confirm status with new ___ registration via financial
counseling
- got subsidized medications from ___ pharmacy at discharge
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lorazepam 2 mg PO Q6H:PRN anxiety
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation 2 puffs every ___ H as needed shortness of
breath/wheezing
4. traZODONE 300 mg PO HS
***has not been taking because lost insurance***
5. Soma *NF* (carisoprodol) 350 mg Oral TID
6. Ibuprofen 800 mg PO BID:PRN pain
7. Vitamin D 800 UNIT PO DAILY
8. Calcium Carbonate 1250 mg PO DAILY
***has not been taking as prescribed***
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *Advair Diskus 500 mcg-50 mcg/Dose 500-50 mcg inhaled twice a
day Disp #*1 Inhaler Refills:*0
2. Ibuprofen 800 mg PO BID:PRN pain
3. Lorazepam 2 mg PO Q6H:PRN anxiety
RX *Ativan 2 mg 2 mg(s) by mouth every six (6) hours Disp #*28
Tablet Refills:*0
4. Soma *NF* (carisoprodol) 350 mg Oral TID
5. traZODONE 300 mg PO HS
6. Vitamin D 800 UNIT PO DAILY
7. Calcium Carbonate 1250 mg PO DAILY
***has not been taking as prescribed***
8. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation 2 puffs every ___ H as needed shortness of
breath/wheezing
9. Acetaminophen 650 mg PO Q6H:PRN pain
RX *8 HOUR PAIN RELIEVER 650 mg 1 Tablet(s) by mouth every six
(6) hours Disp #*28 Tablet Refills:*0
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 Capsule(s) by mouth every six (6) hours
Disp #*28 Tablet Refills:*0
RX *oxycodone 5 mg 1 Capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
back pain
verterbral body fat deposits or hemangiomas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing ___ for
your care. You were admitted for back pain and suspicious
lesions on an MRI of your spine. A repeated MRI with contrast
revealed that these lesions were likely either fat deposits or
hemangiomas which are both BENIGN. Your pain has improved.
During your admission, you were set up with ___
insurance and an appointment was made for you with your new
primary care physician, ___ at the ___ Care
Clinic.
Please continue your home medications. DO NOT take the
lorazepam and the Soma at the same time because these
medications can make you unsteady on your feet and may cause you
to fall.
Please START the following medications:
1. Oxycodone hydrochloride 5 mg up to four times per day as
needed for PAIN
2. acetaminophen 650 mg up to four times per day as needed for
PAIN
Please follow up with Dr. ___ new primary care physician
___:
1. scheduling a mammogram
2. scheduling a colonoscopy
3. follow up about the results of the Chest X ray from ___.
The results were pending at discharge.
Followup Instructions:
___
|
10362557-DS-15 | 10,362,557 | 22,621,798 | DS | 15 | 2168-12-21 00:00:00 | 2168-12-21 15:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Nsaids
Attending: ___
Chief Complaint:
language difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The history is obtained via the patient's granddaughter at
bedside as well as through the assistance of a ___
interpreter.
___ ___ speaking only right-handed woman with
past medical history significant for hypertension,
hyperlipidemia who was noted by her granddaughter to have
difficulty getting her words out today. 911 was called and she
was brought to the emergency room where a code stroke was
activated. As it turns out, the patient felt as if her language
has been more difficult than normal since at least yesterday.
Per the patient's granddaughter at the bedside, the patient's
son whom she lives with, also noticed that she had difficulty
speaking yesterday. Before that, she was relatively highly
functioning, ambulating unassisted although she does have pain
in her feet from varicose veins. She able to take care of all
her ADLs. As for her new speech deficits, the patient and her
granddaughter deny any ___, no neologisms, no gibberish
speech, or dysarthria. She just has new stuttering and starts
sentences but does not finish them. The patient states that she
is having trouble getting the words out. A code stroke was
activated for the patient's new language deficits.
On neuro ROS, language deficits as described above. The pt
denies headache, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, occasional dysuria, pain in her
feet from varicose veins. The pt denies recent fever or chills.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
CPPD
GASTROINTESTINAL BLEEDING
GI BLEED AFTER NSAIDS
HYPERTENSION
OSTEOARTHRITIS
PSEUDOGOUT
RISK ASSESMENT
SPONDYLOSIS
VITAMIN D DEFICIENCY
OSTEOPENIA
Social History:
___
Family History:
No family history of strokes
Physical Exam:
Admission exam:
- Vitals: 97.8 60 175/55 18 99% on room air
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft
- Extremities: Prominent varicose veins in bilateral feet
NEURO EXAM:
Performed with the assistance of the ___ language
interpreter
- Mental Status: Awake, alert, able to tell me that it is
___. Knows that she is in a hospital but not which one.
Cannot tell me the month or the year. When trying to tell me
the year she says "7" "6" "7" "next year is 18" unable to tell
me who the president is. Her speech becomes confused at this
point she starts saying her "doctor is the president." She is
unable to clarify this more. About a minute later, cries out
"___ is the president." She is able to name key, chair, and
feather on the stroke card. Repeatedly says hand, after
prompting gets glove. Unable to name cactus or hammock. When
asked to describe the cookie theft picture. Repeatedly states
"exercising" when pointing at the boy. She also says "she is
holding something" referring to the lady holding the dish. When
asked how many people in the picture, she just points at each of
the figures but is unable to give a number. On further
questioning, continues to repeat "exercising" and "she is
holding something." With 2 attempts, she is able to repeat "it
is always sunny in ___ (again, everything she says is in
___. When asked to touch her right ear with her left
hand, she touches her right ear with her right hand. She does
not get this correct despite several attempts. When asked her
remember table, ___, and apple; takes 2 attempts to register
and recalls none at 3 minutes. Per the interpreter, speech was
not dysarthric with no paraphasic errors but she did have some
stuttering. When asked to pantomime brushing her teeth and
hitting a nail on the head with a hammer, she uses her finger
for both of these actions when using both her left and right
hand.
- Cranial Nerves:
PERRL 3 to 2mm. VFF to confrontation to number counting. EOMI
with saccadic intrusions. Facial sensation intact to light
touch. No facial droop. Hearing intact to room voice. Tongue
protrudes in midline.
- Motor: Normal bulk and paratonia throughout. Right pronation,
no drift. No adventitious movements such as tremor or asterixis
noted.
-Reduced range of motion for the deltoids bilaterally. A lot of
perseveration and difficulty with instructions during the motor
exam making it challenging
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4 ___ ___ 5 5 5 5
R 4 ___ ___ 5 5 5 5
- Sensory: Denies deficits to light touch. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
- Coordination: No dysmetria on FNF.
- Gait: Deferred, although her granddaughter walked her to the
commode in the room, and stated that she was walking at
baseline.
Discharge exam:
Vitals: 124-194/50's, HR 50-60, 96% RA
Gen: NAD
Pulm: breathing well on RA
CV: no cyanosis
Abdomen: Soft, NT/ND, small hematoma in LLQ
Extremities: No edema or cyanosis
Neuro:
NEUROLOGICAL EXAMINATION:
MS - limited given language barrier, continues to have brief
intermittent word finding difficulty (baseline)
CN - PERRL, EOMI, face symmetric at rest and with activation
MOTOR - no pronation or drift, moves all extremities
symmetrically and antigravity
SENSORY - grossly intact to LT throughout
Pertinent Results:
___ 08:01PM %HbA1c-5.6 eAG-114
___ 06:15PM URINE HOURS-RANDOM
___ 06:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 06:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-MOD
___ 06:15PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 06:15PM URINE MUCOUS-RARE
___ 05:29PM K+-3.9
___ 05:10PM CREAT-0.7
___ 05:10PM CREAT-0.7
___ 05:01PM GLUCOSE-139* NA+-142 K+-6.2* CL--106 TCO2-24
___ 04:57PM UREA N-17
___ 04:57PM ALT(SGPT)-6 AST(SGOT)-22 ALK PHOS-83 TOT
BILI-0.6
___ 04:57PM cTropnT-<0.01
___ 04:57PM ALBUMIN-3.7
___ 04:57PM TSH-0.92
___ 04:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:57PM WBC-6.9 RBC-4.41 HGB-12.7 HCT-39.5 MCV-90
MCH-28.8 MCHC-32.2 RDW-14.0 RDWSD-45.6
___ 04:57PM PLT COUNT-155
___ 04:57PM ___ PTT-37.0* ___
CTA head and neck
IMPRESSION:
1. No evidence for an acute intracranial abnormality. Chronic
left posterior
frontal infarct is again seen.
2. Approximately 20% right proximal internal carotid stenosis by
NASCET
criteria.
3. Mild focal irregularity of the distal left internal carotid
artery is most
likely atherosclerotic in this age group, though fibromuscular
dysplasia may
have the same appearance in a younger patient. No left carotid
stenosis by
NASCET criteria.
4. Proximal V3 segment of the non dominant right vertebral
artery is irregular
and smaller in caliber than the distal right V3 segment. This
may be
secondary to its diminutive size versus atherosclerosis.
5. Multiple foci of stenosis in the major intracranial arteries,
likely
atherosclerotic. No major intracranial arterial occlusion.
6. 10 mm left thyroid lobe nodule. The ___ College of
Radiology
guidelines suggest that in the absence of risk factors for
thyroid cancer, no
further evaluation is recommended.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under age ___ or less than 1.5 cm in patients age ___ or
___.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or invasion of local tissues by the thyroid nodule.
MRI head w/o con
IMPRESSION:
1. Scattered late acute to early subacute infarcts in the left
frontal lobe in
the MCA territory.
2. Chronic left frontal infarct.
3. No hemorrhage or suggestion of mass
Brief Hospital Course:
Ms. ___ is an ___ ___ speaking only
right-handed woman with past medical history significant for
hypertension, hyperlipidemia who was noted by her granddaughter
to have difficulty getting her words out in the days prior to
presentation. CTA showed a markedly stenotic L MCA at the
bifurcation. MRI was significant for multiple punctate subacute
infarcts in the L MCA superior division - fitting well with her
reported deficits. Given her intracranial stenosis, she was
treated per ___ with 90 days of DAPT and statin. We allowed
some permissive hypertension for the time being given her known
stenosis, but long term goal is normotensive. She will undergo
an outpatient TTE. She was seen by ___ who recommended home ___.
She has neuro follow up.
Transitional issues:
-long term BP goal normotensive
-outpt neuro follow up
-TTE
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No
4. LDL documented? (x) Yes (LDL =78 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO Q48H
2. Lisinopril 10 mg PO DAILY
3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
4. Vitamin D 1000 UNIT PO DAILY
5. ClearLax (polyethylene glycol 3350) 17 gram/dose oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*60
Tablet Refills:*1
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*1
4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
5. ClearLax (polyethylene glycol 3350) 17 gram/dose oral daily
6. Colchicine 0.6 mg PO Q48H
7. Lisinopril 10 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
___
Dx: Cerebral infarction due to thrombosis of left middle
cerebral artery (ICD 10 I63.312)
Prognosis: good
Duration: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Discharge Instructions:
Dear ___ were hospitalized due to symptoms of difficulty with your
speech resulting from an 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 ___ 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:
-intracranial atherosclerosis
-hypertension
-hyperlipidemia
We are changing your medications as follows:
-START aspirin 81 mg daily
-START Plavix 75mg daily
-START atorvastatin 40 mg daily
Please take your other medications as prescribed.
___ will need to get an ECHO ( ultrasound of your heart)as an
outpatient. Please ___ to schedule the ECHO of
your heart.
Please follow up with Neurology and your primary care physician
as listed below.
If ___ 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
___
- 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:
___
|
10362557-DS-16 | 10,362,557 | 20,102,611 | DS | 16 | 2169-06-17 00:00:00 | 2169-06-19 13:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids
Attending: ___.
Chief Complaint:
Left facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ ___ speaking woman with history of
hypertension, hyperlipidemia and left MCA stroke who presents
with transient left facial droop.
Patient was last seen well ___ around 7 ___. At baseline, she
lives by herself and completes all ADLs. This morning she woke
up
and was making breakfast when she experienced dizziness/room
spinning, nausea, and intermittent chest pain. No dyspnea. She
called her son the morning of admission and said she did not
feel
well. He and her granddaughter arrived around noon, and noted
that she was less responsive than normal, diaphoretic/clammy,
and
had a left-sided facial droop. They did not note any other
symptoms at that time. Her symptoms continued until she was in
the ED.
Per neuro consult note, patient was admitted in ___ with L MCA
stroke after presenting with aphasia. CTA showed a markedly
stenotic L MCA, and she was treated per ___ with 90 days
of
DAPT and
statin. She had an echo which showed an elongated left atrium
and normal ejection fraction. She is currently on aspirin 81
monotherapy.
In terms of prior cardiac history, she has never had an MI. She
has had intermittent chest discomfort over the past days to
weeks
but does not clearly associate them with exertion.
She denies any difficulty speaking, focal weakness, paresthesias
or vision changes. She denies URI sx, sore throat, cough,
dyspnea, abdominal pain, n/v/d, dysuria/hematuria, fever/chills.
In the ED, her facial droop resolved.
In the ED, initial vital signs were:
97.4 62 114/57 16 97% RA
Exam notable for:
AVSS
AAOx2, (and to month)
CN ___ intact, NIHSS 0
RRR
CTABL
Abd S/NT/ND
Labs were notable for:
WBC 13.1
Trop 0.03 x2
UA with 6 epis - moderate leuks, small blood, 30 protein,
Studies performed include:
CXR - No acute cardiopulmonary process. Unchanged cardiomegaly
Non-con CT head: No acute intracranial process identified
Patient was given:
Aspirin 324mg
NS @ 100mL/hr
Consults:
Neurology
Vitals on transfer:
97.6 151 / 80 57 18 97 Ra
Upon arrival to the floor, the patient feels well. All her
symptoms have resolved. Denies chest pain, dizziness, weakness.
She has been able to ambulate without issue.
Past Medical History:
CPPD
GASTROINTESTINAL BLEEDING
GI BLEED AFTER NSAIDS
HYPERTENSION
OSTEOARTHRITIS
PSEUDOGOUT
RISK ASSESMENT
SPONDYLOSIS
VITAMIN D DEFICIENCY
OSTEOPENIA
Social History:
___
Family History:
No family history of strokes
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: 97.6 151 / 80 57 18 97 Ra
General: Well appearing, NAD
CV: RRR, no murmurs
Lungs: CTAB, no wheezes or crackles
Abdomen: Soft, NTND, +BS
Extremities: WWP, no edema, no gross asymmetry in calf size or
calf erythema
Neuro: CN III-XII intact, strength ___ throughout, sensation
intact throughout
DISHCARGE PHYSICAL EXAM
========================
VS: 98.1, 127/73, 64, 18, 95%RA
GENERAL: Very pleasant woman sitting in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: Bradycarida, regular rhythm, S1/S2, no murmurs, gallops,
or rubs
LUNGS: Breathing comfortably on room air, bibasilar crackles, no
wheezes or rhonchi
ABDOMEN: +BS, non tender non distended, no guarding or rebound
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: Face symmetric, EOMI, PERRLA, tongue midline, palate
elevation symmetric, +shoulder shrug, sensation intact V1-V3,
___
strength throughout, sensation intact to light touch, normal
gait
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
===============
___ 01:40PM BLOOD WBC-13.1* RBC-4.58 Hgb-12.8 Hct-40.7
MCV-89 MCH-27.9 MCHC-31.4* RDW-13.6 RDWSD-44.3 Plt ___
___ 01:40PM BLOOD Neuts-53.9 Lymphs-12.2* Monos-32.4*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.05*# AbsLymp-1.59
AbsMono-4.23* AbsEos-0.02* AbsBaso-0.02
___ 01:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-3+*
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+*
Schisto-OCCASIONAL Burr-3+*
___ 01:40PM BLOOD Glucose-143* UreaN-11 Creat-0.7 Na-140
K-4.8 Cl-103 HCO3-23 AnGap-14
___ 01:40PM BLOOD CK-MB-2 proBNP-4196*
___ 01:40PM BLOOD cTropnT-0.03*
___ 04:06AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0
___ 08:05PM BLOOD D-Dimer-740*
DISHARGE LABS
=============
___ 07:50AM BLOOD WBC-14.5*# RBC-4.44 Hgb-12.4 Hct-39.0
MCV-88 MCH-27.9 MCHC-31.8* RDW-13.6 RDWSD-44.2 Plt ___
___ 07:50AM BLOOD Glucose-112* UreaN-10 Creat-0.7 Na-143
K-3.9 Cl-104 HCO3-26 AnGap-13
___ 07:50AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
___ 09:05AM BLOOD %HbA1c-6.0 eAG-126
___ 07:50AM BLOOD Triglyc-65 HDL-39* CHOL/HD-2.4 LDLcalc-41
___ 07:50AM BLOOD TSH-0.94
MICRO
=====
___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
========
___ CT Head: IMPRESSION: No acute intracranial process.
___ CXR: No acute cardiopulmonary process. Unchanged
cardiomegaly.
___ CTAP:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mildly enlarged pulmonary artery is suggestive of pulmonary
arterial
hypertension.
___ MRI/MRA:
1. Small acute punctate most likely embolic infarct in the
lateral aspect of the left precentral gyrus.
2. Loss of flow related signal enhancement in the proximal M2
superior
division on the left suggesting severe stenosis with moderate
decrease in flow related signal intensity in the vessels distal
to this.
3. Generalized atherosclerotic changes of the intracranial
arteries as
described above. This is overall similar to prior CTA of ___.
4. Generalized cerebral atrophy including the medial temporal
lobes.
___ Carotid ultrasound: No stenosis of the bilateral
carotid arteries
___ TTE:
The left atrial volume index is severely increased. The right
atrium is moderately dilated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is mild (non-obstructive) focal hypertrophy of the
basal septum. Doppler parameters are most consistent with Grade
II (moderate) left ventricular diastolic dysfunction. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is mildly dilated with normal free wall contractility.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are 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:
1) Normal biventricular regional/global systolic function.
2) Grade II LV diastolic dysfunction with indeterminate
measurement for assessment of LVEDP.
3) Respirophasic IVC diameter changes suggests normal RA
pressure.
4) Mild to moderate pulmonary systolic arterial hypertension
with mild RV dilation and RV hypertrophy.
Compared with the prior study (images reviewed) of ___, no
significant change visualized.
Compared with the prior study (images reviewed) of ___
Brief Hospital Course:
Ms. ___ is a ___ ___ speaking woman with history of
hypertension, hyperlipidemia and left MCA stroke who presents
with transient left facial droop.
Active Issues
============
#NSTEMI: Patient initially presented with symptoms of
dizziness/nausea with diaphoresis worrisome for cardiac etiology
given her risk factors (HTN, HLD, prior smoking), chest pain and
diaphoresis, and EKG changes (TWI in v1-v6), elevated BNP and
troponin 0.03 x4. There was initially worry for PE with possible
right heart strain on EKG, BNP, and trop elevation on
presentation. CTAP was negative for PE. She was started on
heparin for 48hrs for ACS management. She was unable to be
started on a beta blocker d/t bradycardia. Repeat EKG showed
resolution of TWI in precordial leads. She was continued on
atorvastatin 40mg and ASA 81 mg daily. TTE was done to evaluate
for any new wall motion abnormalities. It showed normal
biventricular regional/global systolic function, grade II LV
diastolic dysfunction, and mild-moderate pulmonary arterial
hypertension. There were no significant changes from prior TTE
in ___. She had no recurrence of symptoms during her
hospitalization. She was started on Plavix in addition to asa.
She will follow up with cardiology and will possibly need stress
test as an outpatient.
#Transient L facial droop
#TIA: Patient had L facial droop at home which resolved when she
was brought to the ED. Ddx includes TIA (hx of stroke) vs
cardiac etiology (NSTEMI given EKG changes and troponin bump vs
arrhythmia given bradycardia with PACs). Head CT was negative
for any acute intracranial process. Left sided symptoms cannot
be explained by prior known left MCA intracranial stenosis.
Neurology was consulted and felt that this likely represented a
TIA. MRI/MRA was done that showed new small ischemic left
cortical infarct that would not explain presenting symptoms. MRA
did show significant intracranial stenosis. Work up reviled
HbA1c of 6.0, TSH 0.94, and LDL 41. At time of discharge carotid
ultrasound was pending. Neurology felt that she should be
started on Plavix as well as ASA for management of intracranial
stenosis for 3 months then Plavix thereafter. She was continued
on atorvastatin 40mg. She had no recurrence of left facial droop
or other focal neurologic symptoms.
#Bradycardia: Patient on tele having episodes of sinus
bradycardia to ___. She was completely asymptomatic with these
episodes. In review of tele it appeared to be sinus bradycarida
with intermittent PACs with pause. Prior EKG do not show any PR
elongation or dropped beats. Heart rate augmented correctly with
exercise with no dropped beats. Looking back in prior records
she was Bradycardic to ___ in clinic. At ___ I would expect
some inherent conduction disease d/t age related calcification.
She was monitored on telemetry during admission without any
issues.
#Leukocytosis: Her WBC was elevated on admission to 13.5 and she
was initially started on ceftriaxone for possible UTI. She was
hemodynamically stable, afebrile, and WBC trending down morning
after admission. UA was contaminated with 6 epithelial cells.
Additionally, CXR and CT showed no lung consolidation concerning
for pneumonia. No other signs of focal infection, therefore
ceftriaxone was discontinued on hospital day one. Her WBC was
elevated at discharge, but she had no other infectious symptoms.
Urine culture grew urogenital flora. She remained
hemodynamically stable and afebrile during admission.
#Pre-Diabetes: HbgA1c was found to be 6 consistent with
diagnosis of pre-diabetes. Discussed results with patient and
family. Explained that management is lifestyle changes with
healthy eating and exercise. She will follow up with PCP for
further management.
===============================
CHRONIC/STABLE ISSUES:
#Hypertension: home lisinopril was held during admission to
allow autoregulation iso of TIA. Her blood pressure ranged from
SBP 110-150s. So she was discharged without restarting
lisinopril. She will follow up with PCP closely after discharge.
#HLD
- atorvastatin 40mg QPM
Transitional issues
===================
[ ] Consider Stress test as an outpatient. Outpatient cardiology
follow-up pending
[ ] HbgA1C 6, dx of pre-diabetes. No new medications added
[ ] Per neurology should continue on asa and Plavix for 3
months, then Plavix only thereafter
[ ] WBC at discharge was 14.5.
[ ] Lisinopril stopped on this admission, and not hypertensive.
Check BP's as outpatient and consider restarting
[ ] Carotid U/S pending at time of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 10 mg PO DAILY
3. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
4. Polyethylene Glycol 17 g PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Polyethylene Glycol 17 g PO BID
6. Vitamin D 1000 UNIT PO DAILY
7. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
TIA
NSTEMI
Secondary Diagnosis
====================
HTN
HLD
L MCA stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
It was a pleasure to take care of you at ___.
WHY WAS I HERE?
You were admitted to the hospital because you had an episode of
dizziness, nausea, sweating, and left facial droop.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL
- You were found to have a heart attack and you were given
medications to help your heart.
- While you were in the hospital you had an MRI that showed new
small stroke that was most likely not the cause of your
symptoms.
- During this hospitalization, you were diagnosed with a TIA or
Stroke. You received materials and information about strokes and
TIAs. This includes information on: understanding what a stroke
is, warning signs of another stroke, calling 911 if warning
signs occur, risk factors for stroke, and care options that may
be available after you leave the hospital. It also includes tips
on steps you can take to lower the chance of another stroke,
including taking prescribed medications, stopping smoking,
lowering sodium and fat in your diet, and having a
mobility/exercise plan.
WHAT SHOULD I DO WHEN I GET HOME?
1) Follow up with your Primary Care Doctor.
2) Follow up with Neurology
3) Follow up with Cardiology
4) ___ need to get a stress test to look at how well your heart
is functioning
3) Take your new medication Plavix.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10362557-DS-17 | 10,362,557 | 25,476,337 | DS | 17 | 2169-06-30 00:00:00 | 2169-07-01 07:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nsaids
Attending: ___.
Chief Complaint:
Weakness, unresponsiveness
Major Surgical or Invasive Procedure:
Pacemaker Placement ___
History of Present Illness:
Ms. ___ is a ___ y/o ___ speaking woman with history
of HTN, HLD, and left MCA stroke who presents following weakness
and unresponsiveness.
After returning home from her hospital discharge on ___, the
___ began feeling fatigued, weak and unwell. She then
developed another episode of unresponsiveness while sitting in a
chair that lasted several minutes. It is unclear if she ever
lost consciousness. No trauma, fall or head strike. EMS was
called and brought her to the ED.
Of note, the ___ was admitted from ___ for
dizziness, nausea, diaphoresis, found to have elevated troponin
to 0.03 x 4 with TWI in ___. CTPA was negative for PE. There
was concern for ACS so she was started on heparin gtt x 48
hours, ASA, atorvastatin 40mg. She did not tolerate a beta
blocker due to bradycardia, including intermittent episodes of
asymptomatic sinus bradycardia to the ___ with PACs and pauses.
A TTE showed normal biventricular systolic function, grade II LV
diastolic dysfunction, and ___ pulmonary hypertension, all
unchanged from ___. Additionally, she present with new left
facial droop that resolved by time of presentation. CT head was
negative and f/u MRI showed new small ischemic left cortical
infarct, felt to not be the culprit lesion. She did have
significant intracranial stenosis on MRA. Neurology was
consulted and believed this was a TIA. She was started on Plavix
in addition to ASA for planned 3 month course.
In the ED initial vitals were: 97.7F BP 100/58 HR 58 RR 16 99%
on RA
EKG: HR 48, junctional rhythm, T wave inversions ___.
Labs/studies notable for: Trop 0.06->0.04, BNP 9211, lactate
1.8, K 5.3->4.4, Cr 1.2->1.0, WBC 15.9.
CXR showed mild pulmonary venous congestion.
CT Head was negative.
___ was given:
- Norepinephrine
- Phenylephrine
- Normal Saline 1.5L
- Aspirin, Plavix, atorvastatin, polyethylene glycol
In the ED, the ___ became hypotensive with SBP in the ___. A
___ IJ was placed and the ___ was started on
norepinephrine and given 1.5L IVF. She had several bradycardic
episodes to the ___ and then became tachycardic to the 160s.
Norepinephrine was discontinued and the ___ was transitioned
to phenylephrine.
The ___ was seen by electrophysiology who noted a junctional
escape rhythm with rate 56, believed her to be due to
___ disarray. ACS was felt to be unlikely as a
bedside TTE showed no wall motion abnormalities and troponins
were downtrending while in the ED.
Vitals on transfer: T 100.1F BP 87/50 HR 62 RR 25 O2 SAT 97% on
4L NC
On arrival to the CCU: The ___ reports intermittent
centralized chest pain at rest that has been occurring for
months, currently less severe. No shortness of breath,
palpitations, cough, abdominal pain, nausea, vomiting, diarrhea,
fever or chills.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, orthopnea, ankle edema, palpitations. On
further review of systems, denies fevers or chills, dysuria,
hematuria, abdominal pain, nausea, vomiting. All of the other
review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- ___ Mellitus
- Hypertension
- Hyperlipidemia
2. CARDIAC HISTORY
- Pump: EF>55%, grade II diastolic dysfunction
3. OTHER PAST MEDICAL HISTORY
Left MCA stroke
Gastrointestinal bleed after NSAIDS
CPPD
Osteoarthritis
Pseudogout
Spondylosis
Vitamin D deficiency
Social History:
___
Family History:
No family history of strokes
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: T 100.1F BP 87/50 HR 62 RR 25 O2 SAT 97% on 4L NC
GENERAL: Elderly, female. Well developed, well nourished in NAD.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink.
NECK: Supple. No JVP appreciated.
CARDIAC: Bradycardic. Regular rhythm with normal S1, S2. No
murmurs, rubs, or gallops.
LUNGS: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
ABDOMEN: Soft, ___. No guarding or masses.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: A&Ox3. CN ___ intact. ___ strength throughout.
PSYCH: Normal mood and affect.
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.5F 125/76 HR69 RR17 96%Ra
GENERAL: lying comfortably in bed, no apparent distress
HEENT: no conjunctival pallor, anicteric sclera, MMM
NECK: supple, no JVP appreciated
CV: S1 and S2 normal, no murmurs, rubs, or gallops.
RESP: CTAB, no wheeze/crackles, breathing comfortably without
use
of accessory muscles of respiration
___: soft, ___, no distention, BS normoactive
EXTREMITIES: warm and well perfused, trace ___ edema
SKIN: no significant skin lesions or rashes. Stable hematoma
around device site.
PULSES: distal pulses palpable and symmetric.
NEURO: A&Ox3, grossly intact
Pertinent Results:
ADMISSION LABS:
================
___ 07:50AM BLOOD ___
___ Plt ___
___ 11:56PM BLOOD ___
___ Im ___
___
___ 07:50AM BLOOD ___
___
___ 07:50AM BLOOD ___
PERTINENT LABS/MICRO:
=====================
___ 03:45AM BLOOD ___
___ Plt ___
___ 11:56PM BLOOD ___
___ 06:27AM BLOOD ___
___ 05:53PM BLOOD ___
___ BCx x2: NGTD
___ urine culture: No growth
___ MRSA screen: Negative
___ Lyme IgG/IgM: Pending
DISCHARGE LABS:
===============
___ 08:15AM BLOOD ___
___ Plt ___
___ 10:45AM BLOOD ___ ___
___ 08:15AM BLOOD ___
___
PERTINENT IMAGING:
===================
___ CXR:
Mild pulmonary venous congestion. Otherwise no acute
cardiopulmonary process. No evidence of acute fractures.
___ CT Head w/o Contrast:
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no acute large territory infarct or intracranial
hemorrhage.
2. Old left superior frontal lobe infarction and right basal
ganglia
infarction.
___ ECHO
Overall left ventricular systolic function is low normal (LVEF
___. There is considerable ___ variability of the
left ventricular ejection fraction due to an irregular
rhythm/premature beats. There is borderline normal right
ventricular free wall function. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. There is a moderate
sized circumferential pericardial effusion. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows and the LVOT VTI
(this is most clear even with the beat to beat variability in
aflutter), consistent with impaired ventricular filling / pre
tamponade physiology. The IVC is enlarged, but remains
respirophasic. The effusion is largest posteriorly and along the
RV base. Towards the apex and along the RV free wall the
effusion is < 1cm in size.
IMPRESSION: Moderate sized, echodense pericardial effusion with
pretamponade physiology. No overt chamber collapse. Low normal
biventricular systolic function.
___ ECHO
The estimated right atrial pressure is ___ mmHg. There is a
moderate to large sized pericardial effusion. The effusion
appears circumferential althought the bulk of the collection is
along the right heart with less posteriorly. The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. No right atrial or right ventricular
diastolic collapse is seen. There is significant, accentuated
respiratory variation in tricuspid valve inflows, consistent
with impaired ventricular filling. The IVC is enlarged, but
remains respirophasic. The effusion is largest up to 2.3 cm near
the base of the RV. Toward the apex effusion is up to 1.8 cm.
Surrounding RV free wall, ___. There are bilateral pleural
effusions. Posteriorly the fluid collection is small.
IMPRESSION: Moderate to large sized, echodense pericardial
effusion with pretamponade physiology. No overt RV or RA chamber
collapse.
Compared with the prior study (images reviewed) of ___:
Effusion slightly enlarged without overt chamber collapse. The
collection at the apex is better visualized.
___ CXR
Marked cardiomegaly, the cardiac silhouette slightly larger than
on ___. Interval placement of pacemaker leads.
Positioning is difficult to confirm on the lateral view and
clinical correlation is therefore requested. Upper zone
redistribution without overt CHF.
Small bilateral effusions with underlying collapse and/or
consolidation, new or slightly larger compared with ___.
___ ECHO
The estimated right atrial pressure is at least 15 mmHg. Overall
left ventricular systolic function is low normal (LVEF 55%).
with borderline normal free wall function. The mitral valve
leaflets are structurally normal. Mild to moderate (___) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. [In the setting of at least moderate to severe
tricuspid regurgitation, the estimated pulmonary artery systolic
pressure may be underestimated due to a very high right atrial
pressure.] There is a moderate sized pericardial effusion. The
effusion appears circumferential. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
No right atrial or right ventricular diastolic collapse is seen.
IMPRESSION: Moderate sized echodense circumferential
pericardial effusion. No RV/RA collapse.
Compared with the prior study (images reviewed) of ___
the rhythm is sinus, left ventricular function is improved,
moderate to severe tricuspid regurgitation is seen, and the IVC
is more dilated. The pericardial effusion is stable.
___ ECHO
Moderate to severe [3+] tricuspid regurgitation is seen. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a moderate sized
pericardial effusion. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
Compared with the prior study (images reviewed) of ___,
no major change.
___ ECHO
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is dilated with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is a small to moderate sized pericardial
effusion. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. Bilateral pleural
effusions are present. Ascites is present.
IMPRESSION: Small to moderate pericardial effusion. Dilated
right ventricle with normal systolic function. Vigorous left
ventricular systolic function. Moderate to severe tricuspid
regurgitation. Mild aortic regurgitation. At least moderate
pulmonary hypertension.
___ ECHO
The estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] Trace aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Severe [4+] tricuspid regurgitation is seen. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. The pulmonary artery systolic
pressure could not be determined. [In the setting of at least
moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is a moderate sized
pericardial effusion. Stranding is visualized within the
pericardial space c/w organization. There are no
echocardiographic signs of tamponade.
IMPRESSION: Focused study. Moderate pericardial effusion
without echocardiographic evidence of tamponade. Mild symmetric
left ventricular hypertrophy with normal cavity size, and
regional/global systolic function. Severe tricuspid
regurgitation. At least moderate pulmonary artery systolic
hypertension.
Brief Hospital Course:
SUMMARY
=========
Ms. ___ is a ___ y/o ___ speaking woman with history
of HTN, HLD, and left MCA stroke who presents with weakness,
unresponsiveness, found to have junctional rhythm and sick sinus
syndrome. Hospital course complicated by hypotension requiring
pressors, intermittent atrial fibrillation with RVR, and concern
for infection treated empirically with cefepime x7 days.
ACTIVE ISSUES
===============
# Sick Sinus Syndrome
# New Atrial Flutter:
# New Atrial Fibrillation: After returning home from discharge
on ___, the ___ had an episode of weakness and
unresponsiveness. EKG notable for a junctional rhythm with
intermittent HRs to the ___ and hypotension requiring a pressor.
EP was consulted and recommended pacemaker placement; however
this was postponed given ongoing hypotension and concern for
infection given leukocytosis and low grade fever on admission.
She remained in a junctional rhythm for ~3 days with
intermittent episodes of atrial fibrillation with RVR. She also
had several sinus pauses up to 9 seconds in length. She also had
several episodes of afib w/ RVR (rates up to 170s) after
converting to sinus rhythm, treated with IV nodal blockers.
Arrhythmia was likely due to sinus node dysfunction, though
exact etiology unknown. TSH was normal, troponin down trended
making ischemia less likely, and no nodal blocking medications
at home. Lyme titers were negative. Her CHADSVASC was 6 with 10%
stroke risk, and HASBLED score was 4 with 9% bleeding risk.
Decision was made to start anticoagulation and she ultimately
was discharged on apixaban. She underwent pacemaker placement on
___ with electrophysiology, and afterwards was started on
diltiazem 240 mg daily and metoprolol tartrate 50 mg q6h and 3
days of prophylactic Vancomycin to finish on ___. She
developed atrial flutter after her procedure. She was discharged
on a consolidated regimen of metoprolol XL 200mg daily.
#Pericardial effusion. There was concern for pericardial
effusion after new rub noted on exam and increased cardiac
silhouette on CXR. Echo with evidence of moderate sized,
echodense pericardial effusion with pretamponade physiology.
Stable on repeat TTEs during hospitalization. Pulsus improved
post conversion to sinus rhythm ___ and repeat TTE on ___ with
stable effusion. Bedside echo ___ with minor improvement in
effusion with no signs of tamponade physiology. Anticoagulation
was held but restarted once effusion was stable on multiple
TTEs. Effusion was stable also after restarting anticoagulation
and stable on the day of discharge.
# Low Grade Fever, Leukocytosis: Presented with a WBC of 15.9,
which uptrended to the ___ in the setting of an initial low
grade fever. She had no focal symptoms and ___ including
UA/CXR/cultures was unremarkable. ID was consulted and she
ultimately completed a 7 day course of cefepime for presumed
infection prior to pacemaker placement.
# Chronic Monocytosis: Noted to have a chronic monocytosis.
Heme/onc was consulted and felt this was likely an indolent
process. Recommended ___ as an outpatient with
hematology/oncology.
# H/o Left MCA Stroke: She had a history of left MCA stroke
without residual focal deficits. She had recently been started
on Plavix during her last admission in the setting of a TIA.
Given concern for TIA etiology being embolic rather than
microvascular, the Plavix was stopped and she was started on
systemic anticoagulation, initially with a heparin gtt and then
apixaban in addition to aspirin. She was discharged with plans
to ___ with neurology.
TRANSITIONAL ISSUES:
=====================
- NEW MEDS: Apixaban 5 twice daily, metoprolol XL 200mg daily
- STOPPED MEDS: Clopidogrel
- ___ in ___ clinic, ___ clinic, neurology clinic, and
with PCP
- ___ instructed to arrive at outpatient cardiology/device
clinic appointment ton ___ 30 minutes early so as to be
seen by the cardiology fellow in clinic that day
- More recent TTE prior discharge showed moderate pleural
effusion, stable from the day before discharge and improved from
initial ECHO. Her TTE also showed severe TR, likely related to
pacemaker placement.
- Consider discontinuing aspirin since she is being
___ with apixaban. This should be addressed at
outpatient neurology ___ after discharge.
- HbgA1C 6, dx of ___. No medications started.
- Consider Stress test as an outpatient after recovery from this
admission
- ___ should have workup for monocytosis with hematology,
appointment scheduled
- Due to family concern about ___ placement, inpatient
team reached out to outpatient provider about continuing
discussions about how to better provide safe living environment
at home versus transitioning to ___ living facility.
Family was also provided list of potential SNFs that would take
the ___ insurance at time of discharge.
- Please continue discussions about code status as an outpatient
# CODE: Full
# CONTACT/HCP: ___ (daughter) ___
(granddaughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Polyethylene Glycol 17 g PO Q12H:PRN constipation
5. Vitamin D 1000 UNIT PO DAILY
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. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 200 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Polyethylene Glycol 17 g PO Q12H:PRN constipation
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
===================
-Sick sinus syndrome
-Atrial fibrillation, paroxysmal
-Pericardial effusion
Secondary diagnoses
=====================
-Monocytosis
-Left MCA stroke
-Hyperlipidemia
-Hypertension
-Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY DID YOU COME TO THE HOSPITAL?
You were hospitalized at ___
because you were feeling lightheaded.
WHAT HAPPENED WHILE YOU WERE HERE?
-You were found to have an abnormal heart rhythm.
-You had a pacemaker placed to improve the rhythm and prevent
you from feeling lightheaded.
-You also had some fluid seen around your heart but after
multiple ultrasounds of your heart it did not get any worse.
-You were also started on a new medication called apixaban which
can help prevent stroke, and metoprolol which is for your heart.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
-Please continue to take your medications as prescribed.
-___ with the clinic appointments scheduled below.
-You are scheduled to see the cardiologists on ___ at 2:20pm to check your pacemaker. PLEASE ARRIVE TO THIS
APPOINTMENT 30 MINUTES EARLY (at 1:50pm) and ask for the
cardiology fellow to see you early to listen to your heart. They
will be expecting you.
It was a pleasure taking care of you.
-Your ___ care team
Followup Instructions:
___
|
10362716-DS-18 | 10,362,716 | 21,244,239 | DS | 18 | 2134-04-17 00:00:00 | 2134-04-23 20:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Latex
Attending: ___.
Chief Complaint:
left lower extremity swelling, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with a past medical history of HTN,
HLD, DVT (___ after pregnancy) who presented with LLE swelling
and fatigue for the past ___ days. Patient reports that she was
in her usual state of health until about ___ days ago when she
developed generalized fatigue and lower extremity swelling and
erythema. Patient denies having had similar symptoms in the
past. She denies dyspnea, orthopnea, fevers or chills.
Vitals in the ED: T97.5, HR 85, BP 116/58, RR 16, 98% RA
Exam notable LLE with pitting edema. Labs notable for: WBC 6.2,
Hb 9.8, Hct 28.2 (baseline Hct 34 per report), PLT 153. Albumin
2.6. Trop <0.01. Cr 0.7. CXR showed evidence of vascular
congestion and interstitial pulmonary edema in the setting of
slightly worsened cardiomegaly compared to ___. Also with
severe degenerative changes of the shoulders. UA unremarkable.
EKG showed isolated TWI in aVL with evidence of LVH. LENIs
showed a completely occluding DVT of the left lower extremity
venous system from the proximal superficial femoral vein down to
the calf veins. The common femoral vein of the left lower
extremity is patent. There was no DVT in the right lower
extremity. Rectal exam was performed and stool was guiac
negative. She received 1000L NS and lovenox 50 mg x1 and was
admitted to the floor.
Upon arrival, vital signs were T 98.2, BP 126/66, HR 77, RR 16,
O2 sat 93% on RA (repeat 95% on RA). Patient complained of LLE
swelling and pain. Also complained of fatigue. Denied chest pain
or shortness of breath.
Of note, the patient recently had an outpatient procedure for
stress incontinence which did not require hospitalization.
Review of Systems:
Denies fevers, chills. Reports decreased appetite over the past
few days. Weight loss over the past few years (unintentional,
baseline weight approximately 112 pounds). Denies chest pain,
shortness of breath, orthopnea, abdominal pain, n/v/d. Denies
change in bowel habits (no constipation, melena or hematochezia)
Past Medical History:
HTN
HLD
DVT 1960s after pregnancy (left leg, reports having had some
veins removed around that time)
Stress incontinence s/p suburerthral sling procedure and
cystoscopy (___)
Arthritis
Cataracts
No history of a colonoscopy
Last mammogram a few years ago and was normal
Last pap smear a few years ago and was negative
Social History:
___
Family History:
No history of cancer or clotting disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T 98.2, BP 126/66, HR 77, RR 16, O2 sat 93% on RA
(repeat 95% on RA).
GENERAL: A+Ox3, NAD, speaking in full sentences and in no
respiratory distress
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
+temporal wasting
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing; 1+ pitting edema of LLE,
tender to palpation, + erythema to the ankle, + varicose veins
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 - T98.9 70 99/51 18 95%RA
GENERAL: A+Ox3, NAD, pale appearing, speaking in full sentences
and in no respiratory distress
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
+temporal wasting
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing; 1+ pitting edema of LLE,
non-tender to palpation, + erythema to the ankle, + varicose
veins
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION:
=================
___ 03:49PM BLOOD WBC-6.2 RBC-2.99* Hgb-9.8* Hct-28.2*
MCV-94 MCH-32.8* MCHC-34.8 RDW-13.6 Plt ___
___ 03:49PM BLOOD Neuts-73.7* Lymphs-13.9* Monos-7.2
Eos-4.8* Baso-0.4
___ 05:55AM BLOOD ___ PTT-36.9* ___
___ 03:49PM BLOOD Glucose-115* UreaN-10 Creat-0.7 Na-135
K-3.9 Cl-100 HCO3-28 AnGap-11
___ 03:49PM BLOOD ALT-27 AST-23 AlkPhos-69 TotBili-0.4
___ 03:49PM BLOOD cTropnT-<0.01
___ 05:55AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.7 Iron-35
___ 03:49PM BLOOD Albumin-2.6*
___ 05:55AM BLOOD calTIBC-143* VitB12-607 Ferritn-116
TRF-110*
___ 05:08PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:08PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 05:08PM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 05:08PM URINE AmorphX-RARE
___ 05:08PM URINE Mucous-OCC
DISCHARGE:
=================
___ 06:15AM BLOOD WBC-5.3 RBC-3.08* Hgb-9.7* Hct-28.8*
MCV-94 MCH-31.6 MCHC-33.7 RDW-13.6 Plt ___
___ 06:15AM BLOOD ___ PTT-36.7* ___
___ 06:15AM BLOOD Glucose-93 UreaN-12 Creat-0.7 Na-134
K-4.2 Cl-101 HCO3-28 AnGap-9
___ 05:55AM BLOOD ALT-24 AST-22 AlkPhos-62 TotBili-0.6
___ 06:15AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0
MICRO:
=================
___ 5:08 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
=================
CHEST (PA & LAT)Study Date of ___
IMPRESSION:
1. Vascular congestion and interstitial pulmonary edema in the
setting of slightly worsened cardiomegaly compared with ___.
2. Severe degenerative changes of both shoulders, right worse
than left.
___ LOWER EXT VEINS
1. Completely occluding DVT of the left lower extremity venous
system from the proximal superficial femoral vein down to the
calf veins. The common femoral vein of the left lower extremity
is patent.
2. No DVT in the right lower extremity.
3. ___ cyst on the left.
Brief Hospital Course:
This is an ___ year old female with past medical history of HTN,
CKD stage 3, remote DVT after pregnancy, admitted ___ with
acute left lower extremity DVT, also found to have normocytic
anemia, guaiac negative, with normal iron studies, started on
anticoagulation with coumadin after discussion with patient and
PCP regarding risks and benefits of anticoagulation options,
discharged home with lovenox bridge and visiting nursing
services for INR checks.
ACUTE ISSUES:
# Acute Left lower extremity DVT: Patient presented with
erythema and swelling of left leg, Doppler revealed completely
occluding DVT of the left lower extremity venous system from the
proximal superficial femoral vein down to the calf veins. Given
patient's CKD, discussed risks and benefits of various
anticoagulation options with patient and PCP; patient referred
Coumadin. She was started on lovenox bridge to Coumadin.
Visiting nursing arranged for INR checks, PCP to coordinate
___ dosing. Son was updated regarding details of this
plan. Regarding etiology of DVT, she had a recent cystocopy,
but no other recent precipitating events. Is not up to date on
cancer screening. Did report a prior DVT after a pregnancy in
___. Discharged home with PCP ___ to determine duration
of anticoagulation (likely ___ months) as well as if any
outpatient workup necessary.
# Normocytic anemia: Patient Hct noted to be 28 this admission.
Guaiac negative stool. Iron studies and B12 were normal. Can be
followed up as outpatient regarding need for additional workup.
#Nutrition: Patients albumin was low at 2.6 and nutrition
recommended ensure supplementation TID
# Patient was evaluated by physical therapy and recommended for
home discharge with physical therapy; patient refused despite
counseling.
CHRONIC ISSUES
# HTN: continued home metoprolol
# HLD: continued home statin
# Urinary incontinence: held home mirabegron as it was not
formulary
# Code: full confirmed
# Emergency Contact: ___ daughter ___
TRANSITIONAL ISSUES
========================
- INR to be drawn on ___, dose adjust warfarin as needed
(currently on 5mg daily)
- Discontinue lovenox when INR theraputic (goal ___ for >24
hours.
- Patient will need to be treated for at least 3 months but
course should be determined after discussion with PCP and
consideration of outpatient workup
- Nutrition recommended Ensure TID for supplementation given low
albumin
- Work up for normocytic anemia with negative guaiac
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Simvastatin 20 mg PO QPM
3. Aspirin 81 mg PO DAILY
4. mirabegron 25 mg oral DAILY
5. Calcium Carbonate Dose is Unknown PO DAILY
6. Acetaminophen ___ mg PO Q6H:PRN pain
7. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Simvastatin 20 mg PO QPM
4. Enoxaparin Sodium 60 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 60 mg/0.6 mL 60 mg SQ twice a day Disp #*10
Syringe Refills:*0
5. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Aspirin 81 mg PO DAILY
7. Calcium Carbonate 1000 mg PO DAILY
8. mirabegron 25 mg oral DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Outpatient Lab Work
Deep vein thrombosis, ICD 453.40- ___, PTT, INR to be drawn on
___
Please fax results to Dr. ___- ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Left lower extremity deep vein thrombosis
SECONDARY: Anemia, Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for a blood clot
in your left lower extremity. You were started on a blood
thinner to treat this blood clot. It is important that you
continue this medication. You will need to continue injections
twice a day until advised by your doctor to stop. You will need
to continue to take coumadin during this time and have your lab
checked on ___. During your hospital stay you were also found
to have low blood counts (anemia). You will need to have this
worked up with your primary care doctor. A colonoscopy should be
considered as you may be having small amount of blood loss
through your intestinal tract.
Please continue to take all your medications as prescribed and
follow up with your PCP.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10362716-DS-21 | 10,362,716 | 24,913,278 | DS | 21 | 2138-03-12 00:00:00 | 2138-03-12 10:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Latex
Attending: ___.
Chief Complaint:
Knee pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Hx numerous DVT's on xarelto, HTN, HL, headache Hx,
stress incontinence, cataracts, PVD, presented to ED BIBEMS from
home after new onset of bilateral knee pain.
Knee pain started the morning of admission when patient first
put weight on
her legs when getting out of bed, located both knees equally,
lasted only several seconds, without any buckling, popping or
other acute change. No injury, fall prior. No pain prior. In
normal state of health the day before. Pain moderate severity,
not associated with a fall, warmth, swelling, fever, other skin
tear or breakdown. No swelling of legs. Had not been missing her
rivaroxaban
Denied urinary Sx incl dysuria, flank pain, n/v, confusion,
fever, chills; is incontinent of urine at baseline. No hematuria
noted. Does not recall having had UTI in the past.
In ED:
VS: afeb, HR 70, 130/70, RR 18, 97% RA
ED Exam: well appearing, no ab TTP, no knee TTP
Labs: wbc 8, hb 11.5, plt 150, normal diff, chem unremarkable,
Cr
0.7, BUN 12, ALT 38, AST 70, AP 64; UA with few bact, 44 wbc, 30
prot, mod leuk
UCx sent + BCx x2
Imaging: cxr read as no acute abnormality, knee plain films
without acute bony abnormality but with a left suprapatellar
effusion, mild
Received: CTX 1g, LR x1L, rivaroxaban 10
Past Medical History:
- Hypertension
- Hyperlipidemia
- DVT 1960s after pregnancy (? SVT for which she underwent
veinectomy)
- DVT ___
- Stress incontinence s/p suburerthral sling procedure and
cystoscopy (___)
- Arthritis
- Cataracts
Social History:
___
Family History:
- No history of cancer or other familial disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: Afebrile and vital signs significant for BP minimally
elevated, but normal rate, oxygenation
GENERAL: Alert and in no apparent distress; conversant and able
to recall all the events of today
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. No ___
edema. DP 2+ bilat
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation, no CVA
tenderness
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. Normal ROM in both
knees, without effusion or joint tenderness. No pain on active
or passive ROM. No crepitus or joint instability bilaterally
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM
VS: 97.7 149/68 78 18 97/RA
GENERAL: elderly woman in NAD, pleasant.
EYES: Anicteric, non-injected
ENT: MMM, grossly nl OP
CV: RRR nl S1/S2 no g/r/m
RESP: CTAB no w/r/r
GI: soft, NT/ND, NABS, no r/g/rigidity.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. Normal passive ROM in
both knees, without effusion or joint tenderness. No overlying
warmth skin changes. No pain on active or passive ROM. No
crepitus or joint instability bilaterally. Left elbow without
TTP. passively ROM full.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented x3, face symmetric, gaze conjugate with
EOMI, speech fluent. ___ strength in b/l ___ hip/knee/ankle
flexion and extension. 4+/5 strength in UE flexion and extension
in shoulder/elbow/wrist. Sensation preserved in b/l ___ to
fine touch. No dysmetria with FNF/H2S bilaterally. NO pronator
drift, no truncal ataxia.
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
___ 09:55PM BLOOD WBC-8.1 RBC-3.48* Hgb-11.5 Hct-35.9
MCV-103* MCH-33.0* MCHC-32.0 RDW-13.4 RDWSD-50.7* Plt ___
___ 09:55PM BLOOD Glucose-117* UreaN-12 Creat-0.7 Na-144
K-3.8 Cl-106 HCO3-26 AnGap-12
___ 09:55PM BLOOD ALT-38 AST-70* AlkPhos-64 TotBili-0.7
___ 10:41PM BLOOD Lactate-1.5
IMAGING
XR Right knee: The bones are relatively demineralized. No acute
fracture or dislocation is seen. No suprapatellar joint
effusion is seen. Chondrocalcinosis is seen in the medial and
lateral joint compartments. Vascular calcifications are seen.
XR Left knee: The bones are relatively demineralized. No acute
fracture or dislocation is seen. Trace suprapatellar joint
effusion is seen. Small patellar spurring is seen. There is
chondrocalcinosis in the medial and lateral joint compartments.
Vascular calcifications are seen.
elbow xray IMPRESSION: No acute bony injury seen, however there
is a moderate joint effusion which may indicate an occult
radial head fracture. Findings suggestive of chronic lateral
and medial epicondylitis.
ct left UE IMPRESSION:
1. No displaced fractures seen.
2. Degenerative changes as described above.
3. Faint chondrocalcinosis.
CXR: Previously seen right lower lobe consolidation has resolved
in the interval since ___. Cardiomegaly.
MICRO:
- UCx no growth, final
- BCx no growth, final
Brief Hospital Course:
___ is a ___ year old woman with a history of DVT on
rivaroxaban, HTN, PVD, admitted with knee and ankle pain thought
secondary to OA, now resolved. Hospital course notable for
significant deconditioning resulting in discharge to rehab.
# Bilateral knee pain, suspect osteoarthritis
# Left Elbow Pain, suspect osteoarthritis.
# Deconditioning: Patient was admitted with pain in her knees
when getting out of bed. No antecedent trauma or fall. xray and
CT imaging was without fracture or dislocation - but rather
suggestive of OA. No significant infusion and there was no
suggestion for infection in the joints or elsewhere. Cultures
were negative. Neurologic exam was normal, non-focal, and no
neurologic imaging pursued. CK normal, no myositis on exam. TSH
normal. She was treated with analgesics and her pain symptoms
improved significantly. However, she was deconditioned with her
hospital stay and required discharge to short term rehab on ___
assessment. She was discharged on acetaminophen and lidocaine
patches PRN for knee pain.
# History of DVT: Home rivaroxaban was continued at 10mg (dose
reduced per outpatient heme)
# HTN: mildly elevated this hospitalization. No medications
started.
# Possible lung nodules: There was notes of this on prior
medical progress notes this admission, but review of most recent
CT imaging and CXR were without nodules. Would correlate with
previous imaging and follow-up as needed.
TRANSITIONAL ISSUES
- Recommend referral as outpatient to orthopedics for assessment
of injections or operative interventions for symptomatic
osteoarthritis.
- Consider hypertension medications should BP remain elevated
after discharge.
Time spent coordinating discharge > 30 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 10 mg PO QPM
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
3. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM
To either knee as needed for knee pain.
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Acetaminophen 650 mg PO TID
4. Vitamin D 1000 UNIT PO DAILY
5. Rivaroxaban 10 mg PO QPM
6.DME
wheelchair- 1
diagnosis-bilateral knee pain and osteoarthritis
duration-13 months
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Knee pain - suspect osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: **
Discharge Instructions:
Dear Ms ___,
You were admitted with knee pain. You had CT scans and xrays
which did not show any signs of fracture and your exam was not
consistent with an infection. You were treated conservatively
with medications and your pain improved. However, due to some
weakness and deconditioning you were having weakness and will
require a rehab stay prior to going home.
You will be discharged with acetaminophen and lidocaine patches
to help your pain going forward.
We recommend that you call your PCP to schedule ___ follow-up
appointment and also consider scheduling an appointment with an
orthopedist to discuss management of osteoarthritis.
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if you develop a
worsening or recurrence of the same symptoms that originally
brought you to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern you.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
10362948-DS-10 | 10,362,948 | 26,605,017 | DS | 10 | 2134-03-12 00:00:00 | 2134-03-12 17:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 05:35PM BLOOD WBC-7.7 RBC-4.90 Hgb-11.8* Hct-40.7
MCV-83 MCH-24.1* MCHC-29.0* RDW-19.2* RDWSD-57.7* Plt ___
___ 05:35PM BLOOD Neuts-79.6* Lymphs-10.2* Monos-8.7
Eos-0.7* Baso-0.3 Im ___ AbsNeut-6.12* AbsLymp-0.78*
AbsMono-0.67 AbsEos-0.05 AbsBaso-0.02
___ 07:58AM BLOOD Poiklo-1+* Ovalocy-1+* Target-1+* RBC
Mor-SLIDE REVI
___ 05:35PM BLOOD Glucose-140* UreaN-17 Creat-0.7 Na-136
K-5.8* Cl-95* HCO3-26 AnGap-15
___ 01:05AM BLOOD Albumin-3.2* Calcium-8.5 Phos-2.2* Mg-1.6
UricAcd-3.1*
___ 01:05AM BLOOD ALT-19 AST-15 LD(___)-212 AlkPhos-60
TotBili-0.5
___ 05:35PM BLOOD ___ PTT-54.9* ___
OTHER PERTINENT LABS
====================
___ 01:05AM BLOOD ___
___ 05:35PM BLOOD proBNP-729* cTropnT-<0.01
___ 01:05AM BLOOD cTropnT-0.02*
___ 05:35PM BLOOD VitB12-315 Ferritn-72
___ 08:05AM BLOOD PSA-6.0*
___ 06:30AM BLOOD IgG-1072
___ 05:17PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-MOD*
___ 05:17PM URINE RBC-2 WBC-11* Bacteri-MANY* Yeast-RARE*
Epi-0
___ SPUTUM CULTURE
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam test result performed by ___
___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
FUNGAL CULTURE (Preliminary):
YEAST.
DISCHARGE LABS
==============
___ 05:26AM BLOOD WBC-8.3 RBC-3.73* Hgb-9.1* Hct-31.5*
MCV-85 MCH-24.4* MCHC-28.9* RDW-17.4* RDWSD-53.8* Plt ___
___ 05:26AM BLOOD ___ PTT-30.4 ___
___ 05:26AM BLOOD Glucose-158* UreaN-15 Creat-0.8 Na-137
K-4.3 Cl-98 HCO3-31 AnGap-8*
___ 05:26AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.7
IMAGING
=======
___ CXR
No substantial interval change from the prior exam. Persistent
opacification
of the left hemithorax compatible with a combination of known
tumor with left
lung collapse and pleural effusion, though postobstructive
pneumonia is
difficult to exclude. Clear right lung.
___ RENAL ULTRASOUND
1. Moderate amount of echogenic debris ___ the urinary bladder,
some of which
may represent stones. Correlation with urinalysis is
recommended as
infectious cystitis is a concern.
2. 2 nonobstructing left renal calculi measuring up to 1.3 cm.
3. No hydronephrosis bilaterally.
___ CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval removal of left mainstem bronchial stent with
improved aeration
within the lower lobe and lingula. Nodular and confluent
opacities within the
left lung have decreased compared the study from ___ but
increased since
___, possibly representing neoplasm and superimposed
infectious
changes.
3. Severe emphysema.
4. Small left pleural effusion.
___ TTE
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is normal left
ventricular wall thickness with a normal cavity size. There is
normal regional and global left ventricular systolic
function. The visually estimated left ventricular ejection
fraction is 60%. There is no resting left
ventricular outflow tract gradient. There is Grade I diastolic
dysfunction. Normal right ventricular cavity size
with normal free wall motion. The aortic sinus diameter is
normal for gender with a normal ascending aorta
diameter for gender. The aortic arch diameter is normal with a
normal descending aorta diameter. The aortic
valve leaflets (?#) 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 physiologic tricuspid regurgitation. The
pulmonary artery systolic pressure could not be
estimated. There is no pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global biventricular
systolic function.
___ PFT
Very severe obstructive ventilatory defect and severe gas
exchange defect. The reduced FVC may be
due to possible gas trapping but a coexisting restrictive defect
cannot be excluded. Suggest lung volume
measurements if clinically indicated. There are no prior studies
available for comparison.
___ CT A/P
1. No compression or thrombosis of the IVC or pelvic veins.
2. Dilated and fluid-filled proximal small bowel loops, with the
duodenum
measuring up to 6.8 cm and jejunum measuring up to 4 cm, with
gradual
transition to collapsed small bowel ___ the left anterior lower
abdomen,
concerning for partial small bowel obstruction. ___ this region,
small bowel
loops are adhesed to the ventral abdominal wall, where the
patient has had
prior hernia repair.
3. The liver is not overtly nodular, however there is widening
of the
periportal hilar fat which can be seen ___ early cirrhosis. No
findings of
portal hypertension. Recommend clinical correlation.
4. Multiple bladder stones, the largest measuring 4.4 x 1.9 cm.
___ BILATERAL LOWER EXT ULTRASOUND
No evidence of deep venous thrombosis ___ the right or left lower
extremity
veins.
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[] Consider transitioning from dilt to another rate control
agent for afib given his supratherapeutic INR on presentation
and hemoptysis, as dilt interacts with the safer DOACs. This
would allow safe transition from warfarin to a DOAC
[] Maintenance warfarin dose is unclear, but likely 4 mg daily
per pharmacy. Titrate warfarin to goal INR ___.
[] Patient on prednisone taper at discharge. He will start
prednisone 10 mg daily (for 3 days) starting ___, then a
maintenance dose of 5 mg. A maintenance dose was selected
because he had been on such a prolonged course of high dose
prednisone; this can be stopped ___ outpatient setting as
clinically indicated.
[] It is unclear if Mr. ___ peripheral edema is ___ HF
exacerbation given his unremarkable TTE. The patient was also
evaluated for cirrhosis, nephrotic syndrome, pelvic compression,
and b/l DVT which were negative (see below). Consider further
work-up of his peripheral edema for other causes.
[] Similarly, his home diuretic was held on discharge given our
uncertainty about HF as a cause of his peripheral edema. Restart
as clinically indicated.
[] Patient is being discharged on insulin given high blood
sugars while on prednisone. Please check blood glucose within
three days of discharge (by ___. Wean insulin as needed as
his prednisone continues to taper.
[] Patient w/ white clumps on straight cath at the end of the
catheter. CT A/P with bladder stones, but nothing to explain his
white clumps. Consider further work-up.
Discharge Wt: 229 lb
Discharge Cr: 0.8
BRIEF SUMMARY
===============
___ with history of severe emphysema/COPD on 4L O2 at baseline,
___ ___ s/p chemo/rads/LUL lobectomy c/b recurrent post
obstructive pneumonia ___ post-op scarring s/p stent placement
c/b migration and stent removal due to no viable airways ___
___, AF on warfarin, CAD, T2DM, heart failure, who p/w
hemoptysis referred from ___ clinic. He was found to have
supratherapeutic INR and received vit K ___ the ED. He remained
hemodynamically stable with stable H/H while admitted. Despite
his INR reversal ___ the ED, he was noted to be volume overloaded
and was admitted for HF exacerbation, for which he was diuresed
with IV Lasix boluses. Of note, it was unclear whether his HF
(with unremarkable TTE while admitted) could explain his
profound peripheral edema; he underwent work-up for cirrhosis,
pelvic compression, bilateral DVT, and nephrotic syndrome, which
was unremarkable. His home diuretic was held given his
unremarkable TTE, to be restarted at the discretion of
outpatient cardiologist. He was also found to have pneumonia/UTI
which was treated with ceftaz. His hospital course was
complicated by SBO likely ___ mesh from prior hernia repair,
resolved after NGT decompression. His warfarin was restarted and
he was discharged on 4 mg daily as a maintenance dose, with INR
to be followed up by outpatient providers.
ACUTE ISSUES:
=============
# Atrial fibrillation
CHADS2VASC 5. Most recent warfarin dosing at assisted living was
2.5 on ___, 5 mg on other days. Given his supratherapeutic
presentation, we coordinated warfarin dosing with pharmacy, and
discharged him on 4 mg daily. His diltiazem was continued while
hospitalized. We considered initiation of a DOAC but did not
start one given interactions w/ dilt. Consider transitioning
dilt to metop as an outpatient and switching from warfarin to a
DOAC.
# Acute on chronic HFpEF ___ pulm HTN
# Leg swelling
Reports increased lower extremity edema and slightly worsening
orthopnea over the last 2 weeks prior to presentation. Pt has
documented history of CHF, outpatient echo ___ ___ w/ normal EF
per PCP, likely ___ HF ___ pulmonary HTN given
significant pulmonary comorbidity. He does not weigh himself at
home but per sheets he is ___ lbs up from 224 lbs ___ ___.
On exam he has primarily right sided findings with significant
bilateral lower extremity/pedal edema. Etiology for exacerbation
unclear, as patient reports he is compliant with meds and diet.
Notably, TTE during admission was fairly unremarkable, thus
work-up of other courses of peripheral edema was undertaken,
which was unremarkable. Pelvic compression syndrome was on Ddx
given cancer hx, LN and lytic lesions on wet reads, but CT A/P
negative. Pt w/o hx cirrhosis and CT A/P w/o
evidence of cirrhosis. Nephrotic syndrome unlikely w/o
significant protein ___ urine and albumin 3.2 on admission. B/L
LENIs negative for b/l DVT. We diuresed with IV Lasix initially,
but eventually held off on further diuresis given patient's
symptomatic improvement and unclear etiology of leg swelling ___
light of unremarkable TTE. We trialed compression stockings, but
patient felt that this worsened his ___ edema and refused to wear
them ___ inpatient setting.
# Hemoptysis, resolved
# Recurrent post obstructive pneumonias
Pt w/ significant history of post-obstructive pneumonias, likely
___ post-operative scarring as previous bx demonstrated
granulation tissue. He has required bronchial stents but IP was
unable to stent him most recently as there were no viable
airways to stent. He was treated for pseudomonas infection
(cultures from bronchial washing) with ciprofloxacin from
___. He denies fevers though notably on prednisone.
Etiology of hemoptysis likely multifactorial from baseline
structural lung disease and operative changes, supratherapuetic
INR, likely pseudomonas PNA as cipro doesn't have great lung
penetration. Legionella neg. Received 10 mg IV vitamin K and
inhaled TXA ___ the ED, as well as 5 days TXA on the floor. He
remained HDS with stable H/H while admitted. Sputum cx obtained
w/ continued pan-sensitive pseudomonas (including ceftaz), other
cultures unremarkable. Antibiotic course notable for vancomycin
(___), ceftazidime (D1 ___. His hemoptysis
resolved, as well as his productive cough.
# Supratherapeutic INR, resolved:
# Coagulopathy:
INR elevated to 7.3 on admission likely ___ cipro interaction
with warfarin. Received 10 mg of IV vit K ___ the ED with
subsequent subtherapeutic INR. His warfarin was managed ___
conjunction with our pharmacists and his discharge dose was 4 mg
daily, as noted above.
#SBO, resolved
Pt w/ nausea and vomiting, found to have partial SBO on CT A/P,
likely small bowel caught on mesh from prior hernia repair. NGT
was placed with significant drainage of bilious fluid and rapid
clinical improvement. Gastrografin KUB later demonstrated
resolution of SBO. His diet was advanced back to regular diet
without further complications.
# Chronic urinary retention:
# UTI
Pt with chronic urinary retention ___ chronic bladder distension
from truck driving who self straight caths at home. P/W
decreased urination, dysuria and exudate within the urine. UA
grossly positive. UCx c/w skin contamination. He received ceftaz
for his PNA, which also treated his UTI. He continued to report
"white, stringy" clumps at his catheter tip after abx, though
his other symptoms resolved. We continued q4-6hr straight cath,
guided by the patient. He was stable at discharge with continued
clumps, which merit further work-up.
# Severe emphysema/COPD on 4L NC:
# Bronchiectasis:
Pt with long standing smoking history and severe COPD on
baseline 4L O2 at home. Of note, prescribed 30 days of pred 50
while at assisted living ___, then again on ___, unclear
why per PCP and pulmonology. No wheezes on exam. Thus, we
tapered his prednisone. at discharge, he had three doses of 10
mg daily pred left to be starting on ___, followed by
maintenance dose of 5 mg daily. A maintenance dose was selected
because he had been on such a prolonged course of high dose
prednisone; this can be stopped at the discretion of outpatient
providers. O2 goal while hospitalized was 88-92%. He was given
duonebs + albuterol nebs q2h:PRN. We continued home budesonide,
Advair, guaifenesin 600 mg q12h.
# Normocytic anemia:
Admission Hb ~11, up from previous baseline Hb 9s, though this
downtrended to Hb ~9 while hospitalized. B12, ferritin normal.
Most likely related to hemoptysis given normocytic presentation
and less likely to be B12, folate, or iron deficiency. We
monitored his H/H while admitted without acute issues or need
for transfusions.
# Thrombocytopenia
Plt 147 on admission. It remained stable throughout admission.
# Hypernatremia, resolved
Free water deficit 3.6L on ___. Likely ___ NPO status iso SBO,
maintenance IVF, and emesis. He received D5W to address his free
water deficit w/ resolution of hypernatremia.
# History of NSCLC:
Dx ___ ___ s/p chemo/rads/LUL lobectomy c/b several
post-obstructive pneumonias now s/p bronchial stent placements
c/b migration and now removal given no viable airways ___.
Note that endobronchial path reports have been consistently
negative for malignancy x3 ___ ___, so not felt to be
contributing to post-obs PNA. Of note, imaging shows stable
thoracic spine compressions/lytic lesion and tissue infiltration
into the left lower lateral intercostal space. CT chest wet read
noted a 1.4cm supraclavicular node however final read not noting
this. Re-read by another rads attending with no evidence of
lytic lesions and stable supraclavicular node from ___, thus
less concerning for recurrent malignancy, however would consider
further work-up of lytic lesions should they return or should
his clinical scenario merit further work-up.
CHRONIC ISSUES:
===============
# Diabetes mellitus II:
HbA1c ___ only 7.2. We held home metformin while inpatient,
which was restarted at discharge. We gave ISS while
hospitalized. We also gave Lantus, as he came ___ with high blood
sugars while on prednisone, which was adjusted as prednisone was
tapered.
# Hyperlipidemia:
Continued home simvastatin 10 mg QHS
# Osteoporosis:
Continued home alendronate 70 mg ___
# Anxiety:
Patient reports taking TID:PRN lorazepam at home, though very
infrequently. We adjust to Lorazepam 0.5 mg PO BID:PRN without
issues during hospitalization.
# Chronic back pain:
Continued home morphine sulfate 15 mg q12h, acetaminophen 650 mg
q6h:PRN.
# Insomnia:
Substituted ramelteon PRN for home melatonin.
# GERD:
Increased home pantoprazole from 20 mg to 40 mg daily iso
steroid use + supratherapeutic INR. This was reduced to normal
home dosing at discharge.
# Gas pains/constipation:
Continued home simethicone QID:PRN, and bowel regimen: senna
BID, miralax, Bisacodyl PR PRN
# Lower extremity dry skin:
Continued home Hydrocerin BID
# History of thrush:
Held home nystatin for now as no evidence of thrush. Resumed on
discharge.
Pt was stable on the day of discharge feeling well. INR
therapeutic. Discharged back to assisted living
>30 min spent on d/c activities on day of discharge ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob
2. Alendronate Sodium 70 mg PO QTHUR
3. Budesonide 0.5 mg IH BID
4. Diltiazem Extended-Release 360 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Furosemide 20 mg PO 3X/WEEK (___)
7. Furosemide 10 mg PO 4X/WEEK (___)
8. GuaiFENesin ER 600 mg PO Q12H
9. Ipratropium-Albuterol Neb 1 NEB NEB QID
10. LORazepam 0.5 mg PO TID:PRN anxiety
11. Morphine SR (MS ___ 15 mg PO Q12H
12. Pantoprazole 20 mg PO Q24H
13. Simethicone 80 mg PO Q6H:PRN bloating
14. Warfarin 5 mg PO 6X/WEEK (___)
15. Hydrocerin 1 Appl TP BID
16. melatonin ___ mg oral QPM:PRN insomni
17. MetFORMIN (Glucophage) 500 mg PO DAILY
18. Simvastatin 10 mg PO QPM
19. Magnesium Oxide 400 mg PO DAILY
20. PredniSONE 50 mg PO DAILY prescribed ___ and ___. Nystatin Oral Suspension ___ mL PO PRN thrush
22. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/wheeze
23. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
24. Senna 8.6 mg PO BID
25. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
26. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
27. Lactobacillus acidophilus 0.5 mg (100 million cell) oral
DAILY dose unknown
28. Warfarin 2.5 mg PO 1X/WEEK (___)
Discharge Medications:
1. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Warfarin 4 mg PO DAILY16
3. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob
4. LORazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam 0.5 mg 1 tab by mouth twice a day Disp #*14 Tablet
Refills:*0
5. PredniSONE 10 mg PO DAILY Duration: 3 Doses
This is dose # 1 of 1 tapered doses
6. PredniSONE 5 mg PO DAILY
Start: After last tapered dose completes
This is the maintenance dose to follow the last tapered dose
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Alendronate Sodium 70 mg PO QTHUR
9. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
10. Budesonide 0.5 mg IH BID
11. Diltiazem Extended-Release 360 mg PO DAILY
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. GuaiFENesin ER 600 mg PO Q12H
14. Hydrocerin 1 Appl TP BID
15. Ipratropium-Albuterol Neb 1 NEB NEB QID
16. Lactobacillus acidophilus 0.5 mg (100 million cell) oral
DAILY dose unknown
17. Magnesium Oxide 400 mg PO DAILY
18. melatonin ___ mg oral QPM:PRN insomni
19. MetFORMIN (Glucophage) 500 mg PO DAILY
20. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*60 Tablet Refills:*0
21. Nystatin Oral Suspension ___ mL PO PRN thrush
22. Pantoprazole 20 mg PO Q24H
23. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
24. Senna 8.6 mg PO BID
25. Simethicone 80 mg PO Q6H:PRN bloating
26. Simvastatin 10 mg PO QPM
27. HELD- Furosemide 20 mg PO 3X/WEEK (___) This
medication was held. Do not restart Furosemide until ___ see
your cardiologist
28. HELD- Furosemide 10 mg PO 4X/WEEK (___) This
medication was held. Do not restart Furosemide until ___ see
your cardiologist
29.Outpatient Lab Work
Date: ___. Labs: ___, INR
ICD-10: I48.91
Provider: ___, MD. Fax: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute on chronic heart failure, with preserved ejection fraction
Atrial fibrillation
Hemoptysis secondary to coagulopathy
Post-obstructive pneumonia
Small bowel obstruction
SECONDARY DIAGNOSIS
===================
Chronic urinary retention
Emphysema
Bronchiectasis
Anemia
Thrombocytopenia
Hypernatremia
Diabetes mellitus II
Hyperlipidemia
Osteoporosis
Anxiety
Chronic back pain
Insomnia
Gastroesophageal reflux 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 taking care of ___ at the ___
___!
WHY WAS I ___ THE HOSPITAL?
==========================
- ___ came to the hospital because ___ were coughing up blood.
___ were seen by the lung doctors ___ the emergency department.
- ___ were admitted because we thought ___ had issues from your
heart failure, where your heart doesn't pump well and ___ get
fluid ___ your lungs and legs. We also thought ___ might have a
pneumonia.
WHAT HAPPENED ___ THE HOSPITAL?
==============================
- ___ were given a water pill (furosemide) through your IV to
get rid of the extra fluid. Your breathing and swelling
improved.
- We adjusted your warfarin dose because of ___ coughing up
blood, which ___ stopped having.
- ___ were given antibiotics for your pneumonia.
- ___ had an obstruction ___ your intestinal tract. We placed a
nasogastric tube (NG tube) to fix this and make your belly feel
better. ___ were back to normal after a few days with the NG
tube.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
We wish ___ the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10362959-DS-5 | 10,362,959 | 29,699,712 | DS | 5 | 2149-02-15 00:00:00 | 2149-02-15 21:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal distension
Major Surgical or Invasive Procedure:
paracentesis x ___: diagnostic paracentesis in ED
-___: 4L drained
-___: 6L drained
-___: 0.5L drained
History of Present Illness:
___ man with NASH cirrhosis c/b esophageal varices and
ascites, HTN, DM2, and recent hospitalization in ___ for
cholangitis and gangrenous cholecystitis s/p open
cholecystectomy failed and T tube placement, now removed, and
s/p ERCP on ___ with sphincterotomy/stent removal, now
presenting with incisional drainage, 10 lb weight gain, and
abdominal pain.
Has had increasing abdominal distention since his initial
surgery. Providers had increased his Lasix which had improved ___
swelling, but didn't improve abdominal swelling. Then came in
for ERCP, got IVF with procedure, which he thinks caused even
more swelling. After that had increased pain, and today noted
leakage from initial CCY scar, which prompted providers to tell
him to come to ED.
In the ED:
- initial VS were: 98.8 89 125/75 18 96% RA
- labs notable for: ascetic fluid with PMN count of 255, ALT 20,
AST 31, Tbili 2.3, Hgb 12.6, plts 109
- RUQ US: moderate ascites, a stone is noted in the neck of the
gallbladder, and gb wall thickening
- transplant surgery was consulted: no acute surgical
intervention
- VS on transfer: 98.7 85 116/79 14 95% RA
On arrival to the floor, patient reports persistent, mild
abdominal discomfort. Says he needs to be home by ___ for a
___ ___ class he teaches.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
___ cirrhosis with h/o esophageal varices
Acute cholangitis/cholecystitis ___, failed open CCY and
Tube placed. ERCP and CBD stenting performed at that time. S/p
stent removal and sphincterotomy ___.
HTN
DM2
Goiter, scheduled for removal
Thrombocytopenia
Social History:
___
Family History:
Reviewed, none pertinent to this hospitalization
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.9 124/71 84 18 95% RA
108.4 kg
GENERAL: NAD
HEENT: PERRL, MMM
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: + BS, distended, TTP, no guarding, dullness to
percussion at bases, + ascities, CCY scar w/o active drainage,
but overlying bandage is crusted w/clear drainage, bandage over
para site c/d/i
EXTREMITIES: 2+ pitting edema to mid-calf
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: 98.4 118/64 85 96%RA
GENERAL: NAD
HEENT: PERRL, MMM
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: + BS, soft abdomen with mild ascites by percussion, CCY
scar w/o active drainage, para site dressing c/d/i
EXTREMITIES: Trace pitting edema
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 11:25PM BLOOD WBC-7.6 RBC-4.26* Hgb-12.6* Hct-36.5*
MCV-86 MCH-29.6 MCHC-34.5 RDW-15.2 RDWSD-46.8* Plt ___
___ 11:25PM BLOOD Neuts-75.3* Lymphs-9.1* Monos-12.0
Eos-2.2 Baso-0.7 Im ___ AbsNeut-5.70 AbsLymp-0.69*
AbsMono-0.91* AbsEos-0.17 AbsBaso-0.05
___ 11:25PM BLOOD ___ PTT-33.9 ___
___ 11:25PM BLOOD Glucose-170* UreaN-15 Creat-0.7 Na-133
K-3.6 Cl-96 HCO3-25 AnGap-16
___ 11:25PM BLOOD ALT-20 AST-31 AlkPhos-136* TotBili-2.3*
DirBili-1.0* IndBili-1.3
___ 11:25PM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.2 Mg-1.5*
___ 11:35PM BLOOD Lactate-1.3
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-4.9 RBC-3.80* Hgb-11.1* Hct-32.5*
MCV-86 MCH-29.2 MCHC-34.2 RDW-14.6 RDWSD-45.0 Plt Ct-73*
___ 06:45AM BLOOD ___ PTT-31.3 ___
___ 06:45AM BLOOD Glucose-152* UreaN-19 Creat-0.8 Na-136
K-3.3 Cl-100 HCO3-25 AnGap-14
___ 06:45AM BLOOD ALT-24 AST-26 AlkPhos-98 TotBili-1.2
___ 06:45AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.6 Mg-1.4*
URINE:
___ 02:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 02:00AM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
PERITONEAL FLUID:
___ 02:09AM ASCITES WBC-711* ___ Polys-36*
Lymphs-39* Monos-21* Mesothe-4*
___ 02:09AM ASCITES TotPro-2.7 Glucose-186
___ 12:30PM ASCITES WBC-333* ___ Polys-31*
Lymphs-18* Monos-38* Mesothe-1* Macroph-12*
___ 12:30PM ASCITES TotPro-2.8 Glucose-216 LD(LDH)-110
Albumin-1.4
___ 10:12AM ASCITES WBC-875* ___ Polys-53*
Lymphs-24* Monos-8* ___ Mesothe-1* Macroph-14*
___ 02:30PM ASCITES WBC-678* ___ Polys-36*
Lymphs-22* Monos-17* Mesothe-9* Macroph-16*
MICROBIOLOGY:
_______________________________________________________
___ 2:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Preliminary): NO GROWTH.
__________________________________________________________
___ 1:51 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
__________________________________________________________
___ 10:12 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Preliminary): NO GROWTH.
__________________________________________________________
___ 10:12 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 7:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:56 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 12:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
RECEIVED IN LAB 1740 PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
__________________________________________________________
___ 5:30 pm PERITONEAL FLUID
RECEIVED IN LAB 1740 PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 2:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 2:09 am
PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 11:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
RUQ US WITH DOPPLER ___:
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The
contour of the liver is smooth. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is
moderate ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 11 mm.
GALLBLADDER: A stone is noted in the neck of the gallbladder.
There is mild thickening of the gallbladder likely due to poor
distention.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
1. Mild gallbladder wall thickening is likely secondary to poor
distention.
2. Moderate volume ascites.
3. The liver has a cirrhotic morphology.
4. The main portal vein is patent.
CXR ___:
IMPRESSION:
Chronic elevation of left hemidiaphragm with adjacent left
basilar opacity favoring atelectasis over infectious pneumonia.
Brief Hospital Course:
___ man with NASH cirrhosis and recent episode of
cholangitis s/p ERCP/stent/sphincterotomy, admitted with SBP.
# SBP: Patient presented with increasing abdominal ascites
despite continuing his lasix 40 mg BID and increasing
spironolactone at home from 100 mg to 150 mg. He underwent a
diagnositic para in the ED with which showed ANC 255. He had
been on ciprofloxacin for recent cholangitis and stent removal
with sphincterotomy on ___ without any fevers, chills. His bili
was initially 2.3 and alk phos 136 but trended down and his RUQ
US with dopplers showed patent portal vein, gallbladder wall
thickening felt due to poor distention. He was started on
ceftriaxone, given albumin on day 1, day 3 and underwent
therapeutic paracentesis on the floor after admission with 4L
drained with ANC of 103. He had low-grade fevers on day 2 of
hospitalization while on ceftriaxone with negative UA, CXR and
blood culture. His ascites worsened and he had a repeat
paracentesis (6L drained, given albumin) with ANC 464. He was
afebrile and felt well but given this finding vancomycin was
added on ___ and he was continued on ceftriaxone. He underwent
a repeat para with 500cc drained on ___ with ANC 244. Given he
continued to be afebrile, no leukocytosis with improved ANC and
peritoneal gram stains showed only PMNs and cultures were
negative he was discharged on bactrim for prophylaxis (not on
ciprofloxacin given he was on ciprofloxacin when he developed
SBP).
# NASH Cirrhosis: Patient with history of NASH cirrhosis,
complicated by ascites and grade II varices. He had increasing
abdominal girth on home diuretics with 10 lb weight gain and
increasing abdominal discomfort. As noted above he underwent
large volume paracentesis (4L, 6L and 0.5 L) and was discharged
on torsemide 80 mg daily (switched from home lasix 40 mg BID),
spironolactone 200 mg daily (increased from 150 mg daily), and
home nadolol.
# s/p ERCP with sphincterotomy/stent removal: Patient had an
ERCP on ___ in the setting of recent cholangitis and had a
stent removal and sphincterotomy. His admission RUQ US showed
gallbladder neck stone but per ERCP this would not be amenable
to ERCP intervention and he was asymptomatic with Tbili and alk
phos which normalized during the hospital course.
# Diabetes type 2:
- continued home Lantus, HISS
# GERD:
- continued home famotidine
Transitional Issues:
===================
1. Acquired SBP while on cipro prophylaxis, so switched to
Bactrim DS as new prophylaxis regimen.
2. Lasix 40mg BID changed to Torsemide 80mg daily.
3. Spironolactone increased from 150mg daily to 200mg daily.
4. Patient instructed to have CBC, CMP, INR drawn on ___.
As patient was discharged on a ___ appointments were not
made - patient to call and schedule appointment with PCP and
hepatologist Dr. ___ on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
2. Famotidine 20 mg PO DAILY
3. Furosemide 40 mg PO BID
4. Nadolol 20 mg PO DAILY
5. Spironolactone 150 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Ciprofloxacin HCl 500 mg PO Q12H
8. Glargine 70 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Vitamin D 1000 UNIT PO DAILY
2. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
3. Famotidine 20 mg PO DAILY
4. Glargine 70 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Spironolactone 200 mg PO DAILY
RX *spironolactone 100 mg 2 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
6. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
7. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet
Refills:*0
8. Nadolol 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Spontaneous Bacterial Peritonitis
Non-alcoholic steatohepatitis cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had an infection
in your belly. We treated you with antibiotics and you improved.
You will now take a new medication called Bactrim to help
prevent these infections in the future.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10363072-DS-10 | 10,363,072 | 22,250,148 | DS | 10 | 2181-04-25 00:00:00 | 2181-04-25 15:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a ___ y.o male with h.o paranoid schizophrenia, with h.o
chronic ETOH abuse per OMR including a PEA arrest and ICU course
for septic shock due to PNA in ___ who was reportedly found to
be living in squalor by a social worker. Per report, he was
discharged from the hospital recently and was supposed to be
taking antibiotics for leg cellulitis. Per report, he has not
been doing so and has several open wounds on his b/l legs. Per
report, he was BIBA after his case manager noted swollen
erythematous b/l ___ with shallow foul smelling ulcers. Per
another report, pt recently discharged from ___.
Pt states that he does not have any pain. He reports that he
wants his "skin to heal over quickly on his legs". He states
that legs are supposed to be down and not elevated. He reports
that his caseworker is "Sister ___. Pt reports that
he was doing well at home but that he pulled the bandaged too
much on his left ankle and it bled a lot and that caused him
concern. He denies fever, chills, increased edema, other joint
pain or rash.
.
In the ED, pt was given a dose of IV vancomycin. Vitals appeared
stable.
.
10pt ROS reviewed and otherwise negative including for headache,
dizziness, CP, sob, palpitations, cough, abdominal pain, nausea,
vomiting, diarrhea, constipation, melena, brbpr, dysuria.
Past Medical History:
Hx of heavy etoh abuse and frequent ED visits
Social History:
___
Family History:
Denies any family history of medical problems stating they all
"exercised"
Physical Exam:
ADMISSION EXAM
Vitals: T 98.4 BP 141/90 HR 89 RR 18 sat 100% on RA
GEN: NAD, comfortable appearing, sitting upright in bed
HEENT: ncat anicteric MMM
NECK:
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
ABD: +bs, soft, NT, ND, no guarding or rebound
back:
GU:
EXTR:b/l ___ brawny edema with mild erythema b/l legs. +diffuse
skin flaking and skin changes c/w fungal infection. L.leg with
wounds, eschar and prior evidence of bleeding near L.ankle
DERM: no rash
NEURO: face symmetric speech fluent, AAOx3
PSYCH: calm, cooperative but tangential
DISCHARGE EXAM
GEN: No acute distress, agitated and perseverating on going home
HEENT: NCAT, anicteric sclera
CV: Normal S1, S2, no murmurs
RESP: Good air entry, no rales or wheezes
ABD: Normal bowel sounds, soft, non-tender, non-distended, no
rebound/guarding;
EXTR / DERM: Bilateral lower extremities bandaged in ACE wraps,
1+ pitting edema to thighs, no streaking erythema; chronic
appearing ulcers on the lateral aspect of both shins, with
moderate amount of purulent drainage
NEURO: Face symmetric, speech fluent, non-focal
PSYCH: Calm, odd affect, apparent fixed delusions and poor
insight
Pertinent Results:
ADMISSION LABS
___ 02:03PM ___ COMMENTS-GREEN TOP
___ 02:03PM LACTATE-0.7
___ 01:57PM GLUCOSE-98 UREA N-15 CREAT-0.6 SODIUM-133
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-31 ANION GAP-10
___ 01:57PM WBC-5.1 RBC-3.31* HGB-9.8* HCT-30.7* MCV-93
MCH-29.6 MCHC-31.9* RDW-13.8 RDWSD-47.2*
___ 01:57PM NEUTS-62.9 LYMPHS-18.4* MONOS-13.5* EOS-4.2
BASOS-0.6 IM ___ AbsNeut-3.18 AbsLymp-0.93* AbsMono-0.68
AbsEos-0.21 AbsBaso-0.03
___ 01:57PM PLT COUNT-214
___ 01:57PM ___ PTT-29.8 ___
___ 12:50PM URINE HOURS-RANDOM
___ 12:50PM URINE HOURS-RANDOM
___ 12:50PM URINE UHOLD-HOLD
___ 12:50PM URINE GR HOLD-HOLD
___ 12:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
IMAGING / STUDIES
LOWER EXTREMITY ULTRASOUND:
1. No evidence of deep venous thrombosis in the visualized right
or left lower extremity veins. The calf veins were not well
assessed.
2. Severe soft tissue edema in the calves bilaterally
ARTERIAL STUDIES:
Finding Doppler evaluation was performed of both lower extremity
arterial
systems at rest.
All waveforms are triphasic bilaterally.
VENOUS MAPS:
FINDINGS DUPLEX EVALUATION WAS PERFORMED OF BOTH LOWER
EXTREMITIES. LIMITED
DUE TO BANDAGES AND PATIENT IS UNCOOPERATIVE .
THERE IS NO OBVIOUS REFLUX IN EITHER THE PROXIMAL DEEP SYSTEM OR
THE SAPHENOUS
VEINS.
IMPRESSION:
INCOMPLETE STUDY BUT NO OBVIOUS DEEP OR SUPERFICIAL REFLUX
Brief Hospital Course:
___ y.o male with h.o chronic paranoid schizophrenia, hypoxic
brain injury, h.o ETOH abuse, reported recent admission for
cellulitis, who presents with increased purulent drainage from
apparently chronic lower extremity wounds. He left against
medical advice before completing a full course of antibiotics.
# Cellulitis, lower extremity ulcers - Increased purulent
drainage is suggestive of bacterial superinfection of apparently
chronic wounds. Location and exam suggestive of venous stasis
ulcers and unknown whether patient has a history of vascular
disease or diabetes. No clinical evidence or history of CHF,
albumin within normal limits at 3.7. Arterial studies within
normal limits. TSH and HbA1c normal. Arterial and venous
studies as above were within normal limits. Vascular surgery
was consulted and recommended 5 days of antibiotics, no surgical
intervention. The patient was treated with vancomycin,
ciprofloxacin, metronidazole, and wound care for 3 days. On the
day of discharge he was transitioned to doxycycline,
ciprofloxacin, and metronidazole to complete a ___oordination of care - ___, social, and psychiatric
history are unclear as the patient is unable to provide reliable
history and has not been seen at ___ since ___. Most
information is based on discussion with nurses and case managers
at ___ ___. Social work
also helped to corroborate information. On the day of discharge
it was discovered that the patient has a PCP, ___ at
___ for the Homeless ___.
# h.o ETOH abuse with h.o prior withdrawals: Reports last drink
2 days prior to admission. He was maintained on the CIWA scale
but had no signs of withdrawal. He was given thiamine, folate,
multivitamins
# Chronic paranoid schizophrenia, history of anoxic brain
injury: Patient denies taking any medications; ___ confirmed
that patient refuses all medications. Patient makes his own
medical decisions and does not have a legal guardian. While he
has poor insight and judgment, he is not felt to be an imminent
danger to himself or others.
Patient left against medical advice before completing his
recommended course of antibiotics. He was able to state the
risks and benefits of leaving before completing the course of IV
antibiotics and stated he was willing to take the oral
medications prescribed. It is unclear based on the patient's
history whether he will adhere to the recommended treatment. I
communicated with ___ nurse and case manager, and our social
work and case managers did the same. They will do their best to
reinforce the plan of care and a copy of the discharge summary
will be sent ___ from ___ ___.
[x]Pt is medically stable for discharge.
[x]Time spent coordinating discharge: > 30 minutes, coordinating
with outpatient providers and arranging home services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*10 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis
Chronic venous stasis ulcers
Chronic paranoid schizophrenia
Hypoxic brain injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were hospitalized for cellulitis (an infection of your
legs).
We recommended that you stay for ongoing treatment but you
strongly preferred to go home instead of completing treatment.
Please continue to take antibiotics as prescribed, and care for
your wounds as instructed
Followup Instructions:
___
|
10363340-DS-13 | 10,363,340 | 24,078,377 | DS | 13 | 2182-08-29 00:00:00 | 2182-08-31 20:04:00 |
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:
___: ___ pleurex catheter placement
History of Present Illness:
___ w/PMH significant for ___ lung metastases
unclear etiology, pleural effusion, a history of breast cancer
who presented to ___ for evaluation of dyspnea. Briefly, pt
developed progressive SOB starting in ___. At baseline, pt
was independent with her ADLs. However, by ___, she was
unable to walk more than a few feet. Pt had CT chest showed
moderate bilateral pleural effusions, L>R, as well as multiple
pulmonary nodules and diffuse sclerosis in T1 and L2 vertebrae
c/f metastasis. Pt was referred to ___ for thoracentesis. 1L
serous fluid was removed from Left effusion, although procedure
was terminated in the setting of air aspiration. Repeat CXR not
concerning for PTX. Pleural fluid analysis notable for total
protein 3.2, LDH 90, WBC 815 (34 polys, 64 lymphs) and RBC 550.
After her procedure, pt reported improved breathing, and she
could walk ~50 feet without having to stop. However, her SOB
worsened significantly over the course of this week. Her SOB is
associated with a cough with occasional production of
white/clear sputum. No fevers, chills night sweats, chest pain
or syncope. She has noticed some increased leg swelling without
tenderness or erythema, particularly over the past few weeks,
L>R. No history of clots
On admission to the ED, VS were 98.7 70 172/50 18 96%. Labs were
notable for WBC 14.3 and lactate of 2.5. CXR showed increased
size of Left pleural effusion. Physical exam was notable for L>R
___ edema. Left LENIS was negative. Pt was treated with
ceftriaxone/azithromycin given leukocytosis. No blood or urine
cultures were drawn.
On Transfer Vitals were: 98.0 83 136/66 18 96% RA. On the floor,
pt continued to complain of dyspnea. Otherwise, no fevers or
chills. Additional ROS was notable for decreased appetite and
subjective weight loss over the past few months. Otherwise, no
nausea/vomiting. Pt has also noticed a new pruritic rash on her
Left chest wall, which started a few weeks ago.
Review of Systems:
(+) rhinorrhea, cough, shortness of breath
(-) fever, chills, night sweats, headache, vision changes,
congestion, sore throat, chest pain, abdominal pain, nausea,
vomiting.
Past Medical History:
DM2 (last A1c 9.8 in ___
CKD stage III
Breast cancer left s/p lumpectomy then XRT ___
Toxic multinodular goiter c/b thyrotoxicosis
History of endometrial polyp
Arrhythmia (echo ___ noted AF but subsequent holter noted
Sinus rhythm, ___ AV block. Nonconducted beats more
consistent with blocked PACs at times with 2:1 conductional
bigeminy.
Mild Aortic stenosis ___ 1.6 cm2)
HTN
HLD
Obesity
Anxiety
Pseudophakia
Social History:
___
Family History:
Rheumatoid arthritis, CAD, PVD
Physical Exam:
On Admission:
Vitals: 97.6; 184/82; 73; 24; 98% 1L
General: Pleasant, ___. Hard of hearing. No acute
distress. AOx3.
HEENT: EOMI. MMM.
Lymph: Left supraclavicular LAD. No cervical, axillary or
inguinal LN appreciated.
CV: Irregularly irregular. No MRG. No JVP appreciated.
Lungs: Pt frequently became SOB during exam, but was able to
speak in full sentences. Decreased air movement at bases
bilaterally, L>R. Fine crackles at lung bases, L>R.
Abdomen: Obses abdomen. Soft, NTND. No HSM appreciated.
Ext: 2+ pitting edema on Right leg up to knee. Trace edema in
Left leg. 2+ DP/Radial pulses, equal bilaterally.
Neuro: ___ grossly intact
Skin: Erythematous, papular rash on Left chest wall.
On Discharge:
Vitals: 98.5/98.1; ___ 18; ___ RA
General: Pleasant, ___. Hard of hearing. Speaking in
full sentences with no SOB. No acute distress. AOx3.
HEENT: EOMI. MMM.
Lymph: Left supraclavicular LAD. No cervical, axillary or
inguinal LN appreciated.
CV: Irregularly irregular. No MRG. JVP flat
Lungs: Breathing comfortably on 3L. No accessory muscle use.
Improved air movement bilaterally, Fine crackles at lung bases,
R>L; L pleurex catheter in place with chest tube to water seal
with dressing in place with small amount of sanguinous drainage,
site is without erythema, induration, purulent drainage
Abdomen: Obese abdomen. Soft, NTND. No HSM appreciated.
Ext: left upper extremity with IV in AC, swollen forearm and
upper arm without erythema, warmth, or induration, LUE visibly >
RUE with decreased skin markings, radial and ulnar pulses 2+;
trace lower extremity edema with TEDS in place
Neuro: axox3; ___ grossly intact
Skin: Erythematous, papular rash on left chest wall wrapping
around to back
Pertinent Results:
On Admission:
___ 01:35PM BLOOD ___
___ Plt ___
___ 02:18PM BLOOD ___ ___
___ 01:35PM BLOOD ___
___
___ 01:35PM BLOOD ___
Immunologic Labs:
___ 06:35AM BLOOD ___
On Discharge:
___ 06:45AM BLOOD ___
___ Plt ___
___ 06:45AM BLOOD ___
___
___ 06:45AM BLOOD ___
IMAGING:
___ CXR:
1. Increased size of small to moderate sized left pleural
effusion. Small
right pleural effusion is relatively unchanged.
2. Bibasilar airspace opacities, likely atelectasis, but
infection cannot be completely excluded.
3. Diffuse pulmonary nodules compatible metastatic disease are
re-
demonstrated.
___ LENIS:
IMPRESSION:
1. Limited study with nonvisualization of the peroneal veins
but, otherwise,no evidence of deep venous thrombosis in the left
lower extremity veins.
2. Subcutaneous edema in the popliteal fossa and calf.
___ CT A/P:
IMPRESSION:
1. Sclerosis of the L2 vertebral body suggestive of bony
metastasis. Another possible 5 mm sclerotic lesion in the T12
vertebral body in the background of heterogeneous appearance of
the bones. Radionuclide bone scan is more sensitive for the
detection of small or early bony metastases.
2. Interval increase in volume of moderate bilateral
nonhemorrhagic pleural effusions. Several right lower lobe
metastases are unchanged from the prior study where there are
better characterized.
3. 10 mm subcapsular hypodensity at the hepatic dome is not
fully
characterized. Recommend ultrasound for further
characterization.
4. Cholelithiasis with large 15 mm gallstone.
5. Diverticulosis.
___ Skeletal Survey:
IMPRESSION:
Multiple views of the axial and appendicular skeleton were
obtained. In the skull, there is no evidence of metastases,
though there is hyperostosis frontalis interna, of no clinical
significance. In the spine, there are extensive degenerative
changes without evidence of compression fracture.
Moderate degenerative changes are seen in the hip joints without
definite lytic change. Contrast material is seen in the urinary
tract and there is extensive calcification of the splenic
artery.
Although no definite metastases are detected, radiographs have a
low
sensitivity. If there is serious concern for metastatic disease,
radionuclide bone scanning would be the next imaging procedure.
___ CXR:
FINDINGS:
There is no evident pneumothorax. left pleural effusion has
decreased .
Moderate right effusion and adjacent opacities are unchanged.
Bilateral lung nodules are better seen in prior CT.
Cardiomediastinal contours are unchanged.. Left pleural catheter
tip is difficult to visualize. Clips in the left axilla are
again noted.
Brief Hospital Course:
Mrs. ___ is an ___ w/___ significant for
___ lung metastases unclear etiology, known
bilateral pleural effusions, a history of breast cancer who
presented to ___ for evaluation of dyspnea.
#Dyspnea: Admission CXR showed worsening left pleural effusion
and stable Right effusion following recent drainage by IP.
Cytology from recent thoracentesis was consistent with
metastatic malignant effusion, likely of breast origin. Pleurex
catheter was placed in Left hemithorax by interventional
pulmonology on ___ with improvement in her symptoms. Pt
was discharged with plan for QOD drainage and f/u with IP on
___. She was also discharged with oxygen for comfort.
-Follow up with PCP
___ Cancer: Cytology from ___ thoracentesis
was mammoglobin (+), CK7(+) ER(+), Her2 equivocal and CK20
negative. Pt was seen by ___ heme/onc. She underwent CT
abdomen/pelvis and bone scan for staging. She was started on
anostrazole and discharged with a plan to follow up with her
primary oncologist, Dr. ___.
-Continue anostrazole
-Follow up with Dr. ___
#Leukocytosis: Pt w/leukocytosis to 14.1 on presentation but
otherwise without infectious symptoms. She received a single
dose of CTX/azithromycin in the ED, and this was discontinued on
admission. Leukocytosis felt to be reactive to malignancy, as pt
had no other signs of infection.
#Left chest wall rash: Pt with erythematous rash on chest wall
and axilla, felt to be related to malignancy. Triamcinolone was
discontinued and pt given Sarna lotion for symptomatic relief.
-Discontinue triamcinolone
___ edema: Pt presented with L>R leg edema, felt to be ___
venous insufficiency. Improved with TEDs. Pt also continued on
home lasix.
#HTN: Pt continued on home atenolol.
#DM2: Pt maintained on home Lantus with SSI
#HLD: Pt continued on home atorvastatin and aspirin
**Transitional Issues**
- Follow up with PCP
- ___ up with interventional pulmonology on ___.
- Follow up with Dr. ___
- ___
- Code: DNR/DNI
Emergency Contact:
-___ (daughter) ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 50 Units Bedtime
2. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
3. Furosemide 40 mg PO DAILY
4. Atenolol 75 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN Dyspnea
7. Vitamin D ___ UNIT PO DAILY
8. Aspirin 81 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 75 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Furosemide 40 mg PO DAILY
5. Glargine 50 Units Bedtime
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Albuterol Inhaler ___ PUFF IH Q6H:PRN Dyspnea
9. anastrozole 1 mg oral daily
RX *anastrozole 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. Outpatient Physical Therapy
Diagnosis: Breast cancer metastatic to lung
Rolling walker
Prognosis: Good
Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Pleural Effusion
Breast cancer
Secondary:
DM2 (last A1c 9.8 in ___
CKD stage III
History of toxic multinodular goiter c/b thyrotoxicosis
Mild Aortic stenosis
HTN
HLD
Obesity
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___
because ___ had difficulty breathing. ___ were found to have
fluid in your lungs, and ___ had a procedure where a drain was
placed in your chest to remove this fluid. When ___ leave, ___
will need to keep this drain in to remove any new fluid that
builds up. The visiting nurses ___ help drain the fluid EVERY
OTHER DAY. ___ can take Tylenol to help control your pain.
___ were also seen by our oncologists to create a plan to treat
your cancer. ___ were started on a medication called
anostrazole. When ___ leave, ___ should follow up with your
oncologist, Dr. ___. Her office is working on getting ___
an appointment. If ___ don't hear from her by ___, ___ should call her office at ___.
___ will go home on oxygen. Please make sure ___ are careful
with the cords and do not place the oxygen near fire or open
flame, as it is highly combustible. The oxygen will help ___
breathe more comfortably.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10363612-DS-12 | 10,363,612 | 24,278,060 | DS | 12 | 2172-03-15 00:00:00 | 2172-03-15 11:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
malaise, urinary frequency, urgency and dysuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year old woman who was referred from ___
for 2 weeks of urinary sympstoms and 1 day of hypotension.
History mostly obtained via translation via daughter (pt is
___ speaking). Patient initially developed sxs of urinary
frequency, urgency and dysuria about 2 weeks ago that she
believes started after a pap smear. Since then, she has had mild
lower abdominal pain, associated with some episodes of
incontinence. Also reports right sided flank pain for the past 2
days, as well as several days of malaise, diffuse myalgias and
arthralgias. Denies nausea/vomiting, fever, chills. ROS also
positive for constipation (usually has BMs daily but now
worsened to once every ___ days in the last week) and dark
stools. She has taken some fiber-based stool softeners and dose
of a laxative suppository without results. Passing gas.
She presented to ___ yesterday where bilateral mild CVAT to
percussion was noted. UA showed SG 1.005. PH 6.5. Positive for
3+ leukocytes, 2+ blood. URINE CULTURE: Gram Negative Rods, Non
Lactose Fermenters >100,000 cfu/mL.
She was given CTX 1gm yest and IVF for presumed pyelonephritis.
Today, she represented to ___ with severe fatigue, given 1L
NS and sent to ___ ED.
In the ED, initial VS were: 103 74 87/48 18 100% RA
ED physical exam was recorded as benign abd, mild suprapubic
discomfort, no focal tenderness, bilateral CVA tenderness R>L,
guiaic positive melenotic stool.
ED labs were notable for:
WBC 13 --> 11
Hb 9.1 --> 8.4
Imaging showed:
CT abd 1. There are multifocal regions of patchy hypodensities
in the right kidney,
as well as possibly the left, with associated mild thickening of
Gerota's
fascia, possibly indicating a region of pyelonephritis.
2. Mild enhancement of the bilateral ureters may indicate
ascending infection.
Additionally, there is mild enhancement of the bladder wall.
Please correlate
with patient's labs and clinical symptoms.
3. A 1.3 x 0 0.8 cm hyperdense region in the liver dome likely
represents
transient hepatic attenuation difference.
Patient was given:
___ 14:51 IVF NS 1000 mL
___ 14:51 PO Acetaminophen 1000 mg
___ 14:51 IV CeftriaXONE 1 gm
___ 16:53 IV Pantoprazole 40 mg
___ 17:41 IVF NS 1000 mL
___ 17:41 IVF NS 1000 mL
Transfer VS were 77 106/56 24 96% RA
When seen on the floor, a ten point ROS was conducted and was
negative except as above in the HPI.
Past Medical History:
Chronic daily headache
Tuberculosis - Finished antiTb medication in ___
Insomnia
Social History:
___
Family History:
Family history of breast cancer
Physical Exam:
ADMISSION EXAM:
Gen: NAD, lying in bed, appears comfortable
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: right sided CVA tenderness to palpation and percussion. No
significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
DISCHARGE EXAM:
Essentially unchanged from admission exam with the exception
that CVA region no longer tender.
Pertinent Results:
___ 05:30PM WBC-11.4* RBC-2.81* HGB-8.4* HCT-25.6* MCV-91
MCH-29.9 MCHC-32.8 RDW-12.4 RDWSD-41.5
___ 05:30PM PLT COUNT-158
___ 02:20PM GLUCOSE-118* UREA N-12 CREAT-1.1 SODIUM-139
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-23 ANION GAP-18
___ 02:20PM ALT(SGPT)-17 AST(SGOT)-16 ALK PHOS-75 TOT
BILI-0.5
___ 02:20PM ___ PTT-38.3* ___
CT abd/pelvis:
1. There are multifocal regions of patchy hypodensities in the
right kidney, as well as possibly the left, with associated mild
thickening of Gerota's fascia, possibly indicating a region of
pyelonephritis.
2. Mild enhancement of the bilateral ureters and the bladder
wall may
indicate ascending infection. Please correlate with patient's
labs and
clinical symptoms.
3. A 1.3 x 0 0.8 cm hyperdense region in the liver dome is not
fully
characterized on this exam and can be concerning for malignancy.
Recommend
further work up with dedicated MRI.
4. Prominence of the venous plexus, which can be seen in pelvic
congestion syndrome.
5. Small amount of free pelvic fluid.
Brief Hospital Course:
Patient is a ___ year old woman who was referred from ___
for 2 weeks of urinary sympstoms and 1 day of hypotension.
# Sepsis from urinary source
# Pyelonephritis:
Pt was initially hypotensive (responded to fluids), with exam
and imaging evidence of ascending UTI. Presentation was
consistent with sepsis from urinary source given leukocytosis,
positive urine culture, fever on presentation, and CVA
tenderness on exam. CT showed multifocal regions of patchy
hypodensities in the right kidney,
as well as possibly the left kidney, with associated mild
thickening of
Gerota's fascia, possibly indicating a region of pyelonephritis.
Urine cultures from HVA showed >100,000 E.coli resistant to
Bactrim and aminoglycosides but otherwise sensitive to
cephalosporins and fluoroquinolones. She was treated with IV
CTX while inpatient which was transitioned to PO levofloxacin
for completion of 10 day course on discharge.
# GIB, ?upper: Patient reported 2 weeks of fatigue as well as
report of dark stools in the setting of constipation. Hct was
normal in ___, now down to ___. On rectal exam, there was
no melena on her rectal vault. She also did not have further
dark stools while inpatient so it was felt that she did not need
further w/u inpatient at this time.
# Constipation: ___ reported constipation for 2 weeks prior to
admission. She was also noted to have external hemorrhoids on
exam. Had 2 BM's while here and no longer felt constipated. ___
started on senna and docusate on discharge.
# Insomnia: she was continued on home QUEtiapine Fumarate 50 mg
PO QHS:PRN and Zolpidem Tartrate ___ mg PO QHS:PRN
# Liver abnormality: CT report read as "A 1.3 x 0 0.8 cm
hyperdense region in the liver dome is not fully characterized
on this exam and can be concerning for malignancy"
TRANSITIONAL ISSUES:
[ ] Pt needs f/u of new anemia and possible dark stools.
Consider outpatient EGD vs. colonoscopy if not done recently
[ ] F/u of liver lesion per above
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clotrimazole Cream 1 Appl TP BID
2. QUEtiapine Fumarate 50 mg PO QHS:PRN insomnia
3. Zolpidem Tartrate ___ mg PO QHS:PRN insomnia
4. DULoxetine 60 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day
Disp #*60 Capsule Refills:*0
2. Levofloxacin 250 mg PO Q24H
RX *levofloxacin 250 mg 1 tablet(s) by mouth every day Disp #*8
Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg one tablet by mouth twice per day
Disp #*60 Tablet Refills:*0
4. Clotrimazole Cream 1 Appl TP BID
5. DULoxetine 60 mg PO DAILY
6. QUEtiapine Fumarate 50 mg PO QHS:PRN insomnia
7. Zolpidem Tartrate ___ mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
pyelonephritis
external hemorrhoids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with urinary symptoms and back pain. We found that
you have a kidney infection. We treated you with antibiotics
and this improved.
You also had dark stools for the last few days. We did a rectal
exam and did not find any evidence of bleeding. You do have
some hemorrhoids from prolonged constipation that may have had
some bleeding.
Followup Instructions:
___
|
10363790-DS-15 | 10,363,790 | 20,659,494 | DS | 15 | 2128-10-18 00:00:00 | 2128-10-19 13:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
Coronary Cath on ___
attach
Pertinent Results:
ADMISSION LABS:
================
___ 03:56PM BLOOD WBC-10.6* RBC-4.52 Hgb-14.2 Hct-41.5
MCV-92 MCH-31.4 MCHC-34.2 RDW-14.5 RDWSD-49.0* Plt ___
___ 03:56PM BLOOD Neuts-73.2* ___ Monos-5.5
Eos-0.2* Baso-0.2 Im ___ AbsNeut-7.79* AbsLymp-2.18
AbsMono-0.58 AbsEos-0.02* AbsBaso-0.02
___ 03:56PM BLOOD Glucose-109* UreaN-12 Creat-0.7 Na-130*
K-4.7 Cl-94* HCO3-24 AnGap-12
___ 03:56PM BLOOD cTropnT-0.25*
___ 12:00AM BLOOD CK-MB-24* cTropnT-0.92*
___ 07:46PM BLOOD Cholest-169
___ 07:46PM BLOOD Triglyc-51 HDL-66 CHOL/HD-2.6 LDLcalc-93
CARDIAC CATH ___
Single vessel coronary artery disease.
Successful PCI with drug-eluting stent of the RCA coronary
artery.
TTE ___
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and mild regional systolic dysfunction c/w
CAD in a PDA distribution. Normal right ventricular cavity size
nd systolic function. Mild tricuspid regurgitation. Normal
estimated pulmonary artery systolic pressure.
DISCHARGE LABS:
===============
___ 07:06AM BLOOD WBC-11.9* RBC-3.94 Hgb-12.4 Hct-37.2
MCV-94 MCH-31.5 MCHC-33.3 RDW-14.4 RDWSD-50.0* Plt ___
___ 07:06AM BLOOD Glucose-83 UreaN-17 Creat-0.6 Na-133*
K-4.3 Cl-102 HCO3-20* AnGap-11
___ 07:56AM BLOOD CK-MB-15* cTropnT-0.88*
___ 07:06AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.1
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Pt had DES placed in RCA. Started on Plavix 75mg which should
be continued for atleast 12 months.
[] Patient started on baby aspirin and atorvastatin which should
be continued indefinitely
[] Patient was also started on metoprolol 50mg daily and her
home lisinopril 40mg was decreased to 20mg. Please titrate these
medications as an outpatient depending on her blood pressures.
[] Please continue smoking cessation efforts as an outpatient.
BRIEF HOSPITAL COURSE:
======================
___ history of high blood pressure, high cholesterol,
smoking history coming with chest pressure found to have an
NSTEMI, underwent cath on ___ with single vessel disease of RCA
s/p ___.
# CORONARIES: No previous PCI
# PUMP: ___ ECHO EF 65%. Repeat TTE on ___ with EF 48%
# RHYTHM: Sinus Rhythm
ACUTE ISSUES:
-------------
# NSTEMI:
Patient presented with chest pressure with cardiac RFs of
current smoking and hypertension, found to have NSTEMI with
elevated troponins and T wave inversions on EKG. She was loaded
with Aspirin and placed on a heparin drip. She underwent cardiac
catheterization on ___ significant for single vessel disease
with DES placed to RCA. She was initiated on Plavix 75mg as well
as ASA 81, Metoprolol succinate 25mg qd, atorvastatin 80mg qd.
She also had an echocardiogram on ___ significant for slightly
reduced EF of 48% with mild LV hypertrophy, mild regional
systolic function c/w CAD in PDA and mild tricuspid
regurgitation. Patient was stabilized on this regimen and
subsequently discharged.
- Lisinopril was decreased from 40mg qd to 20mg qd given
initiation of metoprolol. Please titrate these medications as
needed as outpatient
- Pt should continue on Plavix for ___ year and ASA and
atorvastatin indefinitely
- Please continue smoking cessation efforts as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QSUN
2. Lisinopril 40 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 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. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. 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
6. Alendronate Sodium 70 mg PO QSUN
7. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had a heart attack
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Your heart arteries were examined (cardiac catheterization)
which showed a blockage of one of the arteries. This was opened
by placing a tube called a stent in the artery. You were given
medications to prevent future blockages.
- It is very important to take your aspirin and clopidogrel
(also known as Plavix) every day. These two medications keep the
stents in the vessels of the heart open and help reduce your
risk of having a future heart attack.
- If you stop these medications or miss ___ dose, you risk causing
a blood clot forming in your heart stents and having another
heart attack.
- We have also started you on a couple new medications called
atorvastatin and metoprolol which you should also continue to
take.
- We have decreased your dose of lisinopril from 40mg to 20mg
daily.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
Followup Instructions:
___
|
10363989-DS-8 | 10,363,989 | 20,733,584 | DS | 8 | 2179-07-23 00:00:00 | 2179-07-23 17:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / adhesive tape
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Electrophysiology study ___
History of Present Illness:
___ y/o woman with no significant medical history aside from
tobacco use, presenting after a syncopal event and found to have
paroxysmal SVT prompting admission. History was obtained from
the patient and her fiance who witnessed her syncopal event.
The evening before presentation, patient had a couple glasses of
wine with dinner (unusual for her) and went to take a shower.
While in the shower, she began to feel nauseated and unwell.
Fiance reports that she began shaking and her lips turned blue.
Her eyes rolled back in her head and she lost consciousness.
Fiance broke her fall and lowered her to the floor. No
headstrike or other trauma. Patient awoke after ___ seconds but
continued to feel "off" for a substantial amount of time
afterward (she does not remember exactly how long), with fatigue
and RLE weakness. No tonic-clonic movements, tongue biting, or
incontinence. Fiance helped her walk back to bed and her
symptoms recurred, though this time she did not lose
consciousness. She then slept uneventfully. However, she had
ongoing intermittent presyncopal symptoms during the day of
admission and decided to come to the ED.
She reports good oral intake and does not feel dehydrated. Her
symptoms do not seem to correlate with standing from sitting or
exertion. She reports no fevers or infectious symptoms. No
melena, hematochezia, hematuria, or vaginal bleeding. No chest
pain/pressure, dyspnea, or diaphoresis. +Palpitations. No
headache, vision changes, facial droop, dysarthria, or
paresthesias. +Transient RLE weakness yesterday as above, no
recurrence. No personal history of VTE or cancer. She has never
had symptoms like this before.
Of note, she has a family history of seizures in her brother
(though he is chronically ill with ___, scleroderma, and
CAD); no other relatives with neurologic conditions. She has an
uncle who died suddenly in his ___ of acute pulmonary embolus
(likely provoked by air travel). Father had CHF, CAD, and atrial
fibrillation in his ___. No other family history of heart
disease, arrhythmias, or sudden death.
In the ED:
- Initial VS: T 97 HR 115 BP 148/85 RR 20 SaO2 99% on RA
- EKG: Sinus tachycardia, normal axis, normal intervals, sub-mm
STD in V4-V5
- NIHSS 0, neuro exam was normal other than increased reflexes
- Labs & studies notable for: WBC 14.2, diff normal. Renal
function and lytes normal. Trops and d-dimer negative. Tox
screen negative. CXR normal.
While in the ED, patient had a run of narrow-complex tachycardia
on telemetry with heart rates in the 220s. During this episode,
she had a recurrence of identical symptoms as the prior night.
Tachycardia and symptoms resolved in ___ seconds without
intervention. This was observed by the consulting Neurology
resident, who felt that this was much more likely to be the
cause of her symptoms than a neurologic etiology. Cardiology was
consulted and recommended admission for echocardiogram and EP
evaluation.
After admission to the cardiology ward, patient reported no
recurrence of symptoms since the episode in the ED.
Past Medical History:
PMH:
- cervical dysplasia; reports remote history of abnormal Pap
with no history of LEEP or cervical procedures
- history of ovarian cysts and "ovarian tumor" s/p removal
laparoscopically, reports history of endometriosis, reports
benign path
PSH:
- laparoscopic ovarian cystectomies
- knee surgery
- denies anesthesia complications
Social History:
___
Family History:
Father died in his ___. Had dementia, CAD, CHF, atrial
fibrillation, DM, hypertension. Mother with hypertension.
Brother with scleroderma, ___, tonic-clonic
seizures.
Uncle died in his ___ from pulmonary embolus (likely provoked
by air travel).
Several other relatives with h/o VTE (she does not know
details).
Physical Exam:
On admission:
General: overweight middle aged woman,
VS: reviewed, afebrile, sinus
HEENT: NC/AT. No icterus, injection, or pallor. MMM.
CV: RRR, no murmurs.
Resp: CTAB.
Abd: Soft, NDNT, no HSM or masses.
Extr: Warm, no edema.
Neuro: Alert, oriented, attentive. CN intact. Strength ___ and
symmetric throughout.
Skin: No rashes or lesions.
At discharge:
General: NAD, pleasant
HEENT: NC/AT. No icterus, injection, or pallor. MMM.
CV: RRR, s1/s2; no murmur, rubs or gallops.
Resp: CTABL
Abd: Soft, NDNT, no HSM or masses.
Ext: Warm, no ___ edema bilaterally
Neuro: AAOx3, grossly non-focal
Skin: No rashes or lesions.
Pertinent Results:
___ 09:50PM BLOOD WBC-14.2* RBC-4.24 Hgb-13.1 Hct-39.0
MCV-92 MCH-30.9 MCHC-33.6 RDW-13.2 RDWSD-44.6 Plt ___
___ 07:50AM BLOOD WBC-7.3 RBC-4.38 Hgb-13.3 Hct-40.7 MCV-93
MCH-30.4 MCHC-32.7 RDW-13.2 RDWSD-44.8 Plt ___
___ 07:50AM BLOOD Glucose-91 UreaN-11 Creat-0.7 Na-138
K-4.7 Cl-102 HCO3-25 AnGap-11
___ 09:50PM BLOOD cTropnT-<0.01
___ 09:50PM BLOOD D-Dimer-294
___ 11:51AM BLOOD %HbA1c-5.0 eAG-97
___ 06:40AM BLOOD HDL-44 CHOL/HD-3.6 LDLmeas-92
___ 06:40AM BLOOD TSH-3.1
___ 09:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:25AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 09:25AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:25AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-7
___ 9:25 am URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 09:25AM URINE UCG-NEGATIVE
___ 09:25AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 09:32PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
CXR ___
The lungs are clear without focal consolidation. No pleural
effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
TTE ___
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF = 60%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: normal study
MRI ___
1. Study is moderately degraded by motion.
2. No evidence for acute intracranial hemorrhage or infarction.
3. 1.8 cm pineal cyst. If clinically indicated, consider MRI CSF
flow study for further evaluation.
4. Mild asymmetry of the lateral ventricular system in both size
and
morphology, presumed congenital although age indeterminate given
the lack of prior examinations.
5. Paranasal sinus disease, as described.
TTE ___
No evidence for a patent foramen ovale or atrial septal defect
by agiated saline contrast at rest and with maneuvers. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The mitral valve leaflets are
structurally normal.
IMPRESSION: No intracardiac shunt identified. Normal
biventricular cavity sizes with preserved regional and global
biventricular systolic function.
Electrophysiology Study ___
The patient entered the lab in normal sinus rhythm at 759
ms,/79 bpm, PR interval 150 ms, QRS duration 82 ms, QT interval
384 ms.
___ sites were accessed using the percutaneous modified
Seldinger technique. A ___ and an ___ right femoral vein sheaths
were placed. T wo ___ and a ___ left femoral vein sheaths were
placed. Catheters were advanced under fluoroscopic guidance. A
decapolar catheter was advanced to the coronary sinus. Three
catheters were advanced to high right atrium, His bundle and
right ventricular base. Of note, while manipulating the
catheters inside the heart, the RBBB was inadvertently bumped,
causing RBBB appearance on the 12 lead ECG (QRS duration 125
ms). Baseline AH interval was 75 ms and baseline HV interval was
41 ms.
___ ventricular pacing and programmed ventricular
stimulation were performed from the R V base. Retrograde
conduction was present, was concentric and decremental. VERP was
at 600/260 ms and 400/ 220 ms. ___ was at 410 ms. ___
atrial pacing and programmed atrial stimulation were performed
from the pCS. A VWB was at 260 ms. ___ was at 600/230 ms and
400/220 ms. ___ was below ___ . Double and triple
extrastimuli did not induce any arrhythmia. Atrial burst pacing
down to 200 ms did not induce any arrhythmia.
The EPS was repeated on isoproterenol 2 mcg/min. Burst pacing
down to 200 ms from the pCS did not induce any arrhythmia.
Double and triple extrastimuli from the pCS did not induce any
arrhythmia. At ___ ms 2 A V nodal echoes were seen, but
the observation was not reproducible. ___ was at 400/180 ms.
___ from mid and distal CS poles did not show presence of any
accessory pathway. Burst atrial pacing and programmed atrial
stimulation with double and triple extrastimuli were also
performed from the HRA. No arrhythmia was inducible. ___ was at
400/180 ms from the HRA. Programmed ventricular pacing was
performed from the R V base up to diouble extrastimuli and did
not induce any arrhythmia.
The EPS was repeated in the isoproterenol washout phase but
again no arrhythmia was inducible.
Conclusion
Negative EP study
There were no complications.
Brief Hospital Course:
Ms ___ is a ___ w/ tobacco use disorder, endometriosis
presenting with syncope and paroxysmal SVT witnessed in the ED
with a subsequent negative electrophysiology study.
While in the ED, patient had a run of narrow-complex tachycardia
on telemetry with heart rates in the 220s. During this episode,
she had a recurrence of identical symptoms as the prior night.
Tachycardia and symptoms resolved in ___ seconds without
intervention. BPs remained stable throughout her course.
ACUTE ISSUES:
# Syncope, Paroxysmal SVT, Accelerated Idioventicular Rhythm:
Unexplained syncopal episode at home that EP felt was most
consistent with vasovagal (hot shower, prior alcohol), although
patient reported no prior history of similar symptoms.. While
under evaluation, patient had occasional "flutters" with HR to
100s and SVT to 220s while in the ED. However, no arrhythmias
could be induced on EP study (including isoproterenol) and
echocardiogram (including bubble study) normal. Neurologic
etiology also less likely given unrevealing MRI. No H/O
seizures. No overt evidence for hypovolemia; orthostatics
negative in the ED. Non-generalized seizure was considered less
likely by neurology. TSH, A1c, Urine tox screen, influenza swab,
urinalysis, D-dimer, trops, electrolytes all normal. Patient
developed palpitations the night after her EP study, and
telemetry showed AIVR. She also had a transient right BBB
(related to EP catheter placement). These resolved.
Electrophysiology team recommended beta blocker PRN for
prolonged palpitations so propranolol was prescribed on
discharge.
CHRONIC ISSUES
# Tobacco use: 1 ppd x ___ years.
- Encouraged cessation and provide resources on discharge
# Leukocytosis: Likely reactive. Resolved on Day 1
Transitional issues:
- Patient has a 1.9 cm pineal cyst on head MRI. She has hx of
migraines but not consistent with increased ICP. Neuro believes
it is incidental and will only need f/u is she develops new
neurological symptoms
- Had palpitatations with telemetry showing AIVR for which she
was prescribed PRN propranolol 10 mg to be taken for sustained
HR elevation.
- Follow up with Electrophysiology scheduled
- Continue to encourage smoking cessation, prescribed nicotine
patches and lozenges.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Nicotine Lozenge 2 mg PO Q1H:PRN cravings
RX *nicotine (polacrilex) [Nicorette] 2 mg 1 lozenge PRN Disp
#*30 Lozenge Refills:*0
2. Nicotine Patch 14 mg TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour daily Disp #*30 Patch
Refills:*0
3. Propranolol 10 mg PO BID:PRN palpitations
1 tablet as needed for palpitations that last more than ___
minutes
RX *propranolol 10 mg 1 tablet(s) by mouth BID PRN Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
-Syncope
-Supraventricular tachycardia, spontaneous, but not inducible on
electrophysiology study
-Accelerated idioventricular rhythm
-Palpitations
-Catheter induced transient right bundle branch block
-Tobacco use
-Leukocytosis, transient
-1.8 cm pineal cyst
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 here at ___
___.
Why you were here:
- You lost consciousness. You were brought to the emergency room
where we noticed a fast abnormal heart rate on our cardiac
monitors.
What we did while you were here:
- We had our neurologists evaluate you to rule out a seizure or
stroke. We did an MRI of your brain which did not show any
strokes.
- We had our electrophysiologists (heart rhythm specialists)
review your case and they took you for a special heart study.
They could not find any abnormal electrical pathways in the
heart.
What to do when you go home:
- We have prescribed a medicine that slows heart rate called
Propranolol. If you feel palpitations, sit down to rest and
check your pulse. If it is high (>100) and stays high for more
than ___ minutes, you can take one tablet. If you find that you
are using this a lot, please let your doctor know.
- It is very important for your health that you quit smoking! We
encourage you to speak with your primary care doctor about this.
We have prescribed nicotine lozenges and patches for you. There
are other medications such as daily pills which can help people
quit smoking.
- Call your doctor if you have any of the following:
palpitations that do not respond to the medicine above, chest
pain, dizziness, lightheadedness, leg swelling, head pain,
trouble speaking, trouble walking, weakness in your arms or
legs, fevers, or any other symptoms that concern you.
Sincerely,
Your Care Team
Followup Instructions:
___
|
10364180-DS-22 | 10,364,180 | 29,484,200 | DS | 22 | 2171-04-21 00:00:00 | 2171-04-21 15:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Doxycycline / Bactrim DS
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F PMHx COPD, chronic hyponatremia, HTN, GERD, w chronic abd
pain of uncertain etiology, recent empiric abx therapy for UTI w
macrobid p/w 3d nausea and vomiting, 1d cough. Pt reports she
has a longstanding history of emesis ___ her chronic nausea /
abd pain of uncertain etiology, but that for the last 3d prior
to admission she has had increased fatigue nausea and NBNB
vomitting, several episodes per day. Able to tolerate taking
her medications but unable to tolerate eating anything
substantial during this time. Also reports that for the last
day prior to admission has had increased shortness of breath,
nonexertional, associated w cough productive of clear sputum
that feels like her prior asthma. Patient attempted to go to
her scheduled ___ appointment today, but given ongoing emesis
was referred to ___ ED.
.
In ED initial vital signs were 97.4 88 165/59 16 99% 3L. Exam
was notable for coarse ronchi/rales throughout, nontender abd.
Labs were notable for WBC 8.8 (79N), Na 129, nl LFTs, lactate
1.6, UA w 1 WBC and few bacteria. EKG showed sinus tachycardia
at 102 bpm. Patient was weaned from O2, given nebs, azithro,
methylpred, but "desatted" to 91% on room air on ambulation.
Patient was admitted to medicine for further management. Vitals
prior to tarnsfer were 97.8 °F 102, 130/78 16 91%RA. Access was
20g PIV x1.
.
On arrival to the floor patient was comfortable and pleasant.
She confirmed above story. Reported regular BM, most recent
this AM; denied worsening abdominal pain (same as chronic),
fevers/chills, change in urinary habits; denies sick contacts or
travel.
Past Medical History:
COPD - spirometry in ___: FVC 1.63L (68%), FEV1 1.07L (62%),
FEV1/FVC 66 (91%)
asthma - peak flows 340 at best
hypertension
h/o hyponatremia
vitamin b12 defic
gastritis
h/o abnormal lfts
chronic abdominal pain
alcohol use
ischemic colitis
colon polyps
low back pain
agoraphobia
.
Social History:
___
Family History:
Family History:
Mother with congenital heart disease, HTN, deceased age ___.
Sister with ovarian ca.
Physical Exam:
PHYSICAL EXAMINATION on admission.
VITALS: 98.0 156/64 111 20 94%RA
GENERAL: well appearing elderly female, NAD
HEENT: OP clear, MMM, PERRL, EOMI
NECK: no JVD, supple, no LAD
LUNGS: Prolonged expiratory wheezing throughout, no acccessory
muscles
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no CVA tenderness
EXTREMITIES: 2+ ___ pulses equal bilaterally, no c/c/e
NEUROLOGIC: AOX3, ___ strength x 4 extremities
On discharge: AF 98.5 130-150/50-70 HR80-90 98% on RA
PHYSICAL EXAMINATION:
GENERAL: lying in bed, NAD
HEENT: moist oral mucosa
NECK: no JVD
LUNGS: mild scatterered expiratory wheezes, no acccessory
muscles
HEART: NR, RR, no murmur
ABDOMEN: Soft, NT, ND
EXTREMITIES: No peripheral edema
NEUROLOGIC: AOX3, no gross focal neuro deficit
Pertinent Results:
___ 03:30PM BLOOD WBC-8.8 RBC-3.41* Hgb-11.5* Hct-34.3*
MCV-100* MCH-33.8* MCHC-33.7 RDW-14.5 Plt ___
___ 07:26AM BLOOD WBC-7.3# RBC-3.25* Hgb-10.7* Hct-33.0*
MCV-102* MCH-33.0* MCHC-32.5 RDW-14.6 Plt ___
___ 03:30PM BLOOD ___ PTT-34.0 ___
___ 03:30PM BLOOD Glucose-99 UreaN-15 Creat-0.9 Na-129*
K-4.2 Cl-100 HCO3-15* AnGap-18
___ 07:26AM BLOOD Glucose-122* UreaN-14 Creat-0.9 Na-132*
K-4.4 Cl-103 HCO3-21* AnGap-12
___ 04:00PM BLOOD ALT-12 AST-22 AlkPhos-58 TotBili-0.3
___ 04:00PM BLOOD Lipase-37
___ 07:26AM BLOOD Calcium-9.4 Phos-2.2* Mg-2.2
Brief Hospital Course:
Ms. ___ is a ___ yof with COPD, chronic hyponatremia, HTN,
GERD, chronic abdominal pain, daily vomiting, recent macrobid
for UTI who presented with increased frequency of vomiting.
# Vomiting: History of daily vomiting, chronic nausea and
abdominal NBNB emesis. She was unable to tolerate po on
admission, however was taking po on discharge. She still passing
BM with no e/o acute intraabdominal process; no urinary
symptoms, although has few bacteria in UA; do not believe
symptoms are result of UTI; appearing euvolemic on admission and
discharge.
-Did not require any anti-emetics during hospital course.
# SOB: History of COPD/asthma and appeared at baseline per
patient. Not requiring oxygen and without leukocytosis or
fevers. CXR negative for acute process.
- continued home albuterol q4h PRN
- continued home montelukast, theophylline
- increased advair dose from 250/50 to 500/50 on discharge
- cigarette cessation counseling
# Hyponatremia - 126-130 in past, uncertain of etiology;
currently 128-129 since arrival; received 2LNS in ED; currently
appearing euvolemic
- Na 132 on ___ discharge
# HTN
- continued home enalapril, metoprolol, amlodipine
# Allergies
- continued home flonase
# Chronic Gastritis / Abdominal pain
- continued home ranitidine, pantoprazole
# FEN: avoidided IVF w/ low Na / repleted lytes prn / regular
diet / VitC, VitD
# PPX:
- DVT - given Heparin sc 5000 TID
- Bowel senna/colace
# ACCESS: PIVx1
# CODE STATUS: Full (confirmed)
# CONTACT: ___ ___
# DISPO: medical floor to home with services
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientwebOMR.
1. Enalapril Maleate 20 mg PO DAILY
2. Ipratropium Bromide Neb 1 NEB IH Q6H
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Amlodipine 5 mg PO DAILY
6. Ranitidine 150 mg PO BID
7. Montelukast Sodium 10 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Pantoprazole 40 mg PO Q24H
10. Theophylline ER (Uniphyl) 400 mg PO DAILY
11. Ascorbic Acid ___ mg PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *Advair Diskus 500 mcg-50 mcg/Dose 1 Puff Inhaled once in
morning and once in late afternoon Disp #*1 Inhaler Refills:*0
6. Ipratropium Bromide Neb 1 NEB IH Q6H
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Montelukast Sodium 10 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Ranitidine 150 mg PO BID
11. Theophylline ER (Uniphyl) 400 mg PO DAILY
12. Vitamin D 400 UNIT PO DAILY
13. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Vomiting
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 ___
___ nausea and vomiting. Your nausea and vomiting
resolved while you were here. We were happy to see that you were
able to eat and drink without further vomiting. Your lab results
showed you were not having pancreatitis or any infectious
process. Please follow up with your Gastroenterology and Primary
care doctors for further issues regarding your chronic vomiting.
We had physical therapy evaluate you while you were here and
they reported that you would benefit from a walker and home
physical therapy services.
Followup Instructions:
___
|
10364180-DS-23 | 10,364,180 | 28,654,139 | DS | 23 | 2171-05-22 00:00:00 | 2171-05-22 14:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Doxycycline / Bactrim DS
Attending: ___.
Chief Complaint:
Crampy abdominal pain, emesis, Bright red blood per rectum.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ F with history of COPD, chronic hyponatremia,
chronic epigastric pain, prior admission for presumed ischemic
colitis in ___ who presents with abdominal pain and
hematochezia. The patient reports being in her usual state of
health until last ___, when she described abrupt onset of
sharp bilateral lower quadrant crampy pain. She subsequently had
an episode of non-bloody loose stool, which was followed by 2
episodes of moderate volume bloody stool. In addition, she
described having multiple episodes of non-bloody, non-bilious
emesis. She subsequently called her PCP, who told her to come to
the ED for further evaluation. Of note, the patient was
admitted in early ___ for several episodes of vomiting. She
was treated conservatively and able to tolerate orals on
discharge. She was admitted back in ___ with bloody bowel
movements. At that time, she had a CTA of her abdomen that
showed inflammation in the splenic flexure and descending colon
consistent with ischemic vs. infectious colitis. Of note, she
also had a similar presentation in ___, that was attributed to
ischemic colitis. She has not had a follow colonoscopy since
that time. At baseline, the the patient reports a history of
mild epigastric discomfort sometimes associated with eating,
that she controls with zantac and protonix. She reports that
this pain is markedly different from her baseline epigastric
pain which is higher up. She denies any fevers, chills. Denies
any NSAID usage. Since admission, she reports feeling much
improved, with improved abdominal pain. She now only reports
seeing "flecks" of blood in the toilet. Reports associated
lightheadedness and dizziness.
Past Medical History:
COPD - spirometry in ___: FVC 1.63L (68%), FEV1 1.07L (62%),
FEV1/FVC 66 (91%)
asthma - peak flows 340 at best
hypertension
h/o hyponatremia
vitamin b12 defic
gastritis
h/o abnormal lfts
chronic abdominal pain
alcohol use
ischemic colitis
colon polyps
low back pain
agoraphobia
.
Social History:
___
Family History:
Mother with congenital heart disease, HTN, deceased age ___.
Sister with ovarian ca.
Physical Exam:
Physical exam upon presentation:
VS: temp 98.2 HR 107 BP 181/80 RR18 O294% RA
Gen: elderly woman in NAD
HEENT: PEERLA, EOMI, OP clear
NECK: no JVD
CARD: RRR, distant S1/S2, no m/r/g appreciated
PULM: coughs at baseline producing white sputum, wheezes present
throughout medial airways,wet crackles present throughout lung
fields including anterior apicies
___: ++BS, appears mildly distended, is soft but tender
diffusely which illicit involuntary guarding, tympanic to
percussion with no ascites. Frank blood exsanguinated per rectum
and dripping in diaper. No external hemorrhoids appreciated.
GYN: digital vaginal exam performed, normal external genitalia,
vaginal vault had normal mucosa and no evidence of blood
EXT: warm, bounding pulses present throughout, no tenderness
elicited with palpation, moves all extremities equally
NEURO/PSYCH: AxO3, seems slightly confused and has difficulty
with chronology, otherwise responds appropriately to questions
with out perseveration or abnormal affect.
Physical exam upon discharge:
GEN: Elderly women, NAD.
HEENT: HEENT: PEERLA, EOMI, OP clear
CV: RRR,, Normal S1, S2, no MRG.
PULM: Lungs CTAB
ABD: Soft/nontender/mildly distended. + flatus, + BS
EXT: + pedal pulses. No edema, clubbing, cyanosis.
NEURO: AAOx4.
Pertinent Results:
___
BLOOD Glucose-83 UreaN-5* Creat-1.1 Na-133 K-4.2 Cl-108 HCO3-17*
AnGap-12
Calcium-8.2* Phos-2.5* Mg-2.4
___
BLOOD Glucose-106* UreaN-7 Creat-1.2* Na-131* K-3.5 Cl-104
HCO3-19* AnGap-12 Calcium-8.4 Phos-3.1 Mg-1.8
___
Glucose-121* UreaN-10 Creat-1.2* Na-131* K-3.3 Cl-102 HCO3-19*
AnGap-13
BLOOD WBC-9.5 RBC-3.38* Hgb-11.4* Hct-34.5* MCV-102* MCH-33.7*
MCHC-33.1 RDW-14.3 Plt ___ Calcium-8.2* Phos-3.5 Mg-2.1
___
Glucose-123* UreaN-11 Creat-1.3* Na-130* K-3.7 Cl-102 HCO3-19*
AnGap-13
Calcium-8.2* Phos-4.1 Mg-2.5
___
WBC-10.2 RBC-3.24* Hgb-10.9* Hct-33.4* MCV-103* MCH-33.7*
MCHC-32.7 RDW-14.7 Plt ___ Glucose-100 UreaN-11 Creat-1.0
Na-133 K-4.0 Cl-103 HCO3-20* AnGap-14 Calcium-8.2* Phos-4.7*#
Mg-1.4*
___ 10:30AM BLOOD WBC-9.0 RBC-3.82* Hgb-12.9 Hct-38.5
MCV-101* MCH-33.8* MCHC-33.6 RDW-14.6 Plt ___ Lactate-1.5
___ CT ABD & PELVIS WITH CONTRAST---IMPRESSION:
1. Diffuse colonic mural thickening extending from the distal
transverse
colon to the distal sigmoid colon, new since ___,
and similar to ___, consistent with colitis.
Given distribution, ischemic colitis is likely, although
infectious or inflammatory etiologies are not excluded.
Atherosclerotic plaques are present at the base of the SMA and
___, though these vessels are opacified. No pneumatosis. No
free or portal venous gas.
2. Mildly worsened sclerotic changes of left femoral head,
concerning foravascular necrosis.
3. Right adnexal hypodense lesion, similar to ___.
4. Layering hyperdense material within the gallbladder,
compatible with
sludge.
Brief Hospital Course:
Ms. ___ is a ___ with a complicated medical history (severe
COPD,alcohol abuse and 'ischemic colitis in ___ who presents
to the ED with 12 hours of sudden onset, severe crampy abdominal
pain, bilious emesis and frank blood per rectum. She describes
the pain as epigastric, crampy and sharp ___ pain that is
relieved slightly by vomiting and does not radiate. After
several bouts of emesis last night, she had one episode of
liquid diarrhea and then two episodes of frank blood per rectum,
enough to fill the toilet bowl. She said she felt dizzy at this
time, but denied any CP or SOB. Of note, at baseline she vomits
almost daily. She says she wakes up and coughs which makes her
stomach "turn" which provokes ~1cc clear emesis. The patient was
admitted to the Acute Care Surgery Service for a
gastrointestinal workup to differentiate infectious colitis vs.
ischemic colitis. She underwent CT Scan imaging which revealed
diffuse colonic mural thickening, extending from distal ___ of
tranverse colon to rectum, new since ___ and similar to
___ although greater in extent. Given distribution of
findings, ischemic colitis was a likely consideration. Patient
was kept NPO and IV fluids and IV Antibiotics were initated at
the time of admission. To rule out an infectious source, the
patient had a cdiff sent which was negative. She was also
ordered a Stool culture and Ova & Parasite culture which are
still pending. GI was consulted and they recommended
discontinuing antibiotics and suggested patient follow up for an
outpatient colonoscopy in 1 month. Per the GI team, the most
likely etiology of her current symptoms is due to recurrent
ischemic colitis given abrupt onset with quick resolution, and
presence of inflammation in watershed territory. Infectious
colitis is in differential but less likely. She also appears to
have a baseline chronic dyspepsia, and has had prior endoscopies
that showed evidence of gastritis, although biopsies were
negative for HPylori. The patient felt better after IV hydration
and IV antibiotics so she was advanced to clears and then to a
regular diet, which she tolerated well. Patient's pain was well
controlled with PO pain medications. She denied experiencing any
nausea/vomiting/diarrhea. Vitals remained stable and patient
remained afebrile.
Medications on Admission:
ALBUTEROL SULFATE - albuterol sulfate 2.5 mg/3 mL (0.083 %) Neb
Solution
one ampule(s) inhaled every ___ hours as needed for as needed
for
shortness of breath Use with nebulizer machine
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
Aerosol Inhaler
2 puffs(s) inhaled six times a day as needed for wheezing or
shortness of breath
AMLODIPINE - amlodipine 5 mg tablet
1 Tablet(s) by mouth once a day
ENALAPRIL MALEATE [VASOTEC] - Vasotec 20 mg tablet
one Tablet(s) by mouth twice a day
FLUTICASONE - fluticasone 50 mcg/actuation Nasal Spray, Susp
2 sprays(s) in each nostril daily
FLUTICASONE [FLOVENT HFA] - Flovent HFA 110 mcg/actuation
Aerosol
Inhaler
2 (Two) puffs(s) inhaled twice a day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - Advair Diskus 250
mcg-50
mcg/dose for Inhalation
1 puff(s) inhaled twice daily - always rinse mouth after each
use
GABAPENTIN - gabapentin 300 mg capsule
1 capsule(s) by mouth hs
IPRATROPIUM BROMIDE - ipratropium bromide 0.02 % Soln for
Inhalation
One Ampule inhaled every ___ hours as needed for Shortness of
breath Use with nebulizer machine
IPRATROPIUM BROMIDE [ATROVENT HFA] - Atrovent HFA 17
mcg/actuation Aerosol Inhaler
2 puffs orally four times a day
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr
1 Tablet(s) by mouth once a day
MONTELUKAST [SINGULAIR] - Singulair 10 mg tablet
1 (One) Tablet(s) by mouth once a day
NABUMETONE - nabumetone 500 mg tablet
1 Tablet(s) by mouth bid with food
NITROFURANTOIN MONOHYD/M-CRYST - nitrofurantoin
monohydrate/macrocrystals 100 mg capsule
1 capsule(s) by mouth every twelve (12) hours
NYSTATIN - nystatin 100,000 unit/mL Oral Susp
1 teaspoonful Suspension(s) by mouth swish and spit after
steroid
inhalers
PANTOPRAZOLE [PROTONIX] - Protonix 40 mg tablet,delayed release
1 (One) Tablet, Delayed Release (E.C.)(s) by mouth once a day
RANITIDINE HCL [ZANTAC] - Zantac 150 mg tablet
one Tablet(s) by mouth twice a day
THEOPHYLLINE - theophylline ER 400 mg tablet,extended release
1 Tablet(s) by mouth daily
VIT B12 -
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider; ___) -
Tylenol ___ mg tablet
2 Tablet(s) by mouth every ___ hours as needed for pain
ASCORBIC ACID [VITAMIN C] - (OTC) - Vitamin C 500 mg tablet
1 Tablet(s) by mouth once a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - One Touch Ultra
Test Strips
use as directed three times a day to check blood glucose
CALCIUM CARBONATE [CALCIUM 600] - (OTC) - Calcium 600 600 mg
(1,500 mg) tablet
1 Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - (OTC) - Vitamin D3
400 unit capsule
1 Capsule(s) by mouth once a day
NAPHAZOLINE-PHENIRAMINE - naphazoline-pheniramine 0.025 %-0.3 %
Eye Drops
2 drps eye twice a day
NEBULIZER - Nebulizer Kit misc
for home use treating asthma/COPD use as directed
Provider; OTC) - Gas-X Extra Strength 125 mg capsule
1 Capsule(s) by mouth daily as needed for gas
SODIUM CHLORIDE [OCEAN NASAL] - (Prescribed by Other Provider;
OTC) - Ocean Nasal 0.65 % Spray
2 sprays intranasally twice daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/SOB
2. Amlodipine 5 mg PO DAILY
hold for HR <60 or SBP <100
3. Calcium Carbonate 500 mg PO QID:PRN GERD
4. Enalapril Maleate 20 mg PO BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Gabapentin 300 mg PO HS
7. Metoprolol Tartrate 25 mg PO DAILY
hold for HR <60 or SBP <100
8. Montelukast Sodium 10 mg PO DAILY
9. Ipratropium Bromide MDI 2 PUFF IH QID
10. Pantoprazole 40 mg PO Q24H
11. Nystatin Oral Suspension 5 mL PO QID:PRN for use after
inhalers
12. Ranitidine 150 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
LOWER GI BLEED
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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.
*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.
*Resume ALL medications you were on before admission to the
hospital.
* Avoid all NSAID use.
Followup Instructions:
___
|
10364180-DS-25 | 10,364,180 | 29,187,882 | DS | 25 | 2172-08-08 00:00:00 | 2172-08-08 17:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Doxycycline / Bactrim DS
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH COPD (emphysema, chron bronchitis), asthma, CKD,
hypertension, and pruritic xerosis, recently admitted to ___
for COPD exacerbation vs PNA (dc'd ___ to ___ with
cefpodoxime ending ___. Was feeling moderately well at ___
___ for first couple of nights and then started feeling
increasingly dyspneic with walking there. Noted some pedal
edema, not typical for her. Also described needing to sleep
upright (normal 1 pillow) with feeling of inability to catch
breath lying flat -- i.e. orthopnea. Denies CP, past dx of CHF
or MI. No n/s, fevers, chills, n/v. Dry cough. Has ___ soft
stools daily, but not watery. No BRBPR, no melena. Denies
dysuria, abdominal pain, oliguria.
During her recent admission she was seen by neprhology for ___ AG acidosis and hyperkalemia. Anti-Ro/La were
negative,
making Sjogren's less likely. ___ and anti-dsDNA were
negative. Serum plasma renin normal and aldosterone pending.
Past Medical History:
COPD - spirometry in ___: FVC 1.63L (68%), FEV1 1.07L (62%),
FEV1/FVC 66 (91%)
asthma - peak flows 340 at best
hypertension
h/o hyponatremia
vitamin b12 defic
gastritis
h/o abnormal lfts
chronic abdominal pain
alcohol use
ischemic colitis
colon polyps
low back pain
agoraphobia
.
Social History:
___
Family History:
Mother with congenital heart disease, HTN, deceased age ___.
Sister with ovarian ca.
Physical Exam:
Admission Exam:
Vitals: 97.6 152/52 91 20 94% 3L
General: Alert, oriented, mildly tachypneic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP not elevated
Lungs: Not speaking full sentences, scattered wheezes, focal
rales at L apex anteriorly, scattered rhonchi, tubular BS
variably
CV: RRR, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, 2+ pulses, xerotic changes, trace edema, no clubbing
Neuro: CNs2-12 intact, no pronator drift, ___ strength with ___
in hip flexion limited by pain
Discharge Exam:
Physical Exam:
Vitals: 98.4 100-120/40-50 70-80s 18 93% RA
Initial weight: 60.2 kg. 57.7-->56.2 kg kg I/O: ___
General: Alert, oriented, speaking full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVD
Lungs: CTAB, scattered expiratory wheezes throughout. Crackles
midlung fields down
CV: RRR, no m/r/g. trace lower extremity edema L>R
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Blood tinged foley
Ext: Warm, 2+ pulses, xerotic changes, no edema, no clubbing
Neuro: CNs2-12 intact, no pronator drift, ___ strength with ___
in hip flexion limited by pain
Pertinent Results:
Admission Labs:
___ 02:50PM BLOOD WBC-11.9*# RBC-3.03* Hgb-9.6* Hct-32.2*
MCV-107* MCH-31.8 MCHC-29.8* RDW-13.3 Plt ___
___:50PM BLOOD Glucose-107* UreaN-41* Creat-2.2* Na-136
K-6.6* Cl-107 HCO3-20* AnGap-16
___ 02:50PM BLOOD proBNP-4474*
___ 02:50PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD CK-MB-6 cTropnT-<0.01
___ 05:50PM BLOOD CK-MB-3 cTropnT-<0.01
Discharge labs:
___ 07:05AM BLOOD WBC-10.5 RBC-2.35* Hgb-7.7* Hct-23.6*
MCV-100* MCH-32.8* MCHC-32.7 RDW-12.9 Plt ___
___ 07:05AM BLOOD Plt ___
___ 12:40PM BLOOD Glucose-120* UreaN-94* Creat-3.2* Na-130*
K-4.9 Cl-94* HCO3-26 AnGap-15
___ 07:05AM BLOOD ALT-14 AST-11 LD(LDH)-193 AlkPhos-42
TotBili-0.2
___ 09:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
___ 06:50AM BLOOD ANCA-NEGATIVE B
___ 06:50AM BLOOD PEP-NO SPECIFI
___ 09:15PM BLOOD HIV Ab-NEGATIVE
___ 07:05AM BLOOD TSH-3.4
___ 07:05AM BLOOD Cortsol-15.3
CXR ___
FINDINGS: Frontal and lateral radiographs of the chest
demonstrate top normal
heart size. The cardiomediastinal silhouette and hilar contours
are normal.
Calcification of the aortic knob is unchanged. There is
persistent patchy
opacities in the right lower lobe and periphery of the left
lung. There is
new prominence of the interstitial markings consistent with mild
pulmonary
edema. There are new small bilateral pleural effusions greater
on the right
than the left. No pneumothorax. No displaced rib fracture
identified.
IMPRESSION: Persistent opacities in the right lower lobe and
left upper lobe
with mild pulmonary edema and new bilateral small pleural
effusions.
___ ___
IMPRESSION:
No evidence of deep vein thrombosis in the left leg.
Superficial edema is noted in the left calf.
Renal U/S ___
FINDINGS:
The right kidney measures 11.1 cm and the left kidney measures
10.8 cm. There
is a 8 mm simple cyst in the upper pole of the right kidney.
There is no
hydronephrosis, stones or masses. Renal echogenicity and
corticomedullary
architecture are within normal limits. The bladder is only
minimally
distended and cannot be assessed.
IMPRESSION:
Unremarkable renal ultrasound.
___ CXR
FINDINGS: In comparison with the study of ___, there has been
substantial
decrease in the pulmonary vascular congestion with the cardiac
size remaining
at the upper limits of normal or mildly enlarged. Small
bilateral pleural
effusions are seen with compressive atelectasis at the bases.
Discrete areas
of consolidation are not definitely appreciated on this study.
Hyperexpansion of the lungs with flattening of the
hemidiaphragms is
consistent with chronic pulmonary disease. There is extensive
calcification
in the aortic arch and descending portion.
___ CXR
FINDINGS:
As compared to the prior examination, there has been mild
worsening of the
patient's moderate to severe interstitial pulmonary edema.
Small bilateral
pleural effusions are stable. There is no focal consolidation
or
pneumothorax. Stable, mild cardiomegaly is noted. Aortic
calcifications are
seen. The mediastinal and hilar contours are grossly normal.
IMPRESSION:
Interval worsening of moderate to severe interstitial pulmonary
edema, with
associated small, bilateral pleural effusions.
___ CT Chest non-contrast
IMPRESSION:
1. Multifocal pneumonia, suggesting aspiration. with increased
right pleural
effusion, now moderate and new small left pleural effusion.
2. Moderate pulmonary edema has minimally improved since
___, but
moderate right pleural effusion is larger and small left
effusion is new,
pointing to heart failure.
3. Mediastinal nodes borderline enlarged, the largest in the
subcarinal
station and might be reactive.
4. Moderate-to-severe coronary calcification, and calcification
of the aortic
annulus, aortic valve and mitral annulus, all unchanged since
___
___ CXR
FINDINGS: In comparison with the study of ___, the degree of
pulmonary
vascular congestion has substantially improved, though there is
still evidence
of elevated pulmonary venous pressure. Atelectatic changes are
seen at the
bases, especially on the left. An area of apparent scarring is
again seen in
the left mid zone laterally, is essentially unchanged from the
CT scan of
___.
Brief Hospital Course:
___ h/o COPD, asthma, hypertension, and few months worsening
pruritic xerosis presenting with dyspnea found to have volume
overload, hyperkalemia and renal failure
# Acute on chronic renal failure: Patient presented with acute
renal failure with creatinine of 2.2 (baseline ~1.0), likely
contrast induced from a CT PE on the previous hospital
admission. Her renal failure manifested with hyperkalemia,
volume overload and subsequent respiratory distress. Due to
volume overload, she was diuresed with IV medicines requiring
metolazone as well as high dose IV furosemide. In the setting of
diuresis, her creatinine uptrended due to pre-renal
hypoperfusion up to 3.5. As such, diuresis was discontinued. The
patient continued to make good urine on her own and maintain a
constant weight. Upon discharge, her creatinine was downtrending
and did not require medications for volume overload. Moving
forward, she will likely require initiation of oral diuretics
for what will likely become chronic renal failure. Furthermore,
she will be followed by Nephrology with the possibility for
dialysis planning as she required such high doses of IV diuresis
in ___ to off load volume and potassium due to kidney
dysfunction.
# Acute diastolic CHF: Patient presented with pulmonary edema
requiring 3L of oxygen due to kidney failure as discussed above.
An echo showed a preserved ejection fraction. She was diuresed
with improvement of her dyspnea. Her discharge weight is 56 kg -
there is no known dry weight for her. With this weight, she was
able to maintain a saturation of 93% on room air. Diuresis was
limited due to kidney injury.
# COPD exacerbation: Patient presented with a clinical exam
concerning for acute bronchoconstriction and hypoxemia.
Pulmonary edema contributed to this picture. She completed a
course of antibiotics as well as two prednisone bursts (5 days
each) as her pulmonary exam remained poor throughout admission.
She was treated with duel nebs and maintained on her home COPD
medications. Pulmonary was consulted in ___ and recommended
repeat CT scan and pulmonology follow up for both COPD and
incidental findings on CT of unclear etiology and significance.
# Multi-focal Bacterial pneumonia on CT: Patient clinically did
not have signs of pneumonia but radiographic examination
revealed multiple areas of consolidation. In discussion she with
pulmonology she was treated with levofloxacin. However her
course was cut short because of worsening kidney function in the
setting of diuresis. The CT scan also suggested the possibility
of Mycobacterium avium-intracellulare infection. Induced sputums
could not be obtained in ___ due to logistical challenges. She
will follow up with pulmonology for further workup.
# Hyponatremia: Observed in the setting of diuresis so likely
due to hypovolemia. If she continues to become hyponatremic can
consider tightening her free water intake - 1500 cc from ___ cc
in ___. Opted to not be aggressive in giving fluid in the
setting of dCHF.
# Presyncope: Patient felt light headed with blurry vision most
likely related to over diuresis and uremic toxins. Her blood
pressure was stable. No concern for seizure, new infection,
neurological event, or arrhythmia. Her symptoms resolved with
the cessation of diuresis.
# Pleural effusion: Likely related to ___. Her history of
weight loss and smoking history is concerning for malignancy,
but there were no findings in the lung based upon CT. She will
be followed by pulmonology and repeat CT scan for evaluation.
Based upon CXR, these pleural effusion improved with diuresis.
# Hypertension: Blood pressure was high in ___. Her amlodipine
was discontinued due to lower extremity swelling that confounded
her clinical evaluation of volume status. Labetalol was
initiated and uptitrated until appropriate blood pressure
control.
# Hematuria: Traumatic Foley with aspirin and heparin
prophylaxis. Spontaneously resolved.
# Hyperkalemia: patient presented with potassium observed in
___ as high as 6.9. No ECG changes were observed. She was
supported with calcium gluconate, insulin, Kayexalate and
diuretics while her kidneys recovered. Prior to discharge, her
potassium was normal. However in the setting of kidney disease
and unclear prognosis, she will need lab checks for potassium
and close follow up with nephrology.
# Chest pain: Likely related to anxiety and dyspnea. She was
ruled out for ACS.
# Leukocytosis: No localizing source of infection found in ___
and was likely related to steroid.
# Pruritis: Patient had several months of a pruritic xerotic
rash on admission of unclear etiology. PET CT scan negative
___ so likely no paraneoplastic cause. Rheumatology workup
was negative; ___, anti-dsDNA, anti-Ro, and anti-La are
negative. She was given hydroxyzine PRN with good effect.
# Anemia: There was no evidence of active bleeding. MCV 108,
suggestive of B12, folate deficiency vs marrow. Will defer
workup to outpatient.
TRANSITIONAL ISSUES
========================
- Patient will need daily cardiopulmonary examination,
measurement of input and output, weights, in order to monitor
for volume overload due to CHF and kidney failure for the
possibility of initiation diuretic therapy
- Patient will also need chem 10 every 3 days to evaluate for
electrolyte abnormalities in the setting of kidney failure until
stable
- Full code
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/SOB
2. Acetaminophen 500 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Gabapentin 100 mg PO HS:PRN itch
6. HydrOXYzine 25 mg PO HS:PRN itch
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Montelukast Sodium 10 mg PO DAILY
10. Theophylline ER 400 mg PO DAILY
11. Hydrocerin 1 Appl TP QID:PRN itch
12. Sarna Lotion 1 Appl TP QID:PRN itch
13. Calcium Carbonate 500 mg PO QID:PRN GERD
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
15. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
16. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN chest
discomfort
17. Omeprazole 40 mg PO DAILY
18. Ranitidine 150 mg PO HS
19. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN itch
20. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO BID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Gabapentin 100 mg PO HS:PRN itch
6. Hydrocerin 1 Appl TP QID:PRN itch
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
8. Montelukast Sodium 10 mg PO DAILY
9. Ranitidine 150 mg PO HS
10. Sarna Lotion 1 Appl TP QID:PRN itch
11. Omeprazole 40 mg PO DAILY
12. Theophylline ER 400 mg PO DAILY
13. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID:PRN itch
14. Aspirin 81 mg PO DAILY
15. Guaifenesin ___ mL PO Q6H:PRN cough
16. Labetalol 500 mg PO BID
17. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze/SOB
18. HydrOXYzine 25 mg PO HS:PRN itch
19. Ipratropium Bromide MDI 2 PUFF IH QID
20. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN chest
discomfort
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute of chronic kidney failure
Diastolic Heart failure
COPD exacerbation
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You came because of shortness of
breath. We found that you had built up fluid in your lungs
because your kidneys were not working normally. Due to the
kidney disease, your potassium was also high. We used medicines
to remove the fluid and potassium from your body. We also used
medicines to treat COPD and pneumonia. Your breathing is better
and now ready to go to rehabilitation to work on your strength.
Please continue to take the rest of your medications and follow
up with your doctors.
Followup Instructions:
___
|
10364180-DS-29 | 10,364,180 | 26,234,476 | DS | 29 | 2172-12-09 00:00:00 | 2172-12-09 17:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Doxycycline / Bactrim DS
Attending: ___
___ Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. ___ is a ___ with history of COPD, ___, CKD, and anemia
of chronic disease presenting with dyspnea. The patient
presented to the ED from SNF unresponsive and on bipap with sats
in the 50-60s%. HPI is limited given patient's mental status and
intubation.
The patient has had multiple recent admissions for similar
symptoms, the most recent on ___ - ___, during which time she
was treated for a COPD exacerbation, a multifocal pneumonia, and
dCHF exacerbation. Chest xray consistent with moderate pulmonary
edema and concurrent multifocal pneumonia. An echocardiogram at
the time demonstrated worsening biventricular systolic function
compared to priors, but no other acute abnormalities. Patient
was treated with nebulizers, prednisone, vancomycin/cefepime
(transitioned to levofloxacin for course through ___, and
furosemide at the time with with good improvement.
In the ED, initial vitals were 100 129/49 27 32% T101.8F.
Initial labs demonstrated a leukocytosis to 35k, HCT 30.3%, and
platelets of 540k. Chemistries demonstrated creatinine 1.5
(recent baseline ~2.2-2.3), K 5.7, HCO3 of 19, and phos 6.0. A
troponin was 0.05. A UA demonstrated trace leukesterase, WBC 10,
and moderate bacteria with proteinuria and 1 epithelial cell.
Patient was intubated upon arrival with initial ABG
demonstrating pH 7.11 and pCO2 of 71. A CXR was concerning for a
left-sided pneumonia. The patient was initially given furosemide
given evidence of volume overload, but was transitioned to
vancomycin/cefepime along with IVF after CXR findings were
discovered. She had little urine output during her ED stay.
On arrival to the MICU, initial vital signs were BP:160/88 P:119
R:24 O2:98%. Patient was intubated.
Past Medical History:
- COPD; spirometry in ___: FVC 1.63L (68%), FEV1 1.07L (62%),
FEV1/FVC 66 (91%)
- Asthma - peak flows 340 at best
- dCHF (dry weight likely 56 kg [124 lbs], more recently 109lbs)
- CKD Stage III
- Hypertension
- Hyponatremia
- Vitamin b12 defic
- Gastritis
- h/o abnormal lfts
- Chronic abdominal pain
- Alcohol use
- Ischemic colitis in ___.
- Colon polyps
- Low back pain
- Agoraphobia
- s/p tonsillectomy
Social History:
___
Family History:
- Mother with congenital heart disease, HTN, deceased age ___.
- Sister with ovarian ca.
Physical Exam:
ADMISSION:
Vitals- T: BP:160/88 P:119 R:24 O2:98%
General: intubated and sedated female
HEENT- Mild proptosis, bilateral cataracts
Neck- JVD to angle of jaw, no LAD
CV- RRR (+)S1/S2 no m/r/g
Lungs- Coarse breath sounds bilaterally with prolonged
expiratory phase and some wheezes on expiration
Abdomen- Soft, non-tender, non-distended
GU- Foley
Ext- Cool, 1+ ___ edema bilaterally
Neuro: Sedated, unable to participate in exam.
Pertinent Results:
ADMISSION:
___ 03:30AM BLOOD WBC-35.1*# RBC-3.21* Hgb-9.5* Hct-30.3*
MCV-94 MCH-29.6 MCHC-31.5 RDW-17.1* Plt ___
___ 03:30AM BLOOD Neuts-89.7* Lymphs-4.5* Monos-4.0 Eos-1.4
Baso-0.3
___ 03:30AM BLOOD ___ PTT-30.3 ___
___ 03:30AM BLOOD Glucose-171* UreaN-72* Creat-1.5* Na-133
K-5.7* Cl-101 HCO3-19* AnGap-19
___ 03:30AM BLOOD ALT-10 AST-16 CK(CPK)-37 AlkPhos-47
TotBili-0.3
DISCHARGE
MICRO
___ STOOL C. difficile DNA amplification assay-FINAL
INPATIENT
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
WARD
___ URINE URINE CULTURE-FINAL {YEAST} EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-FINAL
RADIOLOGY:
___ CXR
Worsening multifocal pneumonia on a background of chronic
pulmonary fibrosis. Improved but persistent pulmonary edema.
___HEST W/O CONTRAST
___ Cardiovascular ECHO
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. The
right ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, LV
systolic function has improved.
Brief Hospital Course:
Ms. ___ is a ___ with history of COPD, ___, CKD, and anemia
of chronic disease presenting from SNF with hypoxemia and found
to have infiltrates on CXR with leukocytosis concerning for
pneumonia.
# Multifactorial hypercarbic respiratory failure
Patient presented from SNF on bipap with hypoxemia, intubated
immediately upon presentation to the ED. Initial ABG once
intubated demonstrating respiratory acidosis. Determined to have
infiltrates on CXR in ED with leukocytosis and fever concerning
for pneumonia. Patient was covered broadly for HCAP with
vanc/cefepime, started on steroids for COPD exacerbation.
Patient was extubated on hospital day #2. She was treated with
nebulizers and prednisone for COPD, and gentle diuresis for
___. Patient underwent repeat noncon CT given prior CT
findings, which demonstrated persistent RLL infiltrate and
effusion concerning for pneumonia. Antibiotics completed on
___ after a 7-day course. Sputum cultures for atypical
organisms was pending at time of discharge.
# COPD exacerbation:
Patient required intermittent continuous nebs, nebs were
eventually spaced out to Q4H and patient improved. Patient was
started on prophylactic Bactrim SS daily for PCP prophylaxis
which can be discontinued once recommended by the patient's
pulmonologist. She was discharged with long taper of prednisone
and azithromycin (last day ___.
# Urinary tract infection
Patient found to have UA with trace leukesterase, 10 WBC, and
moderate bacteria possibly suggestive of UTI. Infection was
treated with cefepime.
# Vulvar rash
Patient with subacute rash on vulva, multiple hypopigmented
plaques that are tender to palpation. Previously using epsoms
salts. Unclear etiology. Tenderness concerning for infection,
though patient reports they have not been progressive.
Dermatology was consulted who recommended miconazole/nystatin
cream, zinc oxide, lidocaine, and desitin twice daily. She will
require follow-up in ___ clinic.
# Heart failure with preserved EF
Patient with history of diastolic heart failure,thought to be
euvolemic on exam. Torsemide was held after the last admission
given a rise in creatinine. Minimal diuresis was attempted
without significant output, though patient did end up -3.5L net
at discharge. Torsemide should likely be restarted once
creatinine is stablized.
#Troponinemia
Patient found to have troponin of 0.5 on admission. ECG in the
ED was without acute ischemia. No reported history of CAD and no
catheterizations found in system. Risk factors for CAD include
smoking history and hypertension. During last hospitalization,
patient was also found to have troponin leak which was
attributed to demand ischemia rather than NSTEMI. Enzymes peaked
at 0.07 and then downtrended. Cardiac ECHO showed moderate PA
systolic hypertension with no FWMAs.
#Hyperkalemia
Patient found to have elevated potassium to 5.7 on arrival in a
non-hemolyzed specimen; was 5.6 on the prior admission. This has
been previously attributed to CKD and "functional
hypoaldosteronism" given prior hyponatremia and hyperkalemia,
though prior cortisol levels reportedly normal. Per ___
documentation, was given kayexalate 15mg on ___. ECG in ED
without peaked T waves. Potassium was trended and was stable.
#Hypertension
Patient found to have hypertensive on arrival to the MICU with
pressures ~160 SBP. Patient takes amlodipine, isosorbide, and
hydralazine at home which were restarted once patient was
stabilized.
# CKD
Patient has recent baseline of ___, prior nadir of 1.4 in
___. On presentation, creatinine improved to 1.5 and was
stable.
# Anemia
Patient has had a chronic normocytic to anemia with previous
work-up unrevealing of specific etiology. B12 and folate normal
in ___. TSH normal in ___. Iron, ferritin, transferrin were
consistent with a mixed anemia. In ___, Hematology felt anemia
likely due to combination of chronic renal disease and mild iron
deficiency. EGD in ___ showed gastritis. Colonoscopy in ___
showed polyps with repeat
recommended in ___ yrs. Hematocrit of 30.3% up presentation today,
near most recent baselines.
TRANSITIONAL ISSUES:
-Patient requires lengthy prednisone taper which is provided in
the medicine reconcilliation.
-Follow-up induced sputum for ___ and nocardia to evaluate for
atypical infection.
-Patient should follow-up with Dermatology for further
evaluation of vulvar rash.
-Consider discontinuation of H2-blocker/PPI for past gastritis
given this increases risk of pneumonia.
-Consider restarting torsemide for volume control once
creatinine stable, please recheck chem panel on ___.
-Azithromycin should be discontinued on ___.
-Patient has previously-identified pulmonary nodules which
should continue to be followed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. Amlodipine 10 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Dronabinol 2.5 mg PO DAILY:PRN nausea
7. Ferrous Sulfate 325 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. HydrALAzine 50 mg PO Q8H
11. Ipratropium Bromide MDI 2 PUFF IH QID
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Montelukast 10 mg PO DAILY
14. Nystatin Oral Suspension 10 mL PO QID:PRN thrush
15. Pantoprazole 40 mg PO Q24H
16. Ranitidine 150 mg PO HS
17. Gabapentin 100 mg PO HS:PRN itch
18. Guaifenesin 10 mL PO Q6H:PRN cough
19. HydrOXYzine 25 mg PO HS:PRN itch
20. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation q6h prn wheeze
21. Metoprolol Succinate XL 100 mg PO DAILY
22. Polyethylene Glycol 17 g PO DAILY
23. Senna 17.2 mg PO BID:PRN constipation
24. Tiotropium Bromide 1 CAP IH DAILY
25. melatonin 1 mg oral qHS
26. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
27. Bisacodyl 10 mg PR HS:PRN constipation
28. Calcium Carbonate 1000 mg PO QID:PRN GI upset
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln ___ NEB IH Q4H:PRN wheeze
3. Amlodipine 10 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Guaifenesin 10 mL PO Q6H:PRN cough
8. HydrALAzine 50 mg PO Q8H
9. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
10. Montelukast 10 mg PO DAILY
11. Nystatin Oral Suspension 10 mL PO TID thrush
12. Pantoprazole 40 mg PO Q24H
13. Polyethylene Glycol 17 g PO DAILY
14. PredniSONE 50 mg PO DAILY Duration: 3 Days
Tapered dose - DOWN
15. PredniSONE 40 mg PO DAILY Duration: 3 Days
Tapered dose - DOWN
16. PredniSONE 30 mg PO DAILY Duration: 3 Days
Tapered dose - DOWN
17. Ranitidine 150 mg PO HS
18. Tiotropium Bromide 1 CAP IH DAILY
19. Azithromycin 500 mg PO Q24H
20. Desitin (zinc oxide;<br>zinc oxide-cod liver oil) 13 %
topical daily
21. Miconazole Powder 2% 1 Appl TP TID
22. Nystatin Cream 1 Appl TP BID
23. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discuss with Pulmonary doctor length of Bactrim prophylaxis
course.
24. Theophylline ER 400 mg PO DAILY
25. Bisacodyl 10 mg PR HS:PRN constipation
26. Calcium Carbonate 1000 mg PO QID:PRN GI upset
27. Dronabinol 2.5 mg PO DAILY:PRN nausea
28. Ferrous Sulfate 325 mg PO DAILY
29. Fluticasone Propionate NASAL 1 SPRY NU DAILY
30. Gabapentin 100 mg PO HS:PRN itch
31. HydrOXYzine 25 mg PO HS:PRN itch
32. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation q6h prn wheeze
33. melatonin 1 mg oral qHS
34. Metoprolol Succinate XL 100 mg PO DAILY
35. Senna 17.2 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Health-care associated pneumonia
COPD exacerbation
Diastolic heart failure
Chronic kidney disease
Urinary tract infection
Vulvar dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted with difficulty breathing and required
intubation. Your respiratory failure was likely because of
pneumonia, COPD exacerbation, and possibly heart failure. Please
continue taking all your medications as directed. Please
follow-up with Dr. ___ and Dr. ___.
Followup Instructions:
___
|
10364180-DS-32 | 10,364,180 | 27,786,842 | DS | 32 | 2173-05-27 00:00:00 | 2173-05-27 22:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Doxycycline / Bactrim DS
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ COPD on 3L home O2, ___, CKD III (baseline Cr 1.8-2.0),
anemia of chronic disease and other issues with multiple recent
hospitalizations (8 since ___ who presents for increased
fatigue and worsening shortness of breath. Patient states that
she has been experiencing increased dyspnea on exertion,
subjective low grade fevers, and pharyngitis for the past ___
days, the dyspnea most pronounced when she gets up to go to the
bathroom. She reports increased productive cough with white
sputum for the past ___ weeks. She took some OTC cough syrup,
which helped alleviate the cough. She is also complaining of
nausea and anorexia, which is chronic for her. She states that
all she ate yesterday was some cottage cheese and a slice of
pineapple. Per patient, foods like bread make her nauseous and
have for some time. She is complaining of chest pain that feels
like "someone is holding me down" but is questionable given that
she states this pain is worsened on exertion. She denies
vomiting, abdominal pain, change in bowel habits, and
palpitations.
Of note patient was recently admitted in ___ after being
referred to ED by PCP due to multiple lab abnormalities,
including HCO3 of 12 and AG of 23. Metabolic acidosis thought
secondary to starvation ketosis, HCO3 improved to 20 at time of
discharge.
In the ED, initial vitals: 98.7 71 183/55 16 98% 4L. Initial
labs notable for K 5.3, 4.9 on recheck. Lactate 0.9, HCO3 16,
Lactate 0.9, Trop 0.06, MB 4, CK 79, ___ ___, H/H
13.2/42.4, WBC 9.3.
CXR with opacities in the right lung base, worsened since the
prior study and 1.5 cm right lower lobe lesion which was
concerning for malignancy.
- EKG: SR, T wave inversion in III, seen on prior EKG, no other
ST-T wave changes.
Vitals currently, 97.6 72 196/71 16 98% 4L
ROS:
Patient complaining of fatigue, SOB, DOE, fever, pharyngitis,
cough, and nausea.
No chills, night sweats, or weight changes. No changes in vision
or hearing, no changes in balance. No palpitations. No vomiting.
No diarrhea or constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
- COPD; spirometry in ___: FVC 1.53L (71%), FEV1 0.87L (52%),
FEV1/FVC 57 (74%)
- Asthma - peak flows 340 at best
- dCHF (dry weight likely 56 kg [124 lbs], more recently 109lbs)
- CKD Stage III
- Hypertension
- Hyponatremia
- Vitamin b12 defic
- Gastritis
- h/o abnormal lfts
- Chronic abdominal pain
- Alcohol use
- Ischemic colitis in ___ and ___.
- Colon polyps
- Low back pain
- Agoraphobia
- s/p tonsillectomy
Social History:
___
Family History:
- Mother with congenital heart disease, HTN, deceased age ___.
- Sister with ovarian ca.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================
Vitals-97.6 72 196/71 16 98% 4L
General- Alert, oriented, visibly SOB on exertion
HEENT- Sclerae anicteric, MMM, oropharynx with visible small
plaques on palate and uvula
Neck- supple, JVP not elevated, no LAD
Lungs- Bilateral inspiratory and expiratory wheezes and
scattered rhonchi in all lung fields
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND 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
DISCHARGE PHYSICAL EXAM:
=====================
Vitals: 97.5 220/70 103 20 96% 3L Glucose 107
52.3kg-->52.9kg
Repeat BP at 1000: systolic 165
+1840/BMx3/Incx3
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx without plaques
Neck: supple, JVP not elevated, no LAD.
Lungs: Scattered rhonchi throughout. Mild wheezing throughout.
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Dilated vessels on chest wall, but decreased compared
to presentation.
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. Bony spurt at the medial aspect of left big toe.
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
==============
___ 11:25AM BLOOD WBC-9.3 RBC-4.18* Hgb-13.2 Hct-42.4
MCV-101* MCH-31.6 MCHC-31.2 RDW-17.0* Plt ___
___ 11:25AM BLOOD Neuts-66.6 ___ Monos-8.1 Eos-4.6*
Baso-1.1
___ 11:25AM BLOOD Glucose-70 UreaN-29* Creat-1.6* Na-135
K-5.3* Cl-106 HCO3-16* AnGap-18
___ 11:25AM BLOOD CK(CPK)-79
___ 11:25AM BLOOD CK-MB-4 ___
___ 11:25AM BLOOD cTropnT-0.06*
___ 06:25PM BLOOD cTropnT-0.05*
___ 08:05AM BLOOD CK-MB-3 cTropnT-0.02*
___ 08:05AM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.5 Mg-2.1
___ 11:34AM BLOOD Lactate-0.9 K-4.9
DISCHARGE LABS:
================
___ 08:10AM BLOOD WBC-9.3 RBC-3.80* Hgb-12.1 Hct-37.6
MCV-99* MCH-31.9 MCHC-32.2 RDW-16.6* Plt ___
___ 08:15AM BLOOD Glucose-100 UreaN-56* Creat-2.0* Na-132*
K-5.3* Cl-100 HCO3-22 AnGap-15
___ 08:15AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1
IMAGING:
================
IMPRESSION:
1. Ill-defined opacities in the right lung base, worsened since
the prior
study, likely due to a combination of infection and small
pleural effusion.
2. Slightly improved aeration of the upper lobes.
3. 1.5 cm right lower lobe lesion which was concerning for
malignancy as seen on the recent chest CT is not as well
visualized on the current exam.
MICRO:
================
NONE
Brief Hospital Course:
___ w/ COPD on 3L home O2, dCHF, CKD III (baseline Cr 1.8-2.0),
anemia of chronic disease and other issues with multiple recent
hospitalizations (8 since ___ who presents for increased
fatigue and worsening shortness of breath. Labs concerning for
HCO3 at 16, physical exam significant for oropharyngeal plaques
and lung fields with scattered wheezing and rhonchi, and imaging
concerning for possible right pleural effusion/infection and
malignancy.
#Worsening SOB and fatigue-likely multifactorial:
- Acute on chronic diastolic heart failure
- COPD with acute exacerbation
Pneumonia less likely given that patient is afebrile with normal
WBC. Given worsening clinical function was treated intially for
COPD exacerbation with duonebs, prednisone and azithromycin (of
note, patient is on azithromycin at home). Patient also likely
had exacerbation of diastolic heart failure. Per discussion with
PACT team, prior to hospitalization, pt was preparing to come in
for a PET scan and was very anxious (described as a "panic
attack"). There is suspicion that pt may have become very
hypertensive in the setting of anxiety, which may have led to
acute decompensation of her chronic diastolic heart failure.
She was started on PO Torsemide 10 mg daily with significant
clinical improvement the following morning. It is notable that
pt has a challenging volume status exam, with often difficult to
discern JVP and minimal peripheral edema. She was noted to have
dilated neck (and chest) veins, and a markedly elevated BNP.
Patient improved clinically with these interventions and was at
her baseline respiratory status (3L O2 by nasal cannula) prior
to discharge. Discharge weight was 116 lbs.
#Starvation ketosis-Patient presented during previous admission
on ___ with similar lab abnormalities. On admission
here HCO3 is 16 and AG-18. Patient stated that this was a
recurrent problem for her and that most foods make her nauseous.
Encouraged PO intake and patient was followed by nutrition
team. HCO3 trended up with improved PO intake and was 22 on day
of discharge.
#Hyperglycemia-Patient noted to have elevated blood sugars while
being treated with prednisone. Patient was treated with humalog
sliding scale. Sugars normalized after ___ompleted.
#Asthma
-Continued fluticasone-nasal spray, Advair diskus, and
montelukast.
#Oral thrush-Patient with history of oral thrush, but has not
been taking her home nystatin oral suspension. Exam consistent
with recurrence of oral thrush. Continued home nystatin oral
suspension
#CKD Stage III-Creatinine baseline between 1.8-2.0. On admission
at baseline with creatinine at 1.7. Creatinine monitored daily,
and patient was kept on low phos/potassium/sodium diet.
Discharge creatinine was 2.0.
#Hypertension-Continued hydralazine, metropolol, and imdur. Dose
of imdur was increased to 90mg daily. In addition, amlodipine
5.0mg Qd and torsemide 10mg Qd was added to her regimen and her
hydralazine was decreased to 50mg BID with overall improvement
in her BP control. Pt is prone to periods of significant HTN,
including a brief period with SBP of 220 during this
hospitalization, that resolved with her scheduled
antihypertensives.
#Hyperkalemia-Chronic problem for patient based on previous
discharge summaries. Potassium level on admission was 5.3.
While in house patient was kept on low potassium diet. Patient
had 2 episodes of elevated potassium of > 5.8, both times
treated with calcium gluconate, insulin/dextrose, and
kayexalate. On discharge, patient's potassium had stabilized to
5.3.
#Vitamin B12 deficiency-Patient at stable H/H at 12.1/37.6 but
with MCV at 99 from ___. Vitamin B12 checked on ___ and was
within normal limits.
# Nutrition/history of alcohol use: Continued thiamine and folic
acid
==============
Transitional Issues:
==============
[ ] Follow up with Pulmonology-Dr. ___
[ ] Recommend PET scan to continue possible malignancy workup.
[ ] Recommend continued titration of home BP meds given
hypertension while inpatient
[ ] Recommend follow-up with PCP and nephrologist regarding
chronic hyperkalemia
[ ] Recommend continued encouragement of PO intake by outpatient
providers
[ ] Chem-10 check at follow up appointment to monitor
electrolytes given initiation of torsemide.
[ ] Discharge weight was 116 lbs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Azithromycin 250 mg PO Q24H
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN As needed
4. Calcium Carbonate 1000 mg PO QID:PRN GI upset
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Guaifenesin 10 mL PO Q6H:PRN cough
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Metoprolol Succinate XL 225 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Nystatin Cream 1 Appl TP BID
12. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
13. Ranitidine 150 mg PO BID
14. Theophylline ER 400 mg PO DAILY
15. Loratadine 10 mg PO DAILY
16. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
17. Tiotropium Bromide 1 CAP IH DAILY
18. Multivitamins 1 TAB PO DAILY
19. Thiamine 100 mg PO DAILY
20. HydrALAzine 50 mg PO BID
21. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Azithromycin 250 mg PO Q24H
3. Calcium Carbonate 1000 mg PO QID:PRN GI upset
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN As needed
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. FoLIC Acid 1 mg PO DAILY
7. Guaifenesin 10 mL PO Q6H:PRN cough
8. Metoprolol Succinate XL 225 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Nystatin Cream 1 Appl TP BID
12. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
13. Ranitidine 150 mg PO BID
14. Theophylline ER 400 mg PO DAILY
15. Thiamine 100 mg PO DAILY
16. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
17. Loratadine 10 mg PO DAILY
18. Tiotropium Bromide 1 CAP IH DAILY
19. HydrALAzine 50 mg PO BID
20. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
21. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
22. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 30 mg 3 tablet(s) by mouth Daily Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
- COPD Exacerbation
- Diastolic Congestive Heart Failure Exacerbation
Secondary
- COPD - on home O2 on 3L
- Asthma - peak flows 340 at best
- dCHF (dry weight likely 56 kg [124 lbs], more recently 109lbs)
- CKD Stage III
- Hypertension
- Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure helping to care for you at ___
___. You were admitted on ___ after a
___ day history of worsening shortness of breath and fatigue.
Given your presentation, you were treated for an exacerbation of
your COPD with nebulizers, steroids and Azithromycin. You were
also started on a diuretic for your heart failure to help remove
excess fluid from your body.
While in the hospital, we emailed your Pulmonologist, Dr. ___,
to update him on your condition. You will follow up with him
when you leave the hospital. If his office does not call you
within 2 business days of discharge, please give them a call at
___. You will follow-up in our discharge clinic on
___, and with your primary care physician on ___. You will need a PET Scan once you leave the hospital since
you missed your previous appointment.
During your stay in the hospital, your blood pressure was high
throughout. By discharge, we had changed the dosage of the Imdur
to 90mg per day, kept the hydralazine at 50mg twice a day, and
added 5 mg of amlodipine daily and 10mg of torsemide daily. Your
potassium was also high throughout your hospital stay. You will
follow-up with your primary care physician and nephrologist
regarding this issue.
In addition, we recommend you try to increase your food intake
as it is very important to maintain adequate nutrition. You
improved clinically and it was determined you were safe to be
discharged from the hospital.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your discharge weight was 116 lbs.
We hope you continue to feel better.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
10364180-DS-33 | 10,364,180 | 26,616,247 | DS | 33 | 2173-06-17 00:00:00 | 2173-06-17 13:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Doxycycline / Bactrim DS
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ with COPD on 3L home O2, dCHF, recently discharged
on ___ for exacerbations of both issues presents with
progressive dyspnea and orthopnea.
Ms. ___ came in to her PCP's office for scheduled follow up
after admission earlier this month with the latest in a series
of flares of advanced COPD. She was discharged ___, has had
slow decline in respiratory status, more rapid over last few
days. She has had to sleep sitting up last three nights with O2
sats in mid-80s, as low as 79% at home. Minimal cough and volume
/weight low with minimal edema. No fever. Has been on daily
azithromycin. No prednisone. Her last dose of prednisone was on
___. She does endorse having a runny nose. She denies being
around sick contacts. She feels poorly and is anxious about her
worsening respiratory status.
In the ED initial vitals were: 97.6 76 177/55 20 93% 4L
- Labs were significant for BNP of 27342 and creatinine of 1.8.
CXR revealed pulmonary edema and LENIs did not reveal a DVT.
- Patient was given methylpred 60mg, ipratropium, albuterol,
40mg Iv lasix , azithro 500mg, hydral 50mg PO and Isosorbide
idintrate
Vitals prior to transfer were: 97.5 78 138/58 24 91% Nasal
Cannula
On the floor, patient reported feeling much improved from
earlier this morning. She feels that the steroids helped her the
most.
Past Medical History:
- COPD; spirometry in ___: FVC 1.53L (71%), FEV1 0.87L (52%),
FEV1/FVC 57 (74%)
- Asthma - peak flows 340 at best
- dCHF (dry weight likely 56 kg [124 lbs], more recently 109lbs)
- CKD Stage III
- Hypertension
- Hyponatremia
- Vitamin b12 defic
- Gastritis
- h/o abnormal lfts
- Chronic abdominal pain
- Alcohol use
- Ischemic colitis in ___ and ___.
- Colon polyps
- Low back pain
- Agoraphobia
- s/p tonsillectomy
Social History:
___
Family History:
- Mother with congenital heart disease, HTN, deceased age ___.
- Sister with ovarian ca.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T:98 BP:160/52 HR:86 RR:20 02 sat: 86 on 3L NC
GENERAL: Sitting up hunched over. Breathing with accessory
muscles
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Diffuse scattered bilateral expiratory wheeze
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
97.7 153/62-198/66 ___ 94-96% on 4L
GEN: appears comfortable on 4L NC, appropriate mentation, does
not appear anxious
HEENT: sclera anicteric
NECK: supple, no LAD, no SCM use, JVP at clavicle at 90 degrees
CV: RRR, no m/r/g
LUNG: some expiratory wheezing heard b/l, fair air movement, i/e
ratio ___
ABD: benign, no retractions
EXT: wwp, no edema appreciatedNEURO: grossly intact
Pertinent Results:
ADMISSION LABS
___ 04:00PM BLOOD WBC-8.2 RBC-3.60* Hgb-11.5* Hct-35.7*
MCV-99* MCH-31.9 MCHC-32.2 RDW-16.1* Plt ___
___ 04:00PM BLOOD Plt ___
___ 04:00PM BLOOD Glucose-89 UreaN-47* Creat-1.8* Na-140
K-4.3 Cl-104 HCO3-22 AnGap-18
___ 04:00PM BLOOD ___
___ 04:00PM BLOOD Calcium-10.0 Phos-3.9 Mg-2.0
___ 04:22PM BLOOD Lactate-1.2
DISCHARGE LABS
___ 08:35AM BLOOD WBC-10.5 RBC-3.07* Hgb-9.8* Hct-30.6*
MCV-100* MCH-31.8 MCHC-31.8 RDW-16.2* Plt ___
___ 08:35AM BLOOD Glucose-112* UreaN-95* Creat-2.1* Na-139
K-5.1 Cl-104 HCO3-25 AnGap-15
___ 08:35AM BLOOD Calcium-10.0 Phos-4.3 Mg-2.0
IMAGING:
LENIs
No evidence of deep venous thrombosis in the left lower
extremity veins.
CXR
1. Mild interstitial pulmonary edema, new since ___, and
bilateral small pleural effusions.
2. Bibasilar streaky opacities likely reflect atelectasis,
however, infection
should be considered in the appropriate clinical setting.
3. Severe emphysema. Scattered ill-defined nodules within the
lungs are better
demonstrated on the prior chest CT.
Brief Hospital Course:
___ with COPD on 3L home O2, ___, recently discharged on ___
for exacerbations of both issues presents with progressive
dyspnea and orthopnea found to be wheezing and with a proBNP of
>23000
ACTIVE ISSUES:
#dCHF: recent echo showed preserved LVEF of 55% but evidence of
acute on chronic diastolic heart failure with elevated JVP, mild
pitting edema, pulmonary congestion both clinically and
radiographically, and an elevated pro-BNP of >23000. She was
continued on her home CHF meds of metoprolol, torsemide,
isosorbide mononitrate, and hydralazine. She was also given
lasix 40 mg IV x2 initially for volume reduction and responded
well although I/Os are difficult to measure given her urinary
incontinence. This gave her ___ with a rise in her Cr from
1.8 to 2.7. Over the course of admission her volume status
improved and her Cr downtrended to 2.1 on discharge.
#COPD: on 3L NC baseline at home, GOLD class III. On admission,
she had prolonged expiratory phase and wheezing consistent with
prior obstructive lung disease.She was recently admitted early
this month for a COPD exacerbation and did not complete a
steroid taper. She was treated with Prednisone 40mg PO, duonebs
and continued her home Fluticasone-Salmeterol Diskus,
azithromycin, tiatropium and ipratropium. She initially had an
O2 requirement of 5L NC (and later 6L), and this gradually
downtrended to her baseline 3L NC. She was discharged with no
changes in her home medication and on a steroid taper of 30mg
x5d and decreasing by 10mg every 5d. She had pulmonology follow
up 4d after discharge.
#Asthma: the pt also has documented asthma which could have been
contributing to her dyspnea. She was continued on her albuterol,
Theophylline, and montelukast.
#Hyperkalemia: The pt has CKD stage III, but her course was
remarkable for hyperkalemia to 5.9. The pt refused to adhere to
a low Na low K diet citing that she knows exactly what is best
for her and subsequently her K began to rise over the admission.
She required additional lasix 40 mg IVx2, insulin+D50 x2, and Ca
glucuronate x2. She initially adamantly refused kayexelate again
citing that she knows what is best for her, but when she failed
to respond to the first round of interventions, she was
convinced to take it. Her K responded and downtrended to 5.1 on
discharge.
___: Cr up in the context of lasix administration, but
currently 2.1 downtrending towards baseline (2.3 from 2.7,
baseline 1.8). ___, likely in the context of lasix
administration prerenal.
CHRONIC ISSUES:
#Anemia: acutely down from baseline of 11.4-13.2. Has trended
macrocyctic with h/o of B12 defiency, but currently B12 WNL.
Cannot r/o component of EtOH induced liver disease, folate
deficiency and renal disease. Heme has seen her previous and
thinks it is combination of anemia of chronic disease and renal
failure. Macrocytic here with MCV = 102, but stable H/H at
___. She was given thiamine, folate, and a multivitamin
#Hypertension- largely isolated systolic as diastolic not
affected. She was continued on her home metropolol, and imdur,
amlodipine, torsemide. Her hydralazine was increased to 60 mg PO
qday
TRANSITIONAL ISSUES:
#COPD/CHF: pt largely lacks insight into the factors that
influence the exacerbation of her disease (eg diet rich with
bacon and subsequent salt overload). She also is unaware of her
precarious respiratory status. Education about the role of
excess salt in CHF would be beneficial especially given the
frequency of her readmissions.
#Lung mass: suspicious for lung cancer. Pt is aware but it was
not discussed extensively during this admission. Long term goals
of care especially in light of this finding and her
moderate-severe COPD should be discussed openly with the patient
especially if she is tired of being hospitalized.
#Alcohol Abuse: pt has questionable but documented alcohol
abuse. She denies this, but her laboratory values (macrocytic
anemia) reflect this. Pt should be counseled about this.
#Goals of Care: the pt has had numerous admission for
respiratory distress and has a likely lung cancer which
inevitably portends a poor prognosis. The pt has vocalized
desire to stay out of the hospital. Goals of care should be
defined to determine whether the pt should seek readmission so
frequently.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Calcium Carbonate 1000 mg PO QID:PRN GI upset
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN As needed
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Guaifenesin 10 mL PO Q6H:PRN cough
7. Metoprolol Succinate XL 225 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Nystatin Cream 1 Appl TP BID
11. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
12. Ranitidine 150 mg PO BID
13. Theophylline ER 400 mg PO DAILY
14. Thiamine 100 mg PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
16. Loratadine 10 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. HydrALAzine 50 mg PO BID
19. Amlodipine 5 mg PO DAILY
20. Torsemide 10 mg PO DAILY
21. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
22. Azithromycin 250 mg PO Q24H
Discharge Medications:
1. Wheelchair with oxygen tank and elevating leg rest
Prognosis: Good
Diagnosis: Gait Instability (781.2)
Length: Lifetime
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
4. Amlodipine 5 mg PO DAILY
5. Calcium Carbonate 1000 mg PO QID:PRN GI upset
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN As needed
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Guaifenesin 10 mL PO Q6H:PRN cough
10. HydrALAzine 50 mg PO BID
11. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
12. Metoprolol Succinate XL 225 mg PO DAILY
13. Montelukast 10 mg PO DAILY
14. Nephrocaps 1 CAP PO DAILY
15. Nystatin Cream 1 Appl TP BID
16. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
17. Ranitidine 150 mg PO BID
18. Theophylline ER 400 mg PO DAILY
19. Thiamine 100 mg PO DAILY
20. Tiotropium Bromide 1 CAP IH DAILY
21. Torsemide 10 mg PO DAILY
22. Azithromycin 250 mg PO Q24H
23. Loratadine 10 mg PO DAILY
24. PredniSONE 40 mg PO DAILY
RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACTIVE ISSUES:
COPD Exacerbation
___ Exacerbation
hyperkalemia
CHRONIC ISSUES:
CKD stage III
HTN
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
shortness of breath. Based off clinical exam and laboratory test
in the ED, it was thought that your shortness of breath was due
to a combination of COPD and heart failure exacerbations. You
were treated with intravenous lasix to take some fluid out of
your lungs. You were also given steroids and nebulizers to help
your breathing. Over the course of three days you gradually
improved.
You are being discharged on a steroid taper. You will take 40mg
x5d, 30mg x5d, 20mg x5d, 10mg x5d, and then stop. You should see
your pulmonologist before you finish your steroid course so that
he/she can adjust the duration if necessary.
You should also weigh yourself everyday. Call your doctor if you
gain more than 5 lbs. Your weight at discharge is 53.1 kg.
Thank you for choosing ___ for your care! All the best for the
future!
Sincerely,
___ Treatment team.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10364180-DS-35 | 10,364,180 | 26,309,516 | DS | 35 | 2173-08-06 00:00:00 | 2173-08-09 15:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Doxycycline / Bactrim DS
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo F with COPD on 3L home O2 and ___ who was recently
discharged on ___ for exacerbations of both issues presents
with progressive dyspnea. The patient finished a steroid taper
on ___. She reports that she feels terrible, has body
aches, chills, rhinorrhea, brownish sputum production
(increased), and abd pain. She also complains of a 10lb weight
loss since discharge, weighing 107 lbs prior to admission. O2
sats have been low in the ___ with exertion at home. She
turned up her O2 to 4L but her O2 saturations were still in the
mid ___. Denies fever and CP.
In the ED initial vitals were: 98.3 76 174/56 20 97% 6L
- Labs were significant for WBC 7.1, H/H 9.4/28.4, plt 395, Na
135, K 4.2, Cl 96, HCO3 28, BUN 71, Cr 2.5, glucose 84, BNP
5261, lactate 0.7 and INR 1.1.
- Patient was given azithromycin, albuterol nebs, ipratoprium
nebs.
Vitals prior to transfer were: 98.0 78 152/73 26 92% Nasal
Cannula
On the floor, the pain continues to complain of mild to moderate
dyspnea. She feels improved but notes a productive cough.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria. Otherwise negative 10
system review.
Past Medical History:
- COPD; spirometry in ___: FVC 1.53L (71%), FEV1 0.87L (52%),
FEV1/FVC 57 (74%)
- Asthma - peak flows 340 at best
- dCHF (dry weight likely 56 kg [124 lbs], more recently 109lbs)
- CKD Stage III
- Hypertension
- Hyponatremia
- Vitamin b12 defic
- Gastritis
- h/o abnormal lfts
- Chronic abdominal pain
- Alcohol use
- Ischemic colitis in ___ and ___.
- Colon polyps
- Low back pain
- Agoraphobia
- s/p tonsillectomy
Social History:
___
Family History:
- Mother with congenital heart disease, HTN, deceased age ___.
- Sister with ovarian ca.
Physical Exam:
EXAM ON ADMISSION:
Vitals: 98 165/58 82 20 92% on 6L
GENERAL: mildly increased WOB
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: scattered wheezes and rales, poor airmovement in most lung
fields
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
EXAM ON DISCHARGE:
Vitals: Tm 99.1, 80, 157/55, 20, 100 on 5L
GENERAL: comfortable in NAD; easily able to complete sentences;
eating breakfast without difficulty.
LUNG: significant scattered wheezes, rales, and rhonchi;
moderate air movement in all lung fields
Pertinent Results:
========= LABS ON ADMISSION =========
___ 07:40PM BLOOD WBC-7.1 RBC-2.78* Hgb-9.4* Hct-28.4*
MCV-102* MCH-33.8* MCHC-33.1 RDW-14.8 Plt ___
___ 07:40PM BLOOD Neuts-71.0* ___ Monos-8.7 Eos-1.4
Baso-0.5
___ 07:40PM BLOOD ___ PTT-35.1 ___
___ 07:40PM BLOOD Glucose-84 UreaN-71* Creat-2.5* Na-135
K-4.2 Cl-96 HCO3-28 AnGap-15
___ 06:27AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.9
___ 07:40PM BLOOD proBNP-5261*
___ 07:50PM BLOOD Lactate-0.7
========= LABS PRIOR TO DISCHARGE =========
___ 07:00AM BLOOD Glucose-96 UreaN-52* Creat-2.3* Na-133
K-4.8 Cl-99 HCO3-22 AnGap-17
========= IMAGING =========
CXR ___
Persistent multifocal opacities. Follow-up of the prior findings
worrisome for malignancy is recommended in the near future using
chest CT, since it does not appear that CT findings including a
large nodule in the right lung are well demonstrated on
radiography.
PET-CT ___
1. Progressively enlarging left upper lobe spiculated mass,
right apical spiculated lesion and a more rounded right lower
lobe lesion are poresent. The right lower lobe lesion is new
from PET CT from ___. The left upper lobe lesion is very FDG
avid while the other two lesions are less so. Other multiple
lesions such as a right middle lobe nodule and other sub cm
lesions are too small to characterize by PET.
2. Previously seen spiculated lesions in the left lower lobe
are obscured by a large consolidation, significantly increased
from ___, concerning for infectious process.
3. 10 mm right lower paratracheal station lymph node shows
minimal tracer uptake. Attention on follow up is recommended.
3. Chronic conditions include severe centrilobular and
paraseptal emphysema, cholelithiasis, severe atherosclerotic
disease, cardiomegaly and coronary artery calcification of
indeterminate hemodynamic.
CXR day prior to discharge:
RLL infiltrate, concerning for pneumonia
Brief Hospital Course:
___ yo lady with COPD on 3L home O2, HFpEF, and likely pulmonary
malignancy admitted for COPD exacerbation.
# Goals of care:
Pt. with severe chronic respiratory failure secondary to a
combination of severe COPD, decompensated HFpEF, and possible
underlying pulm malignancy with frequent acute decompensation.
Given overall poor prognosis as well as frequent
hospitalizations, a family meeting was held with pt., daughter,
SW, palliative care, and internal medicine team on ___. Her
outpatient pulmonologist, Dr. ___ her PCP, ___,
___ also involved in discussions leading up to meeting but were
unable to attend. At this meeting, it was established that we
would focus on optimization of symptomatic treatments for
comfort. While pt. was initially in agreement with plan, she
began to struggle with the decision and in the end decided that
she would like to continue to pursue active treatment for her
pulmonary disease with recurrent hospitalizations if needed. Pt.
chose to continue only therapies that she felt were beneficial.
It was established, however, that pt. was DNR/DNI given that
felt medically not indicated by medical care team. She was in
understanding and agreement with this decision.
# Acute on chronic respiratory failure:
Felt to be secondary to combination of COPD exacerbation (see
below), decompensated HFpEF (see below), and nasal congestion
limiting oxygen delivery. CXR prior to discharge also with some
concern for developing pneumonia. Pt. was treated as below for
COPD and heart failure. In addition she was placed on nasal
saline sprays, 3 days of afrin, and given a 7 day course of
cefpodoxime. She was also given a mask for oxygen delivery as
needed for periods of nasal congestion at home.
# COPD exacerbation, GOLD class IV: Chronic respiratory failure.
Pt is on ___ NC baseline at home. Symptoms on admission
consistent with COPD exacerbation likely secondary to not taking
chronic azithromycin at home, recent steroids taper, and
possible viral resp infection. Pt. initially refused prednisone
and so improvement was slow. She was restarted on azithromycin
250mg daily and her other medical management optimized. The day
prior to discharge she had worsening hypoxia and at that time
agreed to start prednisone 5mg daily with improvement in her
oxygenation.
# HFpHF/HTN: Patient has had multiple recent admissions for
heart falure. Echocardiogram on prior admission showed a normal
ejection fraction. Exam on admission not consistent with CHF
exacerbation and BNP improved from last admission. Pt. initially
refused the majority of her HF medications. She became volume
overloaded with increased pulmonary edema and increased weight.
After worsening hypoxia, pt. agreed to reinitiate torsemide at
20mg daily. She was continued on metoprolol, hydralazine, and
amlodipine, but requested decreased hydralazine dosing and
declined all isosorbide dinitrate.
# Hyperkalemia: Recurrent problem during past admissions as
well. Likely combination of high K diet and refusing torsemide
all in setting of advanced kidney disease. Given goals of care
and after discussion of risks of hyperkalemia, pt. requested
full diet without restrications.
# Multifocal lung opacities: Noted on CT chest from ___. Pt.
underwent PET CT this admission that is concerning for
malignancy. After discussion with Dr. ___ Dr. ___,
she is ___ to be a good candidate for biopsy and so at this
time will pursue optimization of resp status.
# Anemia: Stable. Likely secondary to chronic disease and renal
failure.
Transitional issues:
- Please continue ongoing goals of care discussion in
conjunction with palliative care and other providers.
- Pt. discharged home with several medication modifications that
she specifically requested. She was counseled on other medically
preferred options, but given goal of pt. comfort, her requested
modifications were made.
- Cefpodoxime 250mg q24hrs due to concern for developing
pneumonia; 7 day course to end ___.
- CODE: DNR/DNI
- Contact: ___ (daughter; ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
3. Amlodipine 10 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Calcium Carbonate 1000 mg PO QID:PRN GI upset
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN As needed
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Guaifenesin 10 mL PO Q6H:PRN cough
10. HydrALAzine 100 mg PO TID
11. Loratadine 10 mg PO DAILY
12. Metoprolol Succinate XL 225 mg PO DAILY
13. Montelukast 10 mg PO DAILY
14. Nephrocaps 1 CAP PO DAILY
15. Nystatin Cream 1 Appl TP BID
16. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
17. Ranitidine 150 mg PO BID
18. Theophylline ER 400 mg PO DAILY
19. Thiamine 100 mg PO DAILY
20. Tiotropium Bromide 1 CAP IH DAILY
21. Torsemide 40 mg PO DAILY
22. Omeprazole 40 mg PO DAILY
23. Isosorbide Dinitrate 60 mg PO TID
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Azithromycin 250 mg PO Q24H
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN As needed
5. Guaifenesin 10 mL PO Q6H:PRN cough
6. HydrALAzine 40 mg PO TID
RX *hydralazine 10 mg 4 tablet(s) by mouth three times per day
Disp #*90 Tablet Refills:*6
7. Metoprolol Succinate XL 225 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Nystatin Cream 1 Appl TP BID
11. Nystatin Oral Suspension 10 mL PO TID:PRN thrush
12. Theophylline ER 400 mg PO DAILY
13. budesonide 0.5 mg/2 mL inhalation BID
RX *budesonide 0.5 mg/2 mL 1 neb INH twice daily Disp #*60
Ampule Refills:*3
14. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*3
15. Fluticasone Propionate 110mcg 3 PUFF IH BID
RX *fluticasone [Flovent HFA] 110 mcg/actuation 3 puffs INH
twice daily Disp #*1 Inhaler Refills:*3
16. Morphine Sulfate (Oral Soln.) 1.25-2.5 mg PO Q2H:PRN dyspnea
RX *morphine 10 mg/5 mL ___ mL by mouth every 2hrs Disp #*30
Milliliter Refills:*0
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*3
18. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
RX *salmeterol [Serevent Diskus] 50 mcg 1 puff INH twice daily
Disp #*1 Disk Refills:*3
19. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice daily
Disp #*60 Capsule Refills:*3
20. Sodium Chloride Nasal ___ SPRY NU TID:PRN dry nose
RX *sodium chloride 0.65 % 1 spray intranasal three times per
day Disp #*1 Bottle Refills:*3
21. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
22. Calcium Carbonate 1000 mg PO QID:PRN GI upset
23. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN dyspnea
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb INH every 2
hours Disp #*60 Vial Refills:*3
24. Ipratropium Bromide Neb 1 NEB IH Q6H SOB/wheezing
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb INH every 6
hours Disp #*60 Vial Refills:*3
25. Nitroglycerin SL 0.3 mg SL BID:PRN chest pain
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually
twice daily Disp #*30 Tablet Refills:*0
26. FoLIC Acid 1 mg PO DAILY
27. Thiamine 100 mg PO DAILY
28. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
29. Cefpodoxime Proxetil 200 mg PO Q24H
LAST DAY ___.
RX *cefpodoxime 200 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
30. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion Duration: 3
Days
LAST DAY ___.
RX *oxymetazoline 0.05 % 1 spray intranasal twice daily Disp #*1
Bottle Refills:*0
31. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
32. Oxygen
Continuous home oxygen.
___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Chronic obstructive pulmonary disease
Heart failure with preserved ejection fraction
Hypertension
Chronic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ due to shortness of breath. After
numerous medication changes, your breathing improved and we felt
that you were ready for discharge. We feel that it is unlikely
that your breathing will ever return to normal given the
severity of your lung disease, but we hope that these changes
will help you be more comfortable at home with your dyspnea. It
will be important that you continue to take your medications as
directed. Please call Dr. ___ with any questions or concerns.
We wish you all the best.
Followup Instructions:
___
|
10364295-DS-6 | 10,364,295 | 22,865,642 | DS | 6 | 2149-09-28 00:00:00 | 2149-09-28 14:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary angiography (___)
CORONARY ARTERY BYPASS GRAFT x 3 USING LIMA AND RIMA (NO
___
1. Coronary artery bypass graft x 3. Total arterial
revascularization.
2. Skeletonized left internal mammary artery sequential
grafting to the diagonal on the distal left anterior
descending artery.
3. Skeletonized in situ right internal mammary artery graft
to the obtuse marginal artery.
History of Present Illness:
Mr. ___ is an ___ with hx CAD s/p 2 non-overlapping stents
to the LM in ___ in ___ followed by 3 overlapping stents
to the RCA in ___, HLD, autism spectrum disorder,
esophageal cancer who was transferred from ___ after a
positive nuclear stress test with Lexiscan.
The patient was in his normal state of health until 10 days ago
when he began to experience exertional chest pressure. He was
sent for outpatient stress testing today, but was referred to
the ED at ___ after the test was positive. At ___,
the patient denied active chest pain, dyspnea, nausea, vomiting,
weakness. He was given aspirin, Plavix, and started on a heparin
drip. He was subsequently transferred to ___ for evaluation
for cath. Of note, the patient had an stress echo in ___ without evidence of inducible ischemia.
In the ED initial vitals were: temp 98.1F, BP 115/58, HR 69, RR
18, 97% on RA EKG: HR 66, NSR, normal axis, Q waves in V1-V2.
TWI in II, III, aVF. Labs/studies notable for: hgb 11.9, hct
37.8, PTT 150 (on heparin gtt), trop <0.01 Patient was given:
heparin infusion
In the cath lab, patient was found to have severe ostial LMCA
disease and severe ISR of distal LAD DES. Notably, he also
became mildly hypotensive with intracoronary nitroglycerin
administration. Approach was via R radial, but R groin access
was subsequently required.
On the floor, he is chest pain free and feels well.
REVIEW OF SYSTEMS: Negative except as indicated above
Past Medical History:
1. CARDIAC RISK FACTORS
- Dyslipidemia
2. CARDIAC HISTORY
- CAD s/p 2 non-overlapping stents to the LM in ___ in ___
followed by 3 overlapping stents to the RCA in ___
3. OTHER PAST MEDICAL HISTORY
- autism spectrum disorder
- esophageal cancer s/p surgery (removal of esophagus and GE
junction)
- dyslipidemia
Social History:
___
Family History:
Brother with cardiac arrest at ___. Another brother with CAD s/p
stents to 3 vessels, currently alive. Father with fatal MI in
___.
Physical Exam:
ADMISSION EXAM
==============
VS: Reviewed in eFlowsheets.
GENERAL: Well developed, well nourished, in NAD.
HEENT: Normocephalic atraumatic. Sclera anicteric. Conjunctiva
were pink. No pallor or cyanosis of the oral mucosa. No
xanthelasma.
NECK: Supple. JVP at 8cm.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. no thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. Groin site with small hematoma (outlined).
Non-tender, no bruit, good pulses, warm extremities.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
===============
97.5
PO 95 / 59
R Sitting 73 16 98 RA
.
General: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: diminished in bases [x] No resp distress [x]
GI/Abdomen: hypoactive BS [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema tr
Left Lower extremity Warm [x] Edema tr
Pulses:
DP Right: + Left:+
___ Right: Left:
Radial Right: + Left:+
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] Sternum stable [x] Prevena [x]
Other: Rt IJ tlc
Pertinent Results:
ADMISSION LABS
==============
___ 05:09PM BLOOD WBC-5.1 RBC-3.86* Hgb-11.9* Hct-37.8*
MCV-98 MCH-30.8 MCHC-31.5* RDW-13.4 RDWSD-48.1* Plt ___
___ 05:09PM BLOOD Neuts-54.3 ___ Monos-11.2 Eos-3.1
Baso-1.0 Im ___ AbsNeut-2.77 AbsLymp-1.54 AbsMono-0.57
AbsEos-0.16 AbsBaso-0.05
___ 05:09PM BLOOD ___ PTT-150* ___
___ 05:09PM BLOOD Glucose-93 UreaN-25* Creat-1.1 Na-140
K-4.3 Cl-106 HCO3-25 AnGap-9*
___ 05:09PM BLOOD cTropnT-<0.01
INTERVAL LABS
=============
___ 06:02AM BLOOD WBC-4.8 RBC-3.13* Hgb-9.9* Hct-30.2*
MCV-97 MCH-31.6 MCHC-32.8 RDW-13.2 RDWSD-47.0* Plt ___
___ 06:40AM BLOOD ALT-16 AST-22 AlkPhos-57 TotBili-0.7
___ 11:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:02AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.7
___ 11:00PM BLOOD %HbA1c-5.4 eAG-108
___ 06:40AM BLOOD %HbA1c-5.5 eAG-111
___ 11:00PM BLOOD Triglyc-41 HDL-72 CHOL/HD-1.8 LDLcalc-46
___ 12:08PM URINE Color-Straw Appear-Clear Sp ___
___ 12:08PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
DISCHARGE LABS
===============
IMAGING
=======
CAROTID SERIES (___)
IMPRESSION:
Mild atherosclerotic plaque in the bilateral carotid vasculature
and an
estimated less than 40% stenosis in the bilateral internal
carotid arteries.
TTE (___)
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is normal left ventricular wallthickness
with a normal cavity size. There is normal regional and global
left ventricular systolic function.Quantitative biplane left
ventricular ejection fraction is 58 %.Left ventricular cardiac
index is lownormal (2.0-2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. Tissue Doppler suggestsa
normal left ventricular filling pressure (PCWP less than
12mmHg). Normal right ventricular cavity size withnormal free
wall motion. Tricuspid annular plane systolic excursion (TAPSE)
is normal. The aortic sinusdiameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter isnormal. There is no evidence for an aortic arch
coarctation. The aortic valve leaflets (3) are mildly
thickened.There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are mildly
thickenedwith no mitral valve prolapse. There is trivial mitral
regurgitation. The pulmonic valve leaflets are not wellseen. The
tricuspid valve leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. Theestimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.IMPRESSION: Normal biventricular cavity sizes and
regional/global biventricular systolic function.No valvular
pathology or pathologic flow identified. Normal estimated
pulmonary artery systolic pressure.
CHEST PRE-OP PA AND LAT (___)
Heart size is normal. Mediastinum is normal. Lungs are clear.
There is no pleural effusion. There is no pneumothorax.
STUDIES/PROCEDURES
====================
CORONARY ANGIOGRAPHY (___)
LM:The Left Main, arising from the left cusp, is a large caliber
vessel. This vessel bifurcates into the Left Anterior Descending
and Left Circumflex systems. There is an 80% stenosis in the
ostium extending to the mid segment.
LAD:The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a stent in the proximal
segment. There is a stent in the proximal, mid, and distal
segments. There is a 90% in-stent restenosis in the mid and
distal segments. The Diagonal, arising from the proximal
segment, is a medium caliber vessel. There is a 90% stenosis in
the mid 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 medium caliber vessel.The ___ Obtuse
Marginal, arising from the mid segment, is a medium caliber
vessel.
RCA:The Right Coronary Artery, arising from the right cusp, is a
large caliber vessel. There is a stent in the ostium extending
to the distal segment.The Right Posterior Descending Artery,
arising from the distal segment, is a medium caliber vessel.The
Right Posterolateral Artery, arising from the distal segment, is
a medium caliber vessel.IVUS demonstrated severe ostial disease
of the LMCA with a MLA of 4.7 mm2.
Complications:There were no clinically significant complications
Findings
Severe ostial LMCA disease and severe ISR of distal LAD DES.
Due to rapid ISR and now severe ostial LMCA, warrants
discussion whether may be better served with CABG.
Recommendations
Maximize medical therapy
CSURG consult
Groin management and TR band management per routine.
Remains on DAPT due to recent PCI. Will need to discuss early
discontinuation if considering CABG.
MICROBIOLOGY
=============
___ 12:08 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 1:29 pm Staph aureus swab NASAL SWAB.
**FINAL REPORT ___
Staph aureus Preop PCR (Final ___:
S. aureus Negative; MRSA Negative.
(Reference Range-Negative).
Test performed by PCR.
=======================================================
Post op PA LAT CXR:
IMPRESSION:
Resolution of right apical pneumothorax. Left lower lobe
atelectasis. No
evidence of focal consolidation.
.
___ 04:28AM BLOOD WBC-7.1 RBC-2.87* Hgb-8.7* Hct-27.4*
MCV-96 MCH-30.3 MCHC-31.8* RDW-15.2 RDWSD-52.6* Plt ___
___ 04:28AM BLOOD ___ PTT-26.2 ___
___ 04:28AM BLOOD UreaN-26* Creat-1.1 K-4.3
___ 05:55AM BLOOD Glucose-108* UreaN-20 Creat-1.1 Na-137
K-4.2 Cl-103 HCO3-27 AnGap-7*
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
___ year-old male with history of ADHD, autism/Asperger's, CAD
S/P rotational atherectomy and Xience stenting mid and distal
LAD (2.5 x 18 Xience ___ distally post-dilated to 2.75 and
more proximally to 3.5; a 3.0 x 28 Xience proximal to mid,
post-dilated with 3.5) ___, IVUS sized RCA orbital
atherectomy and 3.5 x 38, 3.5 x 38 and 3.5 x 12 mm Xience ___
stents ___, esophageal cancer S/P resection 1990s,
transferred from ___ with exertional chest pain and
positive nuclear stress test. Coronary angiography on ___ via
RFA (loop with pain RRA) showed ostial LMCA 80% (IVUS MLA of
4.7mm2), LAD mid-distal 90% ISR, and D1 mid 90%. Given left main
disease and ISR, decided to proceed with CABG on ___.
The patient was brought to the Operating Room on ___ where
the patient underwent CORONARY ARTERY BYPASS GRAFT x 3 USING
LIMA AND RIMA (NO TEE due to esophageal surgery). Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the Physical
Therapy service for assistance with strength and mobility. By
the time of discharge on POD 4 the patient was ambulating with
assistance, the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to ___
in ___ in good condition with appropriate follow up
instructions.
While in hospital patient had an acute flare of gout.No history
of gout but exam c/w acute glare. Treated with colchicine 1.2
mg followed by 0.6 mg 1 hour later in day one with resolution of
symptoms. Continued colchicine for two days after resolution.
No indication to start ppx at this point but would continue to
monitor for recurrence.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Magnesium Oxide 500 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
10. Pantoprazole 20 mg PO Q24H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Amiodarone 400 mg PO BID
___ bid x 7 days, then 400mg daily x 7 days, then 200mg daily
3. Furosemide 40 mg PO DAILY Duration: 10 Days
4. Isosorbide Dinitrate 5 mg PO TID arterial grafts Duration: 6
Months
5. Metoprolol Tartrate 25 mg PO BID
6. Potassium Chloride 20 mEq PO Q12H
7. Senna 17.2 mg PO DAILY
hold for loose stool
8. Tamsulosin 0.4 mg PO QHS
9. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*40 Tablet Refills:*0
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Clopidogrel 75 mg PO DAILY
13. Cyanocobalamin 1000 mcg PO DAILY
14. Magnesium Oxide 500 mg PO BID
15. Pantoprazole 20 mg PO Q24H
16. Polyethylene Glycol 17 g PO DAILY
17. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
CAD with two vessel CAD with guiding catheter injury leading to
ostial LMCA stenosis with distal LAD in-stent restenosis
CKD stage 2, eGFR 64
Secondary diagnosis:
Gout
Anemia
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
Prevena instructions
· The Prevena Wound dressing should be left on for a total
of 7 days post-operatively to receive the full benefit of the
therapy. The date of Day # 7 should be written on a piece of
tape on the canister to ensure that the nurse from the ___ or
___ facility knows when to remove the dressing and inspect the
incision. If the date is not written, please alert your nurse
prior to discharge.
· You may shower, however, please avoid getting the
dressing and suction canister soiled or saturated.
· You will be sent home with a shower bag to hold the
suction canister while bathing.
· If the dressing does become soiled or saturated, turn
the power off and remove the dressing. The entire unit may then
be discarded. Should this happen, please notify your ___ nurse,
so they may make plans to see you the following day to assess
your incision.
· Once the Prevena dressing is removed, you may wash your
incision daily with a plain white bar soap, such as Dove or
___. Do not apply any creams, lotions or powders to your
incision and monitor it daily.
· If you notice any redness, swelling or drainage, please
contact your surgeon's office at ___.
.
You were admitted because you had chest pain and were found to
have had a blockage in your stent. You had a procedure called a
coronary angiogram completed to look at the blood vessels that
supply oxygen to your heart. This showed that one of the main
arteries was blocked. It also showed that one of the stents
that had been placed had become blocked as well. You were
evaluated by the cardiac surgery team and together you came to
the decision that the best approach to address the blockages
would be to proceed with cardiac surgery (CABG). You had the
CABG surgery performed on ___. You were also treated for a
first episode of gout in your right big toe joint. This
resolved with 3 days of a medication called colchicine.
· Monitor vitals signs including weight and temperature
Concerns - fever of 100.5 degrees Fahrenheit or higher
- weight increase more than two pounds in one
day or five pounds in a week
· Monitor wound healing, teach wound care
Care - SHOWER DAILY - first wash incisions gently
with mild soap
- NO lotion, cream, powder or ointment to
incisions
Concerns - warmth, redness, swelling or increased
tenderness/pain
- ANY fluid or drainage from incisions
· Medication, diet and exercise teaching and compliance
· Follow-up appointment assistance and compliance
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10364295-DS-7 | 10,364,295 | 25,697,496 | DS | 7 | 2149-10-09 00:00:00 | 2149-10-09 12:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male who presented to the emergency room with
complaints of nausea, diarrhea, hypotension. Patient was found
to be hypotension at rehab, now s/p 1 liter IVF in the ED.
Patient states that he has been nauseous and has had low
appetite since his surgery on ___. He did have loose stools x
5 days after
aggressive bowel medications for constipation. He reports not
eating the food for several days due to disliking the cooking.
He denies fevers, chills, chest pain, leg swelling, orthopnea.
He was given IVF and nausea resolved. Ate a full dinner tonight.
Crea ^ 1.4 (peak creatinine 1.3 during past admission). Patient
also reporting night terrors since surgery. Patient refused tx
back to current rehab - therefore, being admitted to OBS with ___
evaluation and new dispo plan.
Past Medical History:
Past Medical History: HLD, HTN, and CAD ___ on ___ and
3
overlapping ___ on ___, esophageal cancer stage IIa
treated with excision (distal esophagus and partial
gastrectomy),GERD, Vit D def, L5 radiculopathy, anal fissure,
gait instability, h/o migraines with aura, severe chronic white
matter disease, Aspergers
Past Surgical History: appendectomy, excision of distal
esophagus
and partial gastrectomy, Coronary artery bypass graft x 3
(___).
Social History:
___
Family History:
Brother with cardiac arrest at ___. Another brother with CAD s/p
stents to 3 vessels, currently alive. Father with fatal MI in
___.
Physical Exam:
Physical Exam
Pulse:81 Resp: 12 O2 sat: 99% RA
B/P Right: 102/43
General: Awake, alert in NAD, denies nausea
Skin: Dry [x] intact [x] Sternal incision healing well with
erythema surrounding incision
HEENT: PERRLA [] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: + Left:+
___ Right: + Left:+
Radial Right: + Left:+
Discharge Physical Exam:
T: 97.6 BP:106/64 HR:74 RR:16 o2sat:96% room air
General: Awake, alert in NAD, denies nausea
Skin: Dry [x] intact [x] Sternal incision healing well with
slight erythema surrounding incision
HEENT: PERRLA [] EOMI []
Neck: Supple [] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: + Left:+
___ Right: + Left:+
Radial Right: + Left:+
Pertinent Results:
___ 06:05AM BLOOD WBC-7.1 RBC-3.35* Hgb-10.2* Hct-31.9*
MCV-95 MCH-30.4 MCHC-32.0 RDW-15.7* RDWSD-53.4* Plt ___
___ 06:05AM BLOOD Glucose-81 UreaN-22* Creat-1.4* Na-137
K-4.6 Cl-103 HCO3-24 AnGap-10
Discharge Labs: ___ 04:40AM BLOOD WBC-5.5
___ 04:40AM BLOOD UreaN-23* Creat-1.4* K-4.3
___ 04:40AM BLOOD Amylase-222*
___ 04:40AM BLOOD Lipase-230*
___ 04:40AM BLOOD Mg-2.0
Abdominal ultrasound: ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There are multiple hepatic
cysts with the largest
measuring 4.2 x 4.2 x 4.5 cm. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CBD: 6 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The pancreas is not well visualized, largely obscured
by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 7.0 cm
KIDNEYS: Normal cortical echogenicity and corticomedullary
differentiation is seen bilaterally. There is no evidence of
stones or hydronephrosis in the kidneys. There are multiple
simple cysts in the bilateral kidneys, measuring up to 0.6 x
0.5 x 0.5 cm on the right and 5.3 x 5.1 x 5.4 cm on the left.
Right kidney: 9.3 cm Left kidney: 11.5 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal
limits.
There are bilateral small pleural effusions.
IMPRESSION
1. Normal sonographic appearance of the hepatobiliary structures
without
suspicious focal lesion.
2. Multiple simple hepatic and renal cysts.
3. Bilateral small pleural effusions.
CXR ___:
1. Similar appearance of known gastric pull-through.
2. Left basilar opacity likely due to combination of atelectasis
and effusion, overall similar compared to prior. Please note
that component of infection is difficult to exclude entirely.
Brief Hospital Course:
___ year old male s/p CABG x 3 on ___ who was admitted with
nausea and hypotension. Pt was admitted to ___ 8. He was
administered IV fluid and labs were checked. Lasix was held due
to a slight increase in Creatnine to 1.3 from 1.1, likely due to
dehydration. Amiodarone was discontinued due to prolonged Qtc
and patient in sinus rhythm - by the day of discharge Qtc 453.
Mildly elevated amylase and lipase but patient asymptomatic and
tolerating po intake well. Abdominal ultrasound was negative for
acute process. Amylase and lipase trending down on the day of
discharge. Will have rehab check pancreatic enzymes and
creatinine/bun in a few days. Renal function stable - cont to
hold Lasix and encourage oral fluids. Patient's nausea and
hypotension resolved by the time of discharge. Patient was
cleared for discharge to ___. All follow up
appointments were advised.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Pantoprazole 20 mg PO Q24H
5. Polyethylene Glycol 17 g PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Magnesium Oxide 500 mg PO BID
8. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
9. Vitamin D 1000 UNIT PO DAILY
10. TraMADol 25 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
11. Tamsulosin 0.4 mg PO QHS
12. Metoprolol Tartrate 12.5 mg PO BID
13. Amiodarone 400 mg PO BID
14. Isosorbide Dinitrate 5 mg PO TID arterial grafts
15. Senna 17.2 mg PO DAILY
16. Acetaminophen 1000 mg PO Q6H
17. Furosemide 40 mg PO DAILY
18. Potassium Chloride 20 mEq PO Q12H
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY recent stents
5. Docusate Sodium 100 mg PO BID
hold if loose stool
6. Isosorbide Dinitrate 5 mg PO TID
x 6 months
7. Magnesium Oxide 400 mg PO BID
8. Pantoprazole 40 mg PO Q24H
9. Polyethylene Glycol 17 g PO DAILY
10. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
11. Senna 17.2 mg PO DAILY
hold for loose stool
12. Tamsulosin 0.4 mg PO QHS
13. Vitamin D 1000 UNIT PO DAILY
14. Metoprolol Tartrate 6.25 mg PO BID
15. Cyanocobalamin 1000 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
nausea/ hypotension
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
If you notice any redness, swelling or drainage, please contact
your surgeon's office at ___.
· Monitor vitals signs including weight and temperature
Concerns - fever of 100.5 degrees Fahrenheit or higher
- weight increase more than two pounds in one day or five
pounds in a week
· Monitor wound healing, teach wound care
Care - SHOWER DAILY - first wash incisions gently with mild
soap
- NO lotion, cream, powder or ointment to incisions
Concerns - warmth, redness, swelling or increased
tenderness/pain
- ANY fluid or drainage from incisions
· Medication, diet and exercise teaching and compliance
· Follow-up appointment assistance and compliance
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
****Please check Amylase/Lipase, Sodium, Potassium, chloride,
serum bicarb , BUN and Creatnine in 3 days & call results to
Cardiac surgery ___
Followup Instructions:
___
|
10364448-DS-22 | 10,364,448 | 20,412,355 | DS | 22 | 2166-12-30 00:00:00 | 2167-01-01 21:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
neck and hip pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of metastatic
breast cancer with extensive bone metastases on Capecitabine who
presents to the ER with headaches and increased pain in her neck
and hip.
.
She reports worsening pain primarily in the psat 2 weeks in her
left hip. It is worse with walking and moving her hip joint;
however she is still able to ambulate. It is a dull pain that
does not radiate. She reports intermittent headaches which have
also been ocurring over the past 2 weeks. She denies vision
changes, changes in speaking or swallowing, muscle weakness, or
numbness/tingling. She has had intermittent nausea which she
attributes to the Dilaudid. She has been taking Dilaudid ___ mg
PO about twice a day which has been helping her neck pain but
has not helped with her left hip.
.
In the emergency department, initial vitals: 97.6 73 115/72 16
97%. Labs were unremarkable. She was given Dilaudid 1mg IV x 2
for pain as well as Ondansetron 4mg IV for nausea.
.
On arrival the floor, she complains primarily of pain in the
left hip. She also notes a discomfort when she urinates and
thinks she may have a urinary tract infection. She denies
fevers or chills. She states that the dilaudid she recevied in
the ER was ineffective.
Review of systems:
(+) Per HPI + dysuria
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. No diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: diagnosed with left breast cancer, T1cN1M0 treated with
lumpectomy and 6 cycles of CMF on either side of her radiation;
did not take Tamoxifen
- ___: left supraclavicular lymphadenopathy and FNA revealed
adenocarcinoma consistent with her prior breast cancer. Was
started on Fulvestrant and was progression free for the next
___ years.
- ___: progression in lower cervical spine and upper thoracic
spine. Continued on Fulvestrant and Anastrazole. Developed
further progression and underwent spine stabilization surgery to
cervical and upper thoracic spine, then radiation to the spine
- ___: started on Xeloda after completing radiation
- ___: surgery for burst fracture of C4
- MRI of lumbar spine showed metastatic disease at L1 and S2
- ___: L1 kyphoplasty with deep bone biopsy, pathology
showed metastatic breast cancer.
OTHER PAST MEDICAL HISTORY:
-Asthma
-Depression
-Hypothyroidism
Social History:
___
Family History:
- Mother had ___ CA at age ___. Still alive.
- Father passed away at age ___ from CHF.
- 1 sister that is alive and healthy.
Physical Exam:
Physical Exam on Admission:
VS: T 97.3 BP 124/78 HR 68 RR 18 99% RA
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses. No pain on palpation of her left hip. Full range of
motion of the left hip joint.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Gait assessment deferred
.
Physical Exam on discharge:
unchanged
Pertinent Results:
Labs on Admission:
___ 07:40PM BLOOD WBC-3.0*# RBC-3.84* Hgb-12.6 Hct-37.2
MCV-97 MCH-32.8* MCHC-33.8 RDW-15.2 Plt ___
___ 07:40PM BLOOD Neuts-67.7 ___ Monos-2.8 Eos-8.1*
Baso-1.0
___ 07:40PM BLOOD Glucose-125* UreaN-12 Creat-0.5 Na-138
K-4.3 Cl-104 HCO3-28 AnGap-10
___ 07:40PM BLOOD Calcium-9.2 Phos-3.5 Mg-2.1
Urine:
___ 09:50PM URINE Color-Straw Appear-Clear Sp ___
___ 09:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
.
Imaging:
.
CT torso (prelim read)
Overall, no significant change in extent of disease from
___.
1. Unchanged mediastinal and hilar lymph nodes.
2. Stable pulmonary nodules. No new nodule.
3. Minimal interval decrease in size of left hepatic lobe
lesion. No new
lesion seen.
4. Diverticulosis without diverticulitis.
.
CT head:
No evidence of acute intracranial process or metastatic disease.
MR is more sensitive than CT for assessment of metastatic
disease of the
brain.
.
Labs on Discharge:
___ 07:50AM BLOOD WBC-2.5* RBC-3.57* Hgb-11.7* Hct-34.7*
MCV-97 MCH-32.8* MCHC-33.7 RDW-16.0* Plt ___
___ 07:50AM BLOOD Glucose-113* UreaN-10 Creat-0.6 Na-140
K-4.0 Cl-104 HCO3-30 AnGap-10
___ 07:50AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of metastatic
breast cancer currently on Capecitabine who presents with
worsening pain in her neck and left hip. Her pain was poorly
controlled on a Fentanyl patch and oral dilaudid at home.
# Hip pain: Initially thought to be due to disease progression
and bone metastates, but this was ruled out with CT scan.
Imaging did not reveal any pathologic fractures. Etiology was
thought to be musculoskeletal in nature. Pain was well
controlled on discharge with Fentanyl patch 50mcg q72 hours
(increased from 25mcg on admission), MS ___ 30mg bid and
Morphine short acting ___ q6h prn pain.
.
# Neck pain: chronic in nature s/p surgery. Similar to baseline.
Pain control as above.
.
# Headache: Frontal headache on admission, resolved. CT head
did not show metastatic disease or hematoma/hemorrhage. Most
likely a tension headache.
.
# Breast cancer: Continued Capecitabine. ANC >1500, afebrile
throughout hospital course. CT torso obtained, did not show
progression of disease.
.
# Hypothyroidism: Continued Levothyroxine at home dose.
.
# Asthma: Continued home Singulair, Advair, Albuterol.
.
TRANSITIONAL ISSUES:
-will f/u with PCP and primary oncologist on discharge
Medications on Admission:
Albuterol 90 mcg 2 puffs q2-4 hours PRN
Capecitabine 1500 mg PO BID x 7 days
Fentanyl 25 mcg/72 hour patch
Advair 500mg/50mcg 1 puff BID
Hydromorphone 2 mg ___ tablets q4H PRN pain
Levothyroxine 112 mcg tablets 1 tab PO daily
Lorazepam 1mg ___ tabs PO BID PRN nausea or anxiety
Singulair 10 mg PO daily
Sertraline 50 mg PO daily
Vitamin C (has not been taking)
Calcium/Vitamin D (has not been taking)
Omega 3 Fatty Acids (has not been taking)
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation q2-4 hours as needed for shortness of breath
or wheezing.
2. capecitabine Oral
3. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
4. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
5. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a
day.
6. lorazepam 2 mg Tablet Sig: ___ Tablets PO twice a day as
needed for nausea or anxiety.
Disp:*30 Tablet(s)* Refills:*0*
7. montelukast 10 mg Tablet Sig: One (1) Tablet PO daily ().
8. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
9. Vitamin C Oral
10. Calcium 500 + D Oral
11. omega-3 fatty acids Oral
12. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*30 Tablet Extended Release(s)* Refills:*0*
13. morphine 15 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hip Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
.
You were admitted to the hospital with left sided hip pain, neck
pain and back pain that was poorly controlled with Dilaudid at
home. We treated your pain with Morphine and you responded
well. You also had a CAT scan of your torso which DID NOT show
progression of your cancer. This confirmed that you hip pain is
NOT from cancer. Most likely, your hip pain is musculoskeletal
in nature and will resolve over time.
.
You also had a CAT scan of your head which also DID NOT show
progression of your cancer.
We have made the following changes to your medications:
-STOP dilaudid
-INCREASE Fentanyl patch from 25mcg to 50mcg
-START MSContin 30mg twice per day (long acting pain medicine)
-START Morphine sulfate ___ every 6 hours as needed for
break through pain
.
On discharge, please call your primary care physician, ___.
___, to schedule a follow up appointment to re-evaluate
your leg pain.
.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
10365491-DS-5 | 10,365,491 | 22,581,459 | DS | 5 | 2145-09-18 00:00:00 | 2145-09-18 11:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
facial droop
Major Surgical or Invasive Procedure:
Core needle bx left axillar mass
Excisional biopsy of axillary mass
History of Present Illness:
CC: ___ droop axillary mass
HPI: Mr. ___ is a ___ man with no known medical
problems who is presenting with L axillary lump since ___ and
two days of L facial droop and dysarthria.
He reports that he first noticed a left axillary mass a few
months ago. It is intermittently painful and has been growing.
No
overlying skin changes or redness and no drainage from the mass.
He is a non-smoker. A week or so ago he started to develop some
left finger numbness/tingling, but has no other left arm
neurologic symptoms. On ___ he woke up and noticed a new
left
facial droop and new dysarthria, which have persisted since that
time. He has no headache, visual changes, changes in
coordination, falls, syncope.
He went to ___ urgent care and was transferred to ___
where
___ showed R cerebral masses with 0.4cm midline shift. In the
context of his L axillary mass this was thought to be suspicious
for metastatic cancer and so he was transferred to ___ for
further care.
ED Course:
Vitals: T 99.4, HR 101, BP 146/89, SpO2 97% on RA
Labs were unremarkable
CT chest with 7.8x6.6 axillary lesion hematoma vs. heterogeneous
mass. CT A/P without neoplasm or acute process
Neurosurgery consulted in the ED and felt there was no
indication
for emergent surgical intervention. They recommended MRI brain,
keppra 1g BID, will continue to follow. He was started on keppra
in the ED.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
None
Social History:
___
Family History:
Mom with lung cancer in her ___
No family history of bleeding or clotting disorders
Physical Exam:
VITALS: BP: 139/86 HR: 89 RR: 18 O2 sat: 98% O2 delivery: Ra
GENERAL: Well appearing man, intermittently tearful
EYES: Anicteric, PERRL
ENT: MMM. No OP lesion, erythema or exudate. Ears and nose
without visible erythema, masses, or trauma.
CV: Heart regular, no m/g. JVP 6cm
RESP: Lungs CTAB no w/r/r. Breathing comfortably
GI: Abdomen soft, NTND. Bowel sounds present.
GU: No suprapubic ttp or fullness
MSK: Extremities warm without edema. Moves all extremities
SKIN: +large left axillary mass without overlying skin changes,
mobile, mildly tender to palpation. No rashes or ulcerations
noted on examined skin.
NEURO: Alert, oriented, +Left facial droop otherwise cranial
nerves all tested and in tact. +Dysarthria. Repetition in tact.
Alert and oriented x3. No dysmetria on FNF or rapid alternating
movements. No pronator drift. ___ strength in upper and lower
extremities.
PSYCH: pleasant, appropriate affect
Patient was examined on day of discharge. Continued left facial
droop, but otherwise a normal physical exam. Drain with
serosanguinous discharge.
Pertinent Results:
___ 09:00PM BLOOD WBC-7.6 RBC-4.75 Hgb-14.8 Hct-42.3 MCV-89
MCH-31.2 MCHC-35.0 RDW-12.7 RDWSD-41.3 Plt ___
___ 09:00PM BLOOD Neuts-70.0 ___ Monos-9.8 Eos-0.3*
Baso-0.3 Im ___ AbsNeut-5.31 AbsLymp-1.45 AbsMono-0.74
AbsEos-0.02* AbsBaso-0.02
___ 09:00PM BLOOD Glucose-89 UreaN-14 Creat-1.0 Na-142
K-4.5 Cl-100 HCO3-26 AnGap-16
___ 06:40AM BLOOD ALT-8 AST-9 LD(LDH)-176 AlkPhos-92
TotBili-0.5
___ 06:35AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0 UricAcd-5.6
___ 06:45AM BLOOD PSA-2.3
___ 06:45AM BLOOD HIV Ab-NEG
CTH (___. ___)
***
CT Chest:
1. 7.8 x 6.6 cm left axillary lesion could represent a hematoma
or heterogenous mass. Ultrasound recommended for further
evaluation.
2. Scattered indeterminate pulmonary nodules measure up to 5 mm.
See recommendations.
3. Right lower lobe bronchopneumonia likely due to atelectasis.
RECOMMENDATION(S):
1. Ultrasound of left axillary lesion.
2. Noncontrast chest CT in 3 months for pulmonary nodules.
CT A/P:
1. No intra-abdominal neoplasm or acute process.
2. Please refer to separate chest CT done the same day for
thoracic findings.
MRI:
IMPRESSION:
1. Study is mildly degraded by motion.
2. Three peripherally enhancing supratentorial brain lesions in
the right
parietooccipital and frontal lobes, most compatible with
hemorrhagic brain
metastases, measuring up to 2.9 cm, as detailed above.
3. Mild vasogenic edema surrounding the largest lesions in the
frontal and
parietooccipital lobes.
4. No acute infarction.
CT CHEST:
IMPRESSION:
1. 7.8 x 6.6 cm left axillary lesion could represent a hematoma
or
heterogenous mass. Ultrasound recommended for further
evaluation.
2. Scattered indeterminate pulmonary nodules measure up to 5 mm.
See
recommendations.
3. Right lower lobe bronchopneumonia likely due to atelectasis.
CT ABD:
IMPRESSION:
1. No intra-abdominal neoplasm or acute process.
2. Please refer to separate chest CT done the same day for
thoracic findings.
Brief Hospital Course:
Mr. ___ is a ___ year-old man with no known medical history
who presented with acute onset of a left facial droop, and a
history of an enlarging left axillary pass. A CT showed multiple
brain masses with associated hemorrhage, mild edema, and mass
effect concerning for metastatic cancer of an unknown primary,
but consistent with metastatic melanoma. Head MRI confirmed that
this was likely metastatic disease, and neurosurgery, oncology,
and neuro-oncology were all consulted. He was started on Keppra
for seizure prophylaxis; steroids were not started. HIV was
negative. A core biopsy of the axillary mass was non-diagnostic
on ___ therefore, he had excision of both the axillary mass
and a melanotic-appearing lesion on the back. Pathology from
this is pending. He is discharging with a JP-drain in place, and
will have a visiting nurse to provide wound care. He has been
instructed to measure daily drain output, and will follow up
with Dr. ___ week, as well as the ___ clinic.
At this time, pathology will be reviewed and a treatment plan
will be determined. This plan was extensively counseled with the
patient, his sister (in ___ who plans to come assist her
brother), and his friend.
Other hospital problems:
1. Microscopic Hematuria. Noted incidentally. Recommend follow
up UA post DC
> 30 minutes spent on discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. LevETIRAcetam 1000 mg PO Q12H
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth Twice daily Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic brain cancer
Left facial droop
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with left facial droop and growing mass in
your left armpit. We found tumors in your brain. You underwent
biopsy and removal of your armpit mass, the results have not yet
returned. You will follow up the results with both Dr. ___
___ Dr. ___ you ___ see next week.
Please take all medications as prescribed and follow up closely
with your doctor for ongoing care. You will need to continue
taking the Keppra (anti-seizure medication) for the time being.
As we discussed, do not drive, swim alone, or do anything that
could injure you if you become incapacitated. If you have any
problems, please call Dr. ___ during office hours
(___). After hours, call the main ___ number and ask
to page Dr. ___.
Followup Instructions:
___
|
10365523-DS-3 | 10,365,523 | 22,429,354 | DS | 3 | 2144-07-05 00:00:00 | 2144-07-10 23:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
procaine / milk / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman who presents with LLQ abdominal
pain. The patient is an extremely poor historian, given her
psychiatric history and possibly mental delay. However, she
reports that she has had abdominal pain for the past 3 months.
It is unclear whether the pain is constant or intermittent. She
also states she has diarrhea and constipation nausea and
vomiting occasionally. She cannot remember all of her
medications but states that she ran out of her seroquel one week
ago. She says that no one knows what to do with her pain.
She went to ___ 2 days ago and was given a
prescription for Reglan, however, she did not have this filled
and today she called EMS and requested to be transferred here to
___. She denies any fever, chills, chest pain, shortness
of breath, dysuria.
Of note, she grew up in foster homes, has a hx of sexual abuse
and has been diagnosed for schitzoaffective disorder, PTSD, and
depression. She has been living on her own with assistance for
___ years now and has a cat but gets lonely. She has VNAs that
come to her house daily to help administer her medications and
on the weekends help with grocery shopping and laundry. She
attends a day program at ___ during the week. Her level of
education is unknown but she can only read and write "a little
bit".
Collateral from her foster mother, who does not have any power
of attorney, confirmed that this is the patient's ___ admission
for the same problem. She has a possible history of heavy
bleeding and poison ingestion. She was physically and mentally
abused by her birth mother and sexually ___ by her brother.
She did not know anything about the patient's birth history.
In the ED, initial vital signs were: T P BP R O2 sat.
Exam notable for LLQ pain without rebound or guarding.
Labs were notable for normocyic anemia. UA had small leukocytes,
30 protein, trace blood.
Patient was given 1L IVF, morphine 10mg, oxycodone 5mg,
metaclopraminde 10mg.
On Transfer Vitals were: 98.5, 89, 125/71, 15, 96% RA
REVIEW OF SYSTEMS:
(+) As per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Asthma
Allergic Rhinitis
Schizoaffective disorder
PTSD
Depression
Constipation
Social History:
___
Family History:
Unknown, reviewed
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98, BP 131/76 - 101/59, P 68-81, RR 18, ___ RA.
General: Obese woman lying in bed, quite voice, in NAD.
HEENT: PERRL, EOMI, mucous membranes moist.
CV: RRR, S1, S2, no S3, S4, murmurs or rubs.
Lungs: Limited exam due to body habitus and poor patient effort
but no crackles or wheezing appreciated on exam.
Abdomen: soft, obese, periumbilical and LLQ tenderness, skin
colored abdominal striae appreciated, +BS, No HSM, no masses.
Ext: No edema
DISCHARGE PHYSICAL EXAM:
Vitals: T 98-98.4, BP 101/61-103/54, HR 87-84, RR 18, SAO2 97%
RA
General: obese woman sleeping in bed in NAD.
HEENT: head ATNC
Lungs: difficult to appreciate secondary to body habitus and
poor patient effort but CTAB
CV: RRR S1, S2, no S3, S4, murmurs or rubs.
Abdomen: mildly tender in LLQ when palpating with stethescope,
somewhat hypoactive BS.
Ext: no edema, pulses +2
Pertinent Results:
ADMISSION LABS:
___ 02:24AM BLOOD WBC-4.8 RBC-3.70* Hgb-9.6* Hct-30.8*
MCV-83 MCH-25.9* MCHC-31.2* RDW-14.6 RDWSD-44.2 Plt ___
___ 02:24AM BLOOD Neuts-50.0 ___ Monos-8.5 Eos-3.3
Baso-0.6 Im ___ AbsNeut-2.42 AbsLymp-1.80 AbsMono-0.41
AbsEos-0.16 AbsBaso-0.03
___ 02:24AM BLOOD Glucose-108* UreaN-13 Creat-0.7 Na-144
K-4.2 Cl-108 HCO3-21* AnGap-19
___ 02:24AM BLOOD ALT-14 AST-24 AlkPhos-51 TotBili-0.1
___ 02:24AM BLOOD Lipase-37
___ 02:24AM BLOOD Albumin-4.2
___ 06:20AM BLOOD calTIBC-364 Ferritn-8.4* TRF-280
IMAGING:
ABDOMINAL US ___:
IMPRESSION:
Limited examination due to patient sedation. Only transabdominal
ultrasound
images were obtained. The right ovary appears normal and the
left ovary is not
definitely visualized, however, it may contain a 1.7 cm cyst.
The study is
within normal limits. If further assessment of the left ovary
is desired,
this will best be performed with a transvaginal sonogram when
the patient is
able to consent to the study.
CT ABD/PELVIS ___:
IMPRESSION:
No acute intra-abdominal process. Left ovarian cyst measuring
1.8 cm.
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-4.6 RBC-3.67* Hgb-9.5* Hct-29.7*
MCV-81* MCH-25.9* MCHC-32.0 RDW-14.0 RDWSD-40.9 Plt ___
___ 06:45AM BLOOD Glucose-88 UreaN-10 Creat-0.6 Na-139
K-3.4 Cl-103 HCO3-24 AnGap-15
___ 06:45AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.1
___ 06:45AM BLOOD TSH-0.92
___ 06:45AM BLOOD tTG-IgA-2
___ 06:20AM BLOOD tTG-IgA-3
Brief Hospital Course:
Ms. ___ is a ___ yo woman with a PMHx of PTSD, depression,
schizoaffective disorder and asthma who presents with LLQ
abdominal pain x 4 months. She has had multiple hospital
admissions for this abdominal pain.
ACUTE ISSUES:
# Abdominal Pain: The patient presented with intractable
abdominal pain mostly in the left lower quadrant sometimes
radiating to the back, worse with eating, and some dizziness, no
nausea or vomiting, or diarrhea and no change with her menstrual
periods. Her last menstrual period started the day after
admission. CT abdomen and pelvis was notable only for a 1.8cm
left ovarian cyst and no other intra-abdominal processes. All
her laboratory values including LFTs, lipase and WBC were all
within normal limits. Urine dip was significant for 30 protein,
small leukocytes, trace blood and few bacteria, culture was
contaminated. Testing for H-pylori and TTg screen for celiac
disease were both negative. We treated her with fluids, clear
liquid diet which was advanced as tolerated, tramadol and IV
morphine. The patient stated that there was no significant
change in her abdominal pain with the pain medication. In
discussion with her foster mother, visiting nurses and new PCP
we found that she had been admitted to a number of different
hospitals multiple times with the same complaint without
definitive diagnosis. She also had OBGyn follow up for possible
endometriosis evaluation but never followed up. After a couple
days the patient was weaned off of the pain medications and her
diet was advanced as tolerated. Nutrition was consulted to help
her with a stomach easy diet and she was given information for
follow up nutrition appointment.
# Anemia, iron deficiency: found anemia on laboratory
evaluation. Iron studies done and consistent with iron
deficiency anemia. Likely from heavy menses. Unable to preform
stool guaiac given pt was on her menstrual period during
admission. Recommend outpatient follow up and possibly
multivitamin with iron supplementation. This was not started at
this time given her ongoing pain and risk for failure.
.
CHRONIC ISSUES:
# PTSD / Depression / Schizoaffective disorder: Continued her
home medications and rechecked TSH (9.2). Discharged with follow
up with psychiatry a couple days after discharge.
.
# Asthma: continued albuterol nebulizer as needed without acute
event.
.
TRANSITIONAL ISSUES:
1. Please help patient schedule nutrition follow up appointment
for diet plan that is easy on stomach. Call ___ to
schedule an appointment.
2. Pt anemic with low ferritin, consistent with iron deficiency
anemia, likely secondary to menstruation. Please consider
increasing iron supplementation and further workup of anemia as
needed.
3. Recommend continued close, frequent physician follow up with
low risk interventions and reassurance.
# Code: Full Code
# Emergency Contact: ___ ___, ___
___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 2.5 mg/0.5 mL inhalation QID:PRN wheeze/SOB
2. Bisacodyl ___AILY:PRN constipation
3. Docusate Sodium 100 mg PO TID
4. cranberry 125 mg oral QAM
5. Venlafaxine XR 75 mg PO QAM
6. Fluticasone Propionate NASAL 2 SPRY NU QAM
7. Gemfibrozil 600 mg PO QAM
8. Levothyroxine Sodium 25 mcg PO QAM
9. Loratadine 10 mg PO QAM
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. mometasone 200 mcg nasal Q12H:PRN SOB
12. Multivitamins 1 TAB PO QAM
13. Omeprazole 20 mg PO BID
14. Prazosin 3 mg PO QHS
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN SOB
16. Promethazine 25 mg PO Q6H:PRN nausea
17. Senna 8.6 mg PO BID:PRN constipation
18. QUEtiapine Fumarate 400 mg PO QHS
19. Montelukast 10 mg PO QPM
20. Spiriva with HandiHaler (tiotropium bromide) 18 mcg
inhalation QAM
21. Oxcarbazepine 300 mg PO BID
22. Acetaminophen 325 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO TID
3. Gemfibrozil 600 mg PO QAM
4. Levothyroxine Sodium 25 mcg PO QAM
5. Multivitamins 1 TAB PO QAM
6. Omeprazole 20 mg PO BID
7. Oxcarbazepine 300 mg PO BID
8. Prazosin 3 mg PO QHS
9. Promethazine 25 mg PO Q6H:PRN nausea
10. Senna 8.6 mg PO BID:PRN constipation
11. Venlafaxine XR 75 mg PO QAM
12. albuterol sulfate 2.5 mg/0.5 mL inhalation QID:PRN
wheeze/SOB
13. Bisacodyl ___AILY:PRN constipation
14. cranberry 125 mg oral QAM
15. Fluticasone Propionate NASAL 2 SPRY NU QAM
16. Loratadine 10 mg PO QAM
17. mometasone 200 mcg nasal Q12H:PRN SOB
18. Montelukast 10 mg PO QPM
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. ProAir HFA (albuterol sulfate) 90 mcg/actuation INHALATION
Q4H:PRN SOB
21. QUEtiapine Fumarate 400 mg PO QHS
22. Spiriva with HandiHaler (tiotropium bromide) 18 mcg
inhalation QAM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Abdominal Pain
SECONDARY DIAGNOSES:
Post-traumatic Stress Disorder
Depression
Anxiety
Asthma
H/O Developmental Delay
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your came here at ___
___. You can to us on ___ with
abdominal pain. We did a CT scan which was normal and ran a
series of lab tests all which were also normal. We treated your
abdominal pain with bowel rest, IV fluids, and pain medication.
We worked with nutrition to put together a meal plan that would
not hurt your stomach. We also set up close follow up with your
physicians for continued treatment of your abdominal pain. We
did not make any medication changes but highly recommend that
you follow up with the appointments that were set up for you.
1. Please follow up with Dr. ___ appointment below.
2. Please follow up with nutrition, call to schedule appointment
at ___
Thank you for choosing ___ for
your healthcare needs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10365629-DS-7 | 10,365,629 | 24,473,903 | DS | 7 | 2167-01-05 00:00:00 | 2167-01-05 16:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / apple / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
/ ibuprofen
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female history of PTSD, OCD, ___
disease, anorexia nervosa history who presents status post
ingestion of multiple substances now with altered mental status
and intermittent convulsions. Patient was found down by her
roommates who had heard a loud thump on the floor at home and
found her tremulous and confused. Roommates later called back to
report the following medications have been taken: Effexor bottle
empty and filled ___, Xanax bottle empty w/ 15 prescribed a
while ago, Viseral bottle empty, 100 caps of Tylenol ___ at 500mg
empty 2 empty bottle, 40 capsule of Tylenol empty; further,
roommates found a letter left for her parents.
Patient is unable to provide any significant past medical
history due to altered mental status. She was initially
transferred to the ICU after ER stay.
On arrival to the floor, the patient does not remember any of
the events. Per the record, her roommate found her down after
hearing a loud thump.
She was found to have an empty Effexor bottle, Xanax bottle, and
had taken 100
capsules of Tylenol p.m. and 40 capsules of plain Tylenol.
She was admitted initially to the ICU ___ for encephalopathy,
and Toxicology was consulted. They recommended starting
infusion
of N-acetyl cysteine for admission Tylenol level of 292, though
LFTs were normal and INR was 1.1. They also recommended giving
Ativan to treat symptoms of Venlefaxine overdose. Neurology was
consulted for the patient's nystagmus, which they attributed to
serotonin syndrome, and agreed with ___ medical
management. Hepatology was also consulted for transaminitis, as
well as psychiatry who thinks she would benefit from inpatient
care after medical stabilization. She never required pressors
or
intubation and was stepped ___ to the floor on ___. Currently,
she reports feeling some nausea but no vomiting. She has no
pain
and feels some anxiety after a challenging conversation with her
roommate earlier this evening.
Complete ROS is otherwise negative.
___ disease Type 1. She was diagnosed at age ___
after significant episodes of epistaxis. She had DDAVP
challenge
which was successful, takes this at times for heavy menstrual
flow (2 sprays)
She has had intermittently elevated LFTs, felt by her primary
care provider to most likely represent the effects of her
starvation. She has not yet had any workup for this.
Past Surgical History:
Right elbow nerve repair
Past Medical History:
___ Disease
Anorexia Nervosa with inpatient admissions
Anxiety
Depression
OCD
PTSD
History of suicidal ideation
Gastroparesis, reportedly diagnosed by nuclear medicine
scan with alternating constipation and diarrhea
Social History:
___
Family History:
FH: No family history of liver disease. No GI cancers. Mother
with hypothyroid, father with diabetes
Physical Exam:
Admission Physical Exam:
GENERAL: Patient is snoring in bed. Unresponsive even to
sternal rub and not responding to painful stimuli.
HEENT: Sclera anicteric, MMM, oropharynx clear. Pupils are
sluggish
NECK: 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. No rigidity noted.
NEURO: Unable to perform ___ to obtunded.
ACCESS: PIV
Discharge Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: alert/engaged, cooperative, comfortable, no distress
EYES: sclera anicteric, EOMI, PERRLA
EENT: without posterior pharyngeal erythema or exudate
Neck: soft without LAD
Lungs: clear bilaterally normal depth/effort
CV: RRR s1/s2 without m/r/g
GI: soft nt/nd bowel sounds present
MSK: normal bulk/tone
SKIN: no rashes or ulcerations noted
NEURO: CN II-XII intact; negative for clonus or increased muscle
tension; moving all ext; nonfocal examination
PSYCH: normal thought content, calm, denies AH/VH
Pertinent Results:
Admission Labs:
___ 02:50AM WBC-7.8 RBC-4.28 HGB-13.4 HCT-38.8 MCV-91
MCH-31.3 MCHC-34.5 RDW-11.9 RDWSD-39.7
___ 02:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-292*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:50AM ALT(SGPT)-40 AST(SGOT)-38 CK(CPK)-216* ALK
PHOS-66 TOT BILI-0.3
___ 06:39AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 06:39AM URINE UCG-NEGATIVE
___ 12:15PM ALT(SGPT)-31 AST(SGOT)-27 CK(CPK)-164 ALK
PHOS-48 TOT BILI-0.3
___ 02:50AM BLOOD ___ PTT-26.2 ___
___ 02:50AM BLOOD ___ 02:50AM BLOOD ALT-40 AST-38 CK(CPK)-216* AlkPhos-66
TotBili-0.3
___ 02:50AM BLOOD Lipase-26
___ 12:15PM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:29PM BLOOD CK-MB-5 cTropnT-<0.01
___ 12:15PM BLOOD Calcium-7.9* Phos-2.4* Mg-1.4*
___ 02:50AM BLOOD Albumin-5.1
___ 05:43AM BLOOD TSH-0.78
___ 12:55PM BLOOD HCG-<5
___ 02:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-292*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:59AM BLOOD pO2-82* pCO2-40 pH-7.35 calTCO2-23 Base
XS--3 Comment-GREEN TOP
___ 02:59AM BLOOD Glucose-88 Lactate-3.8* Na-139 K-3.0*
Cl-103
___ 02:59AM BLOOD freeCa-1.08*
ECHO ___
The left atrium is normal in 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 aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There
is no pericardial effusion.
IMPRESSION: Normal biventricular function. No pathologic
valvular
disease.
___
RUQ ultrasound:
IMPRESSION:
Normal abdominal ultrasound.
___
IMPRESSION:
Normal abdominal ultrasound.
___
Abdomen X-ray:
IMPRESSION:
Mild-to-moderate rectosigmoid fecal loading. Otherwise
unremarkable study.
Discharge Physical exam:
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of PTSD, OCD,
___ disease, anxiety, depression and eating
disorder who presents with polysubstance
overdose with Effexor, Xanax, and Tylenol, initially admitted to
the MICU ___ with encephalopathy, and transferred to the floor
on ___ for further evaluation and medical clearance prior to
transfer to inpatient psychiatry unit. She was continued on NAC
infusion per toxicology recommendations until LFTs normalized.
EBV titers were also sent which were found to be positive for
prior infection but no active condition. Patient had menses
while on medical floor, this contributed to abdominal cramping.
She had no ongoing bleeding that required initiation of DDAVP.
Per neurology, anticipate serotonergic excess will continue to
improve with time. Per toxicology, mild tremor is also likely
related to the venlafaxine overdose and also anticipate it to
improve as she metabolizes venlafaxine. On discharge, per
toxicology, consider alternative agents to SSRIs including
venlafaxine given that they inhibit platelet aggregation and
activity and patient has ___ disease. She was
followed by neurology, toxicology, and psychiatry while on the
medical floor. She is medically cleared for discharge on ___
for inpatient psychiatry hospitalization.
Transitional issues:
-Avoid NSAIDS and SSRI/SNRI class medications given history of
___ disease
-Allergies: updated to include apples and NSAIDs (given concern
for bleeding risk) and morphine
-No Tylenol for three months post discharge
-Continue to monitor QTc
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. acetaminophen-caff-pyrilamine 500-60-15 mg oral unknown
2. Venlafaxine 225 mg PO DAILY
3. HydrOXYzine 25 mg PO Q12H: PRN anxiety
4. ALPRAZolam 1 mg PO Q8H: PRN stressful event
5. Acetaminophen ___ (diphenhydrAMINE-acetaminophen) ___ mg
oral Frequency is Unknown
Discharge Medications:
1. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q6H:PRN sore throat
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Thiamine 100 mg PO DAILY
6. ALPRAZolam 1 mg PO Q8H: PRN stressful event
7. HELD- HydrOXYzine 25 mg PO Q12H: PRN anxiety This medication
was held. Do not restart HydrOXYzine until follow up with PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
1) Intentional Polypharmacy Overdose
2) Acetaminophen Toxicity with elevated transaminase levels and
coagulopathy
3) SNRI Toxicity/Withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were hospitalized for a medication overdose. You were
treated with IV NAC infusions for Tylenol levels. You were
evaluated by psychiatry, neurology, toxicology, and nutrition.
On discharge, you will be going to ___ in ___ for further treatment.
We wish you best wishes in your recovery,
Best wishes,
Your ___ team
Followup Instructions:
___
|
10365870-DS-18 | 10,365,870 | 24,458,163 | DS | 18 | 2163-09-13 00:00:00 | 2163-09-13 18:39:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Univasc / Lisinopril / Isosorbide / Enablex / animal fat
Attending: ___
Chief Complaint:
Fever, dysuria
Major Surgical or Invasive Procedure:
R PCN placement ___
Failed R PCNU placement ___
History of Present Illness:
PCP: ___. MD
CC: ___
HPI: The patient is a ___ y/o M with PMHx of low grade papillary
urothelial cell carcinoma s/p laser ablation on ___, R sided
hydronephrosis s/p PCN placement on ___, R UPJ stricture s/p
balloon dilatation and stent placement on ___, coag+ staph UTI
s/p Bactrim x 3d on ___ and ureteral stent removal on ___,
who presented to ___ yesterday for epi visit for fevers x 4 days
and was referred to the ED after lab work was notable for ___
and
leukocytosis.
Of note, the patient is a somewhat tangential historian. The
historian was obtain from both the patient using the phone
interpreter as well as from review of HCA and ED notes. Please
refer to the HCA epi visit note dated ___ for an excellent
summary of the patient's urologic course leading up to current
presentation.
The patient reports that, following his stent removal on ___,
he initially felt better. However, over the past few days, he
began to experience recurrent urinary frequency, dysuria,
chills,
fevers (up to 39C), and R flank pain (which seems to be
chronic).
As above, he was seen in clinic yesterday where labs were
ordered
and were notable for Cr of 3.0 (up from 2.0 on ___ and ~1.5
prior to that) as well as WBC 11.6. Given these results, he was
referred to the ED. In the ED, imaging was notable for R-sided
hydronephrosis.
ED Course:
Initial VS: 99.0 74 133/49 16 95% RA
Labs significant for mild downtrend in H/H without any evidence
of bleeding. Cr 3.0->2.8. Lactate 0.8. WBC 11.6->8.2. +UA
Imaging: renal U/S with moderate right-sided hydronephrosis
Meds given:
___ 03:15 IV CefTRIAXone 1 gm
___ 03:15 IVF LR
___ 03:49 IV Vancomycin 1000 mg
ED Exam:
Well-appearing no acute distress, no CVAT, abdomen soft
nontender
nondistended, bilateral 1+ edema to mid tibia.
Guaiac neg brown stool
No prostatic tenderness
VS prior to transfer: 98.7 73 121/54 16 95% RA
The patient was ultimately brought to the ___ suite and underwent
R PCN placement. Per report, procedure was notable for drainage
of pus. Cx sent.
On arrival to the floor, the patient endorses the above story.
In
addition, he endorses intermittent palpitations as well as back
and shoulder pains, both of which appear to be chronic.
ROS: As above. Denies headache, lightheadedness, dizziness, sore
throat, sinus congestion, chest pain, shortness nausea,
vomiting,
diarrhea, constipation. The remainder of the ROS was negative.
Past Medical History:
UROTHELIAL CANCER R RENAL PELVIS S/P ABLATION C/B URETRAL
STRICUTRE S/P DILATION AND URETERAL STENT (REMOVED)
CORONARY ARTERY DISEASE s/p stent
GASTRITIS
HYPERCHOLESTEROLEMIA
HYPERTENSION
LOW BACK PAIN
MILD BPH
PAGET'S DISEASE
PERIPHERAL VASCULAR DISEASE
SPINAL STENOSIS
TRIGEMINAL NEURALGIA
JOINT PAIN
BONE SPUR
GLAUCOMA
VENTRAL HERNIA
Social History:
___
Family History:
Mother had ___
Physical Exam:
ADMISSION:
==========
VS - ___ 1850 Temp: 98.5 PO BP: 147/70 HR: 90 RR: 20 O2
sat:
96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GEN - Alert, NAD
HEENT - NC/AT, R pupil round and reactive to light, L pupil
post-surgical, MMM
NECK - Supple, no LAD
CV - RRR, ___ systolic murmur
RESP - CTA B
BACK - R PCN in place with dressing c/d/I; no CVAT; PCN draining
serosanguinous fluid
ABD - S/NT/ND, BS present
EXT - No ___ edema or calf tenderness
SKIN - No apparent rashes
NEURO - Nonfocal
PSYCH - Calm, appropriate
DISCHARGE:
==========
24 HR Data (last updated ___ @ 1204)
Temp: 98.2 (Tm 98.7), BP: 149/71 (139-160/65-71), HR: 77
(77-99),
RR: 18, O2 sat: 98% (96-98), O2 delivery: RA
GENERAL: NAD, sitting comfortably in chair
EYES: R pupil round and reactive, L pupil post surgical with
mild
L ptosis (chronic)
ENT: OP clear
CV: RRR, nl S1, S2, II/VI SEM, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: + BS, soft, NT, ND, no rebound/guarding, no HSM
GU: R PCN in place draining punch colored urine without clots;
no
R CVA tenderness
SKIN: No rashes or ulcerations noted
NEURO: AOx3, CN II-XII intact, ___ strength in all extremities,
sensation grossly intact throughout, gait testing deferred
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION:
==========
___ 08:05PM BLOOD WBC-11.6* RBC-3.94* Hgb-11.2* Hct-36.1*
MCV-92 MCH-28.4 MCHC-31.0* RDW-13.8 RDWSD-47.1* Plt ___
___ 08:05PM BLOOD Neuts-77.7* Lymphs-11.1* Monos-8.3
Eos-2.2 Baso-0.3 Im ___ AbsNeut-8.99* AbsLymp-1.29
AbsMono-0.96* AbsEos-0.25 AbsBaso-0.03
___ 03:00AM BLOOD ___ PTT-27.2 ___
___ 08:05PM BLOOD UreaN-34* Creat-3.0* Na-139 K-5.1 Cl-105
HCO3-22 AnGap-12
___ 10:40PM BLOOD cTropnT-0.03*
___ 05:50AM BLOOD cTropnT-0.04*
___ 05:30AM BLOOD cTropnT-0.04*
___ 05:50AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1
___ 03:10AM BLOOD Lactate-0.8
DISCHARGE:
==========
WBC 9.6, Hgb 10.4 (from 10.4), Plt 245
INR 1.3
Na 142, K 4.3, Cl 107, HCO3 20 (from 19), BUN 32 (from 33), Cr
2.7 (from 2.8, 3.0 on admission), Glu 105, AG 15
Trop 0.03 -> 0.04 -> 0.04
Lact 0.8
UA (___): sm blood, neg nit, lg ___, 30 prot, 5 RBCs, >182 WBCs,
few bact
MICRO:
======
UCx (___): >10K STAPH AUREUS COAG + of 2 morphologies
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
BCx (___): pending x 2
UCx (___): mixed flora
Prior:
------
UCx (___):
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
UCx (___): >100K Yeast
EKG (___): NSR at 81 bpm, nl axis, PR 272 (1st degree AV
block),
QRS 118, QTC 462, RBBB (no change from ___
IMAGING:
========
PCNU attempt (___):
Unsuccessful attempt at conversion of nephrostomy to
nephroureterostomy. New 8 ___ right nephrostomy tube was
placed
R PCN (___):
Successful placement of 8 ___ nephrostomy on the right.
Renal U/S (___):
1. Moderate right-sided hydronephrosis.
2. Debris is noted within the bladder lumen.
Brief Hospital Course:
___ y/o M with hx CAD s/p stenting, PVD s/p stenting, HLD, HTN,
BPH, low grade papillary urothelial cell carcinoma s/p laser
ablation (___), R sided hydronephrosis from R UPJ stricture
s/p PCN placement (___) and balloon dilatation with stent
placement and subsequent removal (___) presenting with one
week of fevers and dysuria, found to have R-sided
hydronephrosis,
___, and complicated UTI, now s/p R PCN placement and failed
attempt at R PCNU.
# Low grade papillary urothelial cell carcinoma s/p laser
ablation:
# R UPJ stricture s/p balloon dilation and stent placement
(removed):
# R-sided hydronephrosis:
# ___ on CKD stage III:
# MRSA UTI:
Mr. ___ is followed by Dr. ___ for ___
papillary urothelial cell carcinoma, now s/p laser ablation
___. He was found to have a R UPJ stricture and R-sided
hydronephrosis for which a R PCN was placed followed by a
ureteral stent ___. He was treated with bactrim x 3d
___ for MRSA cystitis and the stent was removed
___.
He presented this admission with fevers, dysuria, R flank pain,
and leukocytosis and was found to have R hydronephrosis from
persistent ureteral stricture and likely obstructive ___, with
Cr
3.0 from b/l ~1.3-1.6. He was seen by both urology and ___ and
underwent R PCN placement on ___, with fluid culture again
growing MRSA of two different morphologies (Bactrim S),
consistent with complicated UTI. ___ attempted unsuccessful PCNU
transition on ___ (unable to pass ureteral stricture) and R PCN
was therefore replaced. His Cr slowly downtrended without
evidence of post-obstructive diuresis to 2.7 at the time of
discharge. He was treated initially with Vanc/CTX (___) with
resolution of his fevers and leukocytosis and was transitioned
to
Bactrim 1 SS tab BID given CrCl<30 with plan for 10d course from
time of PCN placement (___). Should his renal function
improve, may need to increase dose to DS 1 tab BID to complete
his course. BCx were NGTD at discharge. He was discharged home
with a R PCN and ___ care. He will f/u with Dr. ___
on ___ for discussion of next steps, with tentative plan for
___ to reattempt PCNU vs modified PCNU (given bladder irritation
from double J stents) in 3 weeks ___ to schedule). In addition,
he will f/u with his PCP ___ ___. He should have CBC and BMP
rechecked at urology visit on ___ and decision should be made
regarding Bactrim dosing. Home mirabegron held on discharge; can
be resumed at discretion of urology/PCP.
# Normocytic anemia:
# Hematuria:
Hgb 11.2 on admission from b/l ___. Likely secondary to mild
hematuria without clots secondary to PCN placement/manipulation,
not concerning per urology and ___. Hgb stable at 10.4 on
discharge.
# RBBB:
# 1st degree AV block:
# Elevated troponin:
# CAD s/p stents:
Hx of CAD s/p stenting, followed by Drs ___ as
outpatient. Troponin 0.03 on admission and uptrended slightly to
0.04 on two checks. Likely demand ischemia in setting of CKD and
in the absence of angina. Admission EKG showed known 1st degree
AV block and RBBB (seen on EKG ___ but not ___, stable
on
repeat EKG on HD 2. ACS was thought unlikely in that setting. He
was continued on his home ASA and statin. Home metoprolol was
initially held and resumed prior to discharge.
# HTN:
Home nifedipine, doxazosin, and metoprolol were initially held,
resumed prior to discharge.
# HLD:
Continued home atorvastatin.
# H/o Gastritis:
Continued home pantoprazole.
# L-sided glaucoma:
Continued home brimonidine and ketorolac gtt to L eye.
** TRANSITIONAL **
[ ] continue Bactrim SS 1 tab BID x 7 additional days (through
___ if renal function continues to improve, may need to
increase dose to DS 1 tab BID x 7d
[ ] would repeat CBC/BMP on ___ to ensure stability of anemia
and ongoing improvement in ___
[ ] f/u BCx, pending at discharge
[ ] resumption of home mirabegron per PCP/urology
# CODE STATUS: FULL (confirmed)
# CONTACT/HCP: ___ (son) ___ updated ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Simethicone 120 mg PO TID:PRN gas
3. Metoprolol Tartrate 25 mg PO BID
4. NIFEdipine (Extended Release) 30 mg PO BID
5. Atorvastatin 80 mg PO QPM
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Pantoprazole 40 mg PO Q24H
8. Aspirin 81 mg PO DAILY
9. Loratadine 10 mg PO DAILY:PRN allergies
10. mirabegron 25 mg oral DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Doxazosin 4 mg PO DAILY
13. brimonidine 0.2 % ophthalmic (eye) BID
14. Sulfameth/Trimethoprim DS 1 TAB PO BID
15. ketorolac 0.4 % ophthalmic (eye) TID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. brimonidine 0.2 % ophthalmic (eye) BID
5. Doxazosin 4 mg PO DAILY
6. Ketorolac 0.4 % ophthalmic (eye) TID
7. Loratadine 10 mg PO DAILY:PRN allergies
8. Metoprolol Tartrate 25 mg PO BID
9. NIFEdipine (Extended Release) 30 mg PO BID
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Pantoprazole 40 mg PO Q24H
12. Simethicone 120 mg PO TID:PRN gas
13. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 7 Days
Take through ___
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
14. Vitamin D 1000 UNIT PO DAILY
15. HELD- mirabegron 25 mg oral DAILY This medication was held.
Do not restart mirabegron until instructed by Dr. ___ your
primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MRSA UTI
R-sided hydronephrosis
R ureteral stricture s/p PCN placement
Anemia
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with a urinary tract infection
and kidney injury, likely due to your known ureteral stricture.
You underwent placement of a right-sided nephrostomy tube and
were treated with antibiotics, which you will need to continue
through ___.
Please follow up with your urologist, Dr. ___, on ___ and
with your primary care doctor on ___. You may be contacted by
the interventional radiology team to schedule a procedure to try
and "internalize" your nephrostomy tubes. You can discuss this
more with Dr. ___ on ___.
With best wishes,
___ Medicine
Followup Instructions:
___
|
10365870-DS-19 | 10,365,870 | 24,623,649 | DS | 19 | 2164-04-08 00:00:00 | 2164-04-09 23:01:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Univasc / Lisinopril / Isosorbide / Enablex / animal fat
Attending: ___.
Chief Complaint:
Decreased urine output from nephrostomy
Major Surgical or Invasive Procedure:
PCN replacement
History of Present Illness:
HPI: Mr. ___ is a ___ man with history of upper tract
urothelial cancer of the right pelvis s/p laser ablation, right
hydronephrosis due to UPJ stricture s/p PCN placement,
presenting
with decreased output from the nephrostomy tube and right flank
pain.
The patient is interviewed with the assistance of a ___
telephone translator. The patient recently saw his PCP ___ ___.
At that time, he reported a concern for leakage around his tube;
this was not observed at that visit. He also reported
generalized
itching that he believes is related to eating meat; he had no
apparent rash and was referred to an allergist. He reports that
he was in his usual state of health until the day of admission,
when he report decreased output from his urostomy tube, right
flank pain, and a feeling of warmth (he denies fevers). He also
reports change in the color of the fluid draining from his
nephrostomy tube, which concerned him for infection. He reports
dysuria that started today. He denies any abdominal pain,
nausea,
vomiting, diarrhea, or constipation.
In the ED, initial VS were 99.6 83 150/59 16 99% RA.
Labs notable for CBC with WBV 10.6, H/H of 10.0/33.2, Plt 280.
BMP with BUN 44 and Cr of 2.8. UA grossly positive.
Physical exam notable for pus and slight erythema at the site of
the nephrostomy tube, otherwise, soft, nontender abdomen.
He received IV cefepime, IV NS, IV vancomycin.
Urology saw the patient and recommended ___ exchange of the
chronic nephrostomy tube.
On arrival to the floor, the patient recounts the above history.
He denies any pain at present. He denies any other complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Urothelial cancer R renal pelvis s/p ablation complicated by
ureteral stricture s/p dilation and ureteral stent (removed)
- CAD s/p stent
- Gastritis
- HLD
- HTN
- Low back pain
- Mild BPH
- Paget's disease
- peripheral vascular disease, right SFA stent and left SFA
stent
with known left pop occlusion
- Spinal stenosis
- Trigeminal neuralgia
- Ventral hernia
Social History:
___
Family History:
FAMILY HISTORY:
- Mother: ___ disease
Physical Exam:
VITALS: 98.5 133/59 80 18 96 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, left pupil surgical
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, systolic murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation; right PCN
in place draining yellow urine; no pus surrounding PCN site
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: Very pleasant, appropriate affect
Pertinent Results:
___ 09:00PM BLOOD WBC-10.6* RBC-3.65* Hgb-10.0* Hct-33.2*
MCV-91 MCH-27.4 MCHC-30.1* RDW-14.5 RDWSD-48.9* Plt ___
___ 09:00PM BLOOD ___ PTT-30.7 ___
___ 09:00PM BLOOD Glucose-116* UreaN-44* Creat-2.8* Na-139
K-4.9 Cl-103 HCO3-21* AnGap-15
Microbiology:
- Blood culture (___): pending
- Urine culture (___): pending
- Urine culture (___): pending
Imaging:
- CT A/P (___):
1. Interval placement of a right percutaneous nephrostomy tube
with persistent moderate right hydronephrosis. While the
neprhostomy tube tip appears coiled within the right lower pole
renal pelvis in appropriate position, findings are suspicious
for
malfunction or occlusion.
2. Interval development of fat stranding around the right
ureteral pelvic junction, nonspecific but compatible with an
underlying inflammatory/infectious process. A 2.2 x 1.9 cm
hypodense lesion in the ureteropelvic junction, which may
represent an extrarenal pelvis or a focal fluid collection, is
incompletely characterized in the absence of intravenous
contrast.
- Renal Ultrasound (___): No evidence of renal abscess.
___ 8:45 pm URINE
URINE CULTURE (Preliminary):
PSEUDOMONAS SPECIES. >100,000 CFU/mL.
PSEUDOMONAS MENDOCINA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS SPECIES
| PSEUDOMONAS MENDOCINA
| |
CEFEPIME-------------- 4 S 2 S
CEFTAZIDIME----------- 32 R 16 I
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
LEVOFLOXACIN---------- 0.25 S <=0.12 S
MEROPENEM------------- 4 S 2 S
PIPERACILLIN/TAZO----- 16 S 16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Discharge labs
___ 06:30AM BLOOD WBC-9.9 RBC-3.42* Hgb-9.4* Hct-31.0*
MCV-91 MCH-27.5 MCHC-30.3* RDW-14.6 RDWSD-48.9* Plt ___
___ 06:20AM BLOOD Glucose-100 UreaN-42* Creat-2.8* Na-145
K-4.7 Cl-112* HCO3-18* AnGap-15
Brief Hospital Course:
SUMMARY/ASSESSMENT: Mr. ___ is a ___ man with history
of upper tract urothelial cancer of the right pelvis s/p laser
ablation, right hydronephrosis due to UPJ stricture s/p PCN
placement, presenting with decreased output from the nephrostomy
tube and right flank pain.
ACUTE/ACTIVE PROBLEMS:
# Low-grade papillary urothelial cell carcinoma s/p laser
ablation:
# Right hydronephrosis due to right UPJ stricture s/p PCN:
# Acute on chronic renal failure:
He underwent ___ exchange of nephrostomy tube and tolerated the
procedure well. He was given IVF, and creatinine was trended
given ___ (but likely post renal cause), but creatinine failed
to improve despite decompression and receipt of IVF. He was
given a f/u appointment with nephrology on the day after
discharge. No eosinophilia to suggest ATN, he had good UOP
after PCN was replaced, was eating and drinking well.
# Urinary tract infection: Urinalysis positive on admission. Of
note, prior urine cultures have grown MRSA and Enterococcus. He
was initially treated with vancomycin and ceftriaxone. He
endorsed dysuria. He was discharged with the antibiotic
ciprofloxacin, and culture results obtained show that he was
growing two separate strains of pseudomonas. Given that he
initially had dysuria, this was felt not to be a contaminant,
and he will complete 7 days of antibiotic ciprofloxacin, which
the pseudomonas organisms are sensitive to
CHRONIC/STABLE PROBLEMS:
# Anemia: Admission H/H of 10.0/33.2, within recent baseline. No
signs or symptoms of active bleeding.
- Trend CBC
# HTN:
- Continue NIFEdipine
- Continue doxazosin
- Continue metoprolol
# HLD:
- Continue statin
# Left glaucoma:
- Continued home brimonidine and ketorolac eye gtts
# PVD s/p stent:
# CAD s/p stent:
- Continue Aspirin 81 mg PO DAILY
- Continue Atorvastatin 80 mg PO QPM
- Continue Metoprolol Tartrate 25 mg PO BID
# History of Gastritis:
- Continue Pantoprazole 40 mg PO Q24H
Greater than ___ hour spent on care on day of d/c
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Atorvastatin 80 mg PO QPM
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
3. Doxazosin 4 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. mirabegron 25 mg oral DAILY
6. NIFEdipine (Extended Release) 30 mg PO BID
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Pantoprazole 40 mg PO Q24H
9. Aspirin 81 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Loratadine 10 mg PO DAILY:PRN allergies
12. simethicone 125 mg oral QID:PRN gas
13. Ketorolac 0.5% Ophth Soln 1 DROP LEFT EYE TID
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q24H
take for one week.
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID
5. Doxazosin 4 mg PO DAILY
6. Ketorolac 0.5% Ophth Soln 1 DROP LEFT EYE TID
7. Loratadine 10 mg PO DAILY:PRN allergies
8. Metoprolol Tartrate 25 mg PO BID
9. mirabegron 25 mg oral DAILY
10. NIFEdipine (Extended Release) 30 mg PO BID
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Pantoprazole 40 mg PO Q24H
13. simethicone 125 mg oral QID:PRN gas
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Uroepithelial carcinoma with chronic nephrostomy tube
Acute kidney injury
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:
You were admitted with decreased output from your nephrostomy,
so it was changed by our radiologists, and now it is functioning
well. You suffered some mild kidney injury on account of your
tube being blocked. We have made an appointment for the
nephrologists to see you tomorrow.
Our radiologists will reach out to you to schedule a followup
tube exchange in about six months.
There is evidence that you have a urinary tract infection.
Please finish an additional week of antibiotics (ciprofloxacin
250 mg) daily for one week. I have sent this prescription to
the ___ on ___.
Followup Instructions:
___
|
10366072-DS-13 | 10,366,072 | 26,322,992 | DS | 13 | 2155-07-09 00:00:00 | 2155-07-09 16:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
dizziness, gait unsteadiness
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr. ___ is an ___ old man with a past medical history
of
HTN, hyperlipidemia, pre-DM and prostate cancer who presents at
the request of his neighbor for a month of progressive dizziness
and gait unsteadiness.
History is obtained from patient's neighbor, who was concerned
about him and helped patient and his wife bring the patient to a
PCP appointment today. She reports that for the past ___ weeks,
she has noticed that ___ has been complaining of dizziness,
like a lightheaded feeling. He has also been quite unsteady when
walking or standing, tending to lean back when standing and has
fallen four times with possible head strike. She has noticed
that
he has looked more pale and thinner and his wife reports a 20 lb
weight loss in the past few months.
The patient himself denies any symptoms. Reports he has been
walking fine and denies any complaints. He will endorse some
ongoing lightheadedness with standing and nausea. No headaches
or
vomiting.
His wife reports that he has been more irritable lately, but
otherwise has not had any significant personality change. She
does note some memory impairment, however.
According to the ED, they spoke with the neighbor who was
concerned about the state of the patient's home. There was an
apparent hoarding situation and she is very concerned about him
returning there.
The wife does note that the patient has been going to work. She
drops him off nightly around 11pm and picks him up at 7am. He
works as a ___. He does not pay finances or drive. They go
grocery shopping together and he is otherwise independent of
other ADLs.
On neuro ROS, the pt does endorse double vision when looking to
the left, but is inconsistent about this.
He denies headache, loss of vision, blurred vision, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, as above.
The pt denies recent fever or chills. No night sweats or recent
weight loss or gain. Denies cough, shortness of breath. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
HYPERTENSION
HYPERLIPIDEMIA
LUNG NODULE
PRE-DIABETES
DIVERTICULOSIS
___ ___
H/O PROSTATE CANCER
s/p radiation in ___ sees urology at ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
EXAM ON ADMISSION:
Physical Exam:
Vitals: T: 97.4 P: 101 R: 16 BP: 160/61 SaO2: 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted
in oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, ___, ___.
He
is unable to relay history. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. He has a right INO,
but otherwise full extraocular movements. Bilateral blink to
threat.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, paratonia throughout. No pronator drift
bilaterally.
Left > right arm postural tremor. No asterixis.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick. Some misses on
proprioception on the right toe only. Romberg positive with eyes
open.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: BIlateral end intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF when he closes one eye (gets
rid
of double vision). Leans backwards when sitting at edge of bed.
-Gait: Wide-based, short, small steps. Two person assist and
staggers to both sides.
EXAM ON DISCHARGE:
Mental status:
No evidence of aphasia. Speaks in complete sentences that are
detailed. Appears to be confabulating.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3 mm
III, IV, VI: INO right eye with nystagmus with adduction, does
not cross midline
Possible right eye exotropia.
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: The shoulders rise symmetrically with shrugging.
XII: Tongue protrudes in midline.
Motor:
Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
Sensory:
No deficits to light touch throughout. He appreciates
cold temperature on the sole and dorsal aspect of feet.
proprioception intact at thumb
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Coordination:
No difficulty with finger to nose and keeping a rhythmic beat in
the upper right and left extremities.
Gait:
not tested today
Pertinent Results:
___ 06:05AM BLOOD WBC-7.2 RBC-3.99* Hgb-9.7* Hct-32.8*
MCV-82 MCH-24.3* MCHC-29.6* RDW-14.6 RDWSD-43.1 Plt ___
___ 10:53AM BLOOD Neuts-75.6* Lymphs-12.5* Monos-8.9
Eos-2.0 Baso-0.5 Im ___ AbsNeut-5.04 AbsLymp-0.83*
AbsMono-0.59 AbsEos-0.13 AbsBaso-0.03
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-111* UreaN-19 Creat-1.0 Na-140
K-4.9 Cl-98 HCO3-28 AnGap-14
___ 06:05AM BLOOD ALT-17 AST-14 LD(LDH)-133 AlkPhos-77
___ 06:05AM BLOOD Albumin-3.4* Calcium-9.6 Phos-4.1 Mg-1.7
___ 08:21AM BLOOD %HbA1c-6.1* eAG-128*
___ 08:21AM BLOOD Triglyc-93 HDL-39* CHOL/HD-2.6 LDLcalc-45
___ 08:21AM BLOOD TSH-2.0
___ 10:53AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGES:
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ man with falls, dizzinesss, who can't
deviate his
right eye to the left. Rule out intracranial process.
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast. Coronal and sagittal reformations as well as bone
algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.2 cm; CTDIvol = 49.7 mGy
(Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: No prior relevant imaging is available on PACS at
the time of
this dictation.
FINDINGS:
No evidence of acute infarction,hemorrhage,edema, or mass
effect. Bilateral,
symmetric prominence of the ventricles and sulci indicates
cortical volume
loss. Bilateral cavernous internal carotid artery and V4
vertebral artery
calcifications are extensive.
No evidence of fracture. Mucosal thickening in the right
maxillary sinus is mild. A left maxillary sinus mucous
retention cyst is small. The frontal sinuses are
underpneumatized. The visualized portion of the remaining
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Bilateral scleral calcifications are normal for the
patient's age.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Cortical atrophy.
3. Minimal paranasal sinus disease.
___ CTA HEAD AND NECK
IMPRESSION:
1. Focus of low-attenuation right pons may be artifact or
infarct. Chronic
left cerebellar small infarct..
2. Advanced intracranial atheromatous plaque, with severe
narrowing of the
cavernous segment of the left internal carotid artery, an area
of occlusion
within the right V4 segment, and other areas of severe narrowing
with the
bilateral V4 segments.
3. Advanced extracranial vascular narrowing. Long segment wall
thickening and
moderate to severe narrowing bilateral vertebral arteries.
Short-segment
narrowing high cervical ICAs bilaterally, with approximately 50%
narrowing of
right internal carotid artery and 60 % narrowing of the distal
left internal
carotid artery. Findings may be from aggressive atheromatous
disease.
Component of arterial dissection, particularly on the vertebral
arteries
cannot be excluded. Please note that medium to large vessel
vasculitis could
have a similar appearance, however is considered less likely
given the
patient's age, clinically correlate.
MRI and MRA BRAIN W/O CONTRAST ___:
IMPRESSION:
1. Moderately degraded exam due to motion artifact.
2. Acute to subacute infarcts within the lower right cerebral
peduncle and
adjacent to the floor of the third ventricle to the right of
midline in the expected location of the trochlear nucleus and
medial longitudinal fasciculus.
No definite intracranial hemorrhage.
3. Occlusion of the proximal V4 segment and severe narrowing of
the left V4 segment and cavernous segment of the left internal
carotid artery. These findings are much better appreciated on
CTA from the previous day ___. No new arterial
occlusion is identified within the circle ___ or major
branches.
Brief Hospital Course:
___ man with HTN, hyperlipidemia, h/o prostate cancer,
who presented for subacute progressive dizziness and unsteady
gait, found to have acute to subacute infarcts in right medial
longitudinal fasciculus. His exam is notable for a somewhat
confabulatory, intattentive gentleman with a right INO causing
diplopia, with full stength except right IP, impaired
proprioception, and a wide based, unsteady gait with a tendency
to retropulse backwards.
Imaging notable for acute to subacute infarct in lower right
cerebral peduncle, in location of the trochlear nucleus and
medial longitudinal fasciculus. Etiology of his stroke is likely
secondary to artery-to-artery emboli based on CTA demonstrating
occlusion of the right vertebral artery and sevre stenosis of
the left vertebral artery. Another possible stroke etiology is
hypoperfusion. TTE without intracardiac source of clot
(suboptimal study). Telemetry during hospital admission was
without events of arrhythmia.
TRANSITIONAL ISSUES:
- discontinue clopidogrel in 3 months, continue Aspirin
# acute to subacute right pontine infarct, including right MLF
- Stroke risk factors: HbA1C 6.1%, LDL 45
- continue aspirin 81mg, clopidogrel 75 (started here) for total
of 3 months then transition to aspirin alone (___)
- continue atorvastatin 80 (home dose)
- BP goal: ___ to help maintain perfusion to the
posterior circulation in the setting of the severe posterior
circulation arterial atherosclerosis.
- dispo to acute rehab for further ___
# Prophylaxis and Hospital issues:
- DVT: SQ heparin/pneumoboots, re-assess per mobility with ___
in rehab
- Health Care Proxy: ___
Relationship:Wife
Phone ___
- Code Status: Full
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 - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes
4. LDL documented? (x) Yes (LDL =45)
5. Intensive statin therapy administered? (x) Yes
6. Smoking cessation counseling given? (x) Yes
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes
10. Discharged on antithrombotic therapy? (x) Yes Type: (x)
Antiplatelet
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. Simvastatin 20 mg PO QPM
2. Lisinopril 10 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Cyanocobalamin 250 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC BID
UNTIL ___ RE-ASSESSES PATIENT'S MOBILITY STATUS IN REHAV
7. Senna 8.6 mg PO BID:PRN constipation
8. Thiamine 100 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. HELD- Lisinopril 10 mg PO DAILY This medication was held.
Do not restart Lisinopril until you talk to your primary care
physician, goal SBP 110-150
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
subacute ischemic stroke
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 Mr. ___,
You were hospitalized due to symptoms of dizziness and gait
instability resulting from an ACUTE ISCHEMIC STROKE, a condition
where a blood vessel providing oxygen and nutrients to the brain
is blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
High cholesterol, High Blood Pressure,
We are changing your medications as follows:
- Cholesterol lowering medication changed to: Atorvastatin 80 mg
- START TAKING aspirin 81 mg every day for three months
- START TAKING clopidogrel 75mg every day three months
*** After three months you should discontinue the clopidogrel
and continue only on aspirin 81 mg daily.
- STOP TAKING SIMVASTATIN
- STOP TAKING LISINOPRIL 10MG until you follow-up with your
primary
care physician and with your neurologist
Please take your other medications as prescribed. Please
follow-up with Neurology and your primary care physician. If you
experience any of the symptoms below, please seek emergency
medical attention by calling Emergency Medical Services (dialing
911). In particular, since stroke can recur, please pay
attention to the sudden onset and persistence of these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10366630-DS-19 | 10,366,630 | 27,887,286 | DS | 19 | 2180-12-09 00:00:00 | 2180-12-12 13:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever and altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o with DM, CKD, confusion, altered mental status,
presenting with fever, worsening mental status, found to have
urinary retention, ___, sepsis w/ fever, large fecal ball w/
concern for sterco colitis s/p removal and t11 burst fracture
with 7 mm retropulsion.
Patient was noted to have fever, lethargy, confusion from
baseline this morning at ___ (___
___. She was transferred to ___, where she was found
to have Cr >7, hypernatremia. Obtained CT torso noncontrast
given no clear infection on CXR or UA. CT notable for likely
pneumonia, T11 fracture of unclear chronicity and an 8.0 cm
stool ball that was removed. Given 2L IVF, vanc/zosyn and
transferred to ___.
In ED initial VS: T 100.8F, HR 81 BP 112/81 RR 20 94% Nasal
Cannula. Patient unresponsive to verbal stimuli, responsive to
painful stimuli. She was straight cathd for 1L of urine.
Notable labs include Na 160, Cr 7.4, BUN 115, HC3O 13, AG 30,
lactate 2.0, WBC 25.3, Hb 11.0. UA exhibited 7 WBC, negative for
nitrite, few bacteria. Renal ultrasound negative for
hydronephrosis. Renal and ortho spine were consulted, and she
was given 250 cc LR.
On arrival to the MICU, T 99.4 F, HR 76, BP 105/45, 100% on RA,
patient opened her eyes to voice and squeezed both hands on
command, but was nonverbal and difficult to arouse.
Past Medical History:
DM II
HTN
HLD
CKD (stage 1)
Cerebrovascular disease
Major Depressive Disorder
Anxiety Disorder
Psychosis
Repeated Falls
Social History:
___
Family History:
unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================================
VITALS: T 99.4 F, HR 76, BP 105/45, 100% on RA
GENERAL: Opens eyes to voice, briefly tracks provider.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: mild crackles in LLL, decreased BS in RLL. No wheezing
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Barely palpable ___ pulses, no edema, cool extremities
NEURO: moves all extremities
DISCHARGE PHYSICAL EXAM
===================================
Vitals: 97.1, HR 78, BP 145/81, RR 16, 100 Ra
GENERAL: A&Ox2, (no oriented to date/year, ___)
LUNGS: CTAB. No wheezing
CV: RRR, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, nontender, nondistended
EXT: Barely palpable ___ pulses, no edema
NEURO: Alert, moves arms and legs to command
Pertinent Results:
===================================
ADMISSION LABS:
===================================
___ 01:30PM BLOOD ___
___ Plt ___
___ 01:30PM BLOOD ___
___ Im ___
___
___ 01:30PM BLOOD Plt ___
___ 06:16PM BLOOD ___ ___
___ 01:30PM BLOOD ___
___
___ 03:12AM BLOOD ___ LD(LDH)-261* CK(CPK)-437*
___
___ 06:16PM BLOOD ___
___ 06:16PM BLOOD ___
___ 06:26PM BLOOD ___
___ Base XS--7
___ 01:51PM BLOOD ___
___ 06:26PM BLOOD ___
===================================
DISCHARGE LABS:
===================================
___ 05:30AM BLOOD ___
___ Plt ___
___ 05:30AM BLOOD ___
___
___ 05:30AM BLOOD ___
===================================
MICROBIOLOGY:
===================================
___ urine culture - No growth
___ Blood cultures x2 - No growth
___ C diff negative
===================================
IMAGING:
===================================
___ Renal ultrasound:
No hydronephrosis. Kidneys are atrophic bilaterally with
echogenic cortices in keeping with medical renal failure.
___ CT head w/o contrast:
No acute intracranial abnormality.
___ Bilateral lower extremity ultrasounds:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
Brief Hospital Course:
Ms. ___ is a ___ with DM, CKD, dementia who was transferred
from OSH after p/w worsening confusion in the setting of urinary
retention, ___, sepsis ___ stercoral colitis iso large fecal
ball), and a T11 vertebral burst fracture. She was initially
septic in MICU briefly, but quickly improved s/p disimpaction at
OSH. Her course was complicated c/b ATN ___ sepsis. Pt's kidney
function improved, requiring electrolyte repletion and IVF. Her
course was also complicated by altered mental status, initially
with obtundation which improved with treatment of constipation,
sepsis, and ___. She continued to have fluctuating mental status
on abnormal baseline most c/w hospital delirium. She improved to
near baseline and was discharged to her long term care facility
with instructions to follow up with PCP.
=======================
ACUTE ISSUES ADDRESSED
=======================
#Fever/leukocytosis: The patient initially presented to the MICU
with a fever and leukocytosis with multiple sources of
infection. She had a CT scan showing a possible pneumonia, a UA
showing WBCs and some bacteria, as well as an 8cm stool ball
with surrounding bowel inflammation consistent with stercoral
colitis. She was started on Vancomycin and Zosyn for broad
coverage. C Diff was tested for which was negative. The
patient's fever improved with disimpaction, blood cultures
remained negative, and Vancomycin was discontinued in the ED.
She remained on zosyn until ___. Upon transfer to the floor
patient remained afebrile with stable vital signs, and required
no further antibiotics.
___ on CKD: The patient presented with a creatinine of 7.1 from
a baseline of 2.4. This was likely secondary to a ___
etiology as the patient had had poor PO intake, constipation and
appeared very dry on exam with dry mucous membranes and poor
pulses. The patient's urine sediment also revealed some brown
mud casts consistent with ATN and a preener etiology. The
patient was quite rigid on exam, and a CK was obtained to assess
for possible rnhabdomylosis leading to renal failure, however CK
was not elevated. Renal was consulted, who did not feel that
urgent dialysis was indicated. Moreover, multiple family
meetings occurred during which time it was decided that dialysis
was not within the goals of care. The patient was given IV
fluid, and her creatinine slowly improved. Upon transfer to the
floor, renal function continued to improve, and was 2.0 on day
of discharge.
#Toxic metabolic encephalopathy: The patient was found to be
initially obtunded. This was attributed to toxic metabolic
encephalopathy caused by uremia, fever, hyperNa, as well as a
component of ICU delirium. A CT head was negative on admission
to rule out an acute central process, which as negative. As the
patient's renal function, and her metabolic panel improved her
mental status also improved, though continued to remain somewhat
altered at time of discharge, though close to baseline per
family.
#AG metabolic acidosis: The patient presented with an anion gap
metabolic acidosis. This was likely secondary to uremia given
that she did not have an elevated lactate, and that she had no
ketones in her urine. Her gap improved slowly with improving
renal function. She was initially started on bicarb tabs, but
these were discontinued prior to discharge given the
normalization of her bicarb.
#Hypernatremia: The patient presented with a sodium of 160
likely due to hypovolemic hypernatremia given her AMS, poor PO
intake. With fluid resuscitation, the patient's sodium improved.
#T11 fracture of unclear chronicity: The patient had a T11
fracture found on CT in the setting of a nursing home report of
frequent falls. The fracture was likely subacute based on its
appearance on CT. ___ was consulted who recommended no
surgical intervention, but outpatient follow up for the fitting
of a brace for comfort while ambulating.
#GOC- DNR/DNI per MOLST. HCPs expressed that patient would not
want dialysis
=======================
CHRONIC ISSUES ADDRESSED
=======================
# HTN: BP meds initially held given sepsis. Restarted home
metoprolol and amlodipine prior to discharge.
# DM II- A1c 6.3% on ___, poorly compliant with medications so
glipizide 5 mg was recently stopped by PCP. She was on an
insulin sliding scale in the hospital, and should continue to
have fingersticks checked at her facility.
# HLD - Continued home atorvastatin
# Depression/anxiety/psychosis- hx of hallucinations. Her home
bupropion and venlafaxine were continued and renally dosed while
she was in the hospital. Her nighttime standing haloperidol was
stopped given encephalopathy.
# CVA - Continued home clopidogrel
=======================
TRANSITIONAL ISSUES:
=======================
MEDICATIONS:
- New Meds: Bisacodyl
- Stopped Meds: N/A
___
- Follow up: PCP
- ___ required after discharge:
-- patient should have CBC checked in one week to trend
leukocytosis
-- patient should have lytes checked in one week to evaluate Cr
and bicarb, and consideration be given to restarting bicarb
tablets (held at time of discharge given normalization of
bicarb)
OTHER ISSUES:
- patient should consider to have her blood glucose monitored,
and consideration be given to starting an insulin regimen for
glucose control
- given that patient presented with sepsis thought to be ___
stercoral colitis, bowel movements should be closely monitored,
and bowel regimen uptitrated as needed to maintain at least 1 bm
a day
- Consider dementia ___ if not done already
- Consider switching metoprolol to carvedilol for BP management
- F/u with kyphoplasty provider at the ___ clinic
(___) if pain continues to be an issue
- Communication: ___ (cousin) and
___
- Code: DNR/DNI (MOLST in chart)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. BuPROPion XL (Once Daily) 150 mg PO DAILY
4. Calcium Carbonate 600 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Acetaminophen 650 mg PO Q6H:PRN fever
9. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild
10. FoLIC Acid 1 mg PO DAILY
11. Haloperidol 0.5 mg PO Q12H:PRN psychosis/hallucination
12. Haloperidol 2 mg PO QHS
13. Metoprolol Tartrate 50 mg PO BID
14. Nicotine Patch 14 mg TD DAILY
15. Senna 17.2 mg PO QHS
16. TraZODone 25 mg PO QHS:PRN Depression
17. Venlafaxine XR 300 mg PO DAILY
18. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY Constipation
2. Acetaminophen 650 mg PO Q6H:PRN fever
3. amLODIPine 10 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. Calcium Carbonate 600 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. Haloperidol 0.5 mg PO Q12H:PRN psychosis/hallucination
12. Metoprolol Tartrate 50 mg PO BID
13. Nicotine Patch 14 mg TD DAILY
14. Senna 17.2 mg PO QHS
15. TraZODone 25 mg PO QHS:PRN Depression
16. Venlafaxine XR 300 mg PO DAILY
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute kidney injury on chronic kidney disease
# Metabolic encephalopathy
# T11 vertebral fracture
# Hypertension
# Diabetes mellitus
# Stercoral colitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You came to ___ because you were confused. You were found to
have severe constipation and some injury to your kidneys. Please
see more details listed below about what happened while you were
in the hospital and your instructions for what to do after
leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
===================================
WHAT HAPPENED AT THE HOSPITAL?
===================================
- You were found to be constipated, and stool was removed at the
outside hospital
- You were also found to have a spine fracture
- The spine surgeons saw you and did not think that you would
benefit from surgery
- Your kidney function and mental status improved considerably
- You improved and were ready to leave the hospital
==================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==================================================
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see below).
It was a pleasure to be a part of your care team, and we wish
you all the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10366725-DS-18 | 10,366,725 | 23,863,317 | DS | 18 | 2112-02-02 00:00:00 | 2112-02-02 18:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
acute liver injury (hospital transfer from ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo woman with no significant PMH who was
transferred from ___ due to progressive fatigue and
jaundice
with lab findings c/w acute liver failure and acute on chronic
anemia.
Patient endorses 2 months of worsening loss of appetite, 1 month
of progressive jaundice, and a few weeks of fatigue and nausea.
Endorses intermittent diarrhea and abdominal pain anytime she
eats or drinks. Denies fevers, black or bloody stools.
Admits to drinking ___ shots of liquor per day for about ___
years.
No history of withdrawal seizures. Her last drink was when she
went to ___ today where she was found to be in
acute liver failure. Was transferred here for further
evaluation.
She denies any recent travel but did immigrate from ___ ___
years
ago. Endorses full vaccination. Does not take any medications,
no
herbs, no allergies. Denies any abdominal or chest pain, but
endorses mild SOB iso recent cold, no pruritus. No weight loss,
IVDU, smoking. Has a boyfriend of ___ years, no concern for STI.
No family history of liver disease or anemia.
Of note, she had a previous admission to ___ for
respiratory
failure from multifocal pneumonia. During that admission, she
was
noted to have transaminitis, for which GI was consulted. They
believed the cause to be from alcohol usage, but noted a ratio
AST 93: ALT 107 at that time. Patient was also anemic with a
Hgb
of 11.6, MCV 73.6. At the time, GI work-up included: IgG 1475,
IgM 80, negative ___, negative proteinase 3, negative
myeloperoxidase Ab, anti-AMA, actin IgG antibody and liver/kid
microsomes ab all wnl. After discharge, she was lost to
GI/hepatology follow up.
In the ED, initial vitals were: 98.2, HR 107, BP 133/78, RR 18,
93% RA
Exam was notable for: jaundice, ill appearing but no acute
distress, no abd tenderness, guaiac positive brown stool.
Labs were notable for:
OSH labs:
- Na 128, K 2.9 (repleted), Cl 88, Bicarb 26, Cr 0.9, Mg 1.6
- Tbili 23.2, Dbili 19.7, AST 418, ALT 62, ALP 223
- LDH 635, Lipase 840
- Lactate 2.5
- INR 2.1
- Target cells (mod) on RBC smear
- negative Hep A, hep B surface antigen, hep B core antibody,
hep
C
ED labs:
- 8.9>7.2/20.5<168
- ALT 54, AST 344, AP 181, Lipase 206, Tbili 25.5, Dbili 19.2,
Albumin 2.3
- Na 128, Cl 87, K 3.6, Cr 0.5
- ___ 23.5, PTT 30.8, INR 2.2
- Lactate 3.3 -> 2.2
- UA with Lg Bili and few bacteria
- Serum tox negative
- HCG negative
Studies were notable for:
OSH RUQUS: Cirrhosis, trace ascites, nonvisualization of the
pancreas. No intra-or extrahepatic ductal dilation.
The patient was given:
- Pantoprazole 40 mg IV Q12 H
- Mg 2 gm IV 1x
- 1L LR bolus
- 1 unit pRBC
On arrival to the floor, patient was stable and vitals were
98.9,
BP 109 / 74, HR 127, RR 18, O2 Sat 94 on RA.
Past Medical History:
None
Social History:
___
Family History:
Father deceased
Mother has no known medical conditions
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 99.5, BP 112/76, HR 105, RR 18, O2 95% on RA
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera markedly icteric.
NECK: No JVD
CARDIAC: Regular rhythm, normal rate. ___ holosystolic murmur
best appreciated at RUSB.
LUNGS: Bibasilar crackles with diminished lung sounds at bases.
ABDOMEN: Normal bowels sounds, distended, non-tender to deep
palpation in all four quadrants. Negative fluid wave.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. Asterixis?
DISCHARGE PHYSICAL EXAM:
========================
VITALS:24 HR Data (last updated ___ @ 1120)
Temp: 99.1 (Tm 99.4), BP: 137/77 (127-144/77-86), HR: 109
(103-121), RR: 20 (___), O2 sat: 96% (93-97) RA, Wt: 188.27
lb/85.4 kg
GENERAL: NAD. Comfortably sleeping, but arousable. Alert and
interactive.
HEENT: Sclera icteric.
CARDIAC: Regular rhythm, normal rate. ___ holosystolic murmur
best appreciated at RUSB.
LUNGS: Crackles at left base, diminished breath sounds at R
base.
ABDOMEN: Soft, ND/NT.
EXTREMITIES: Warm, 1+ pitting edema bilaterally up to mid calf.
No palmar erythmea.
NEUROLOGIC: AOx4.
Pertinent Results:
ADMISSION LABS
___ 04:27PM BLOOD WBC-8.9 RBC-2.44* Hgb-7.2* Hct-20.5*
MCV-84 MCH-29.5 MCHC-35.1 RDW-27.6* RDWSD-69.2* Plt ___
___ 04:27PM BLOOD Neuts-72.0* Lymphs-13.0* Monos-12.1
Eos-0.8* Baso-0.6 NRBC-2.7* Im ___ AbsNeut-6.41*
AbsLymp-1.16* AbsMono-1.08* AbsEos-0.07 AbsBaso-0.05
___ 04:27PM BLOOD ___ PTT-30.8 ___
___ 04:27PM BLOOD Glucose-147* UreaN-8 Creat-0.5 Na-128*
K-3.6 Cl-87* HCO3-25 AnGap-16
___ 04:27PM BLOOD ALT-54* AST-344* AlkPhos-181*
TotBili-25.5* DirBili-19.2* IndBili-6.3
___ 04:27PM BLOOD Albumin-2.3* Calcium-7.5* Phos-1.4*
Mg-1.4*
HEPATOLOGY LABS WORK-UP
___ 07:05AM BLOOD %HbA1c-5.4 eAG-108
___ 08:10AM BLOOD Triglyc-242* HDL-<10*
___ 07:05AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* HAV Ab-NEG
___ 07:05AM BLOOD HBsAb-POS
___ 07:05AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 07:05AM BLOOD ___ Titer-1:40*
___ 08:10AM BLOOD IgG-1728* IgA-1033* IgM-84
___ 07:05AM BLOOD HIV Ab-NEG
___ 04:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 07:05AM BLOOD HCV Ab-NEG
___ 06:29AM BLOOD TSH-11*
___ 06:29AM BLOOD Free T4-1.0
___ 04:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
___ 07:57AM BLOOD WBC-13.1* RBC-2.54* Hgb-7.7* Hct-23.9*
MCV-94 MCH-30.3 MCHC-32.2 RDW-21.9* RDWSD-74.2* Plt ___
___ 07:57AM BLOOD ___ PTT-33.0 ___
___ 07:57AM BLOOD Glucose-254* UreaN-20 Creat-1.1 Na-140
K-4.2 Cl-106 HCO3-21* AnGap-13
___ 07:57AM BLOOD Albumin-2.9* Calcium-8.5 Phos-2.2* Mg-1.7
___ 07:57AM BLOOD ALT-36 AST-145* LD(LDH)-334* AlkPhos-159*
TotBili-16.2* DirBili-11.6* IndBili-4.6
MICROBIOLOGY
___ 4:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ Blood cultures: NGTD
___ MRSA: negative.
IMAGING
___ RUQUS:
1. Cirrhotic morphology of the liver. Patent hepatic
vasculature.
2. Limited examination of the liver for lesions due to lack of
penetration of
sound waves. An alternative imaging modality is recommended.
RECOMMENDATION(S): Recommend alternative imaging such as liver
MRI or
multiphasic liver CT for further evaluation for liver lesions.
___ CXR:
Lungs are low volume with mild pulmonary vascular congestion.
Cardiomediastinal silhouette is stable. There is subsegmental
atelectasis in
the right lung base. There is no pleural effusion. No
pneumothorax is seen
___ TTE:
LVEF 75-80%. Hyperdynamic biventricular systolic function with
high cardiac output. No clinicallysignificant
valvular disease seen. Mild pulmonary hypertension, likely
flow-related.
The patient has evidence of high output syndrome (e.g. anemia,
thyrotoxicosis, thiamine deficiency,
peripheral shunt, etc.).
___ CXR:
Ill-defined right lower lobe density and trace right pleural
effusion,
compatible with pneumonia in this patient with fever.
___ LIVER MRI
1. Cirrhosis with confluent hepatic fibrosis and sequelae of
portal
hypertension including splenomegaly, small to moderate ascites,
a recanalized
paraumbilical vein, and upper abdominal varices.
2. Moderate underlying hepatic steatosis with an estimated fat
fraction of
20.1%. Due to a technical error, iron quantification cannot be
performed.
Regardless, evaluation for iron deposition in the liver is
limited in the
setting of hepatic steatosis. No evidence of iron deposition in
the spleen,
pancreas or bone marrow to indicate hemochromatosis.
3. Bibasilar airspace consolidations concerning for multifocal
pneumonia.
4. Small right pleural effusion.
___ EGD:
Varices in distal esophagus.
Congestion, petechiae and mosaic mucosal pattern in the stomach
fundus and body compatible with portal hypertensive gastropathy.
Normal mucosa in the whole examined duodenum.
___ ___
FINDINGS:
There has been interval placement of a Dobbhoff enteric tube,
which appears to terminate in the proximal jejunum. There are
no abnormally dilated loops of large or small bowel. There is no
free intraperitoneal air. There are no unexplained soft tissue
calcifications or radiopaque foreign bodies. There are small
bilateral pleural effusions and bibasilar atelectasis. Mild
pulmonary edema is seen in the lung bases.
Brief Hospital Course:
___ immigrant from ___ with PMH significant for EtOH use
disorder presenting with jaundice, fatigue and poor PO intake x2
months, found to have labs cirrhosis, alcoholic hepatitis, and
anemia, course complicated by multifocal pneumonia and ___.
TRANSITIONAL ISSUES
===================
[] Labs on ___: CBC, CMP, LFTs, INR.
[] F/u hypophosphatemia: discharged on daily phos repletion.
[] Hepatology f/u with Dr. ___.
[] F/u alcohol abstinence.
# CODE: Full code
# CONTACT: ___ (boyfriend) - ___
ACUTE/ACTIVE ISSUES:
====================
#Acute on chronic liver injury
#Alcoholic hepatitis
Presenting with Childs Class C, MELD 28 --> ___, MDF 78 -->
53.9 (___). This is pt's first presentation of acute alcoholic
hepatitis, thought to be due to heavy alcohol use. RUQUS, liver
MR ___ due to limited RUQUS views) notable for cirrhosis,
likely NASH + EtOH cirrhosis given elevated BMI and EtOH use
disorder. HIV neg, hep panel consistent with prior HBV
immunization. HgbA1c 5.4%. HSV1+. Minimal ascites, US guided
diagnostic paracentesis on ___ without evidence of SBP and no
peritoneal fluid culture growth to date. ___ EGD with 1 cord of
grade 1 esophageal varices seen in the distal esophagus, portal
hypertensive gastropathy. Did not initiate steroids during this
hospitalization given initial multifocal pneumonia and improving
bilirubin and transaminases with conservative management. S/p
Dobhoff placement ___, home tube feeds set up prior to
discharge.
#Fever
#Multifocal PNA
Pt developed fever, cough, CXR c/f RLL PNA and liver MRI
demonstrated multifocal PNA. Fevers could also have been related
to hepatitis. For her PNA, she was started on
(vanc/ceftaz/azithromycin) for multifocal PNA then transitioned
to ceftazidime after negative MRSA swab, completed 7 day course
on ___. Afebrile since ___.
#EtOH abuse
#Risk for withdrawal
Ongoing alcohol use with ___ liquor drinks per day for ___ years -
last drink on ___ ___. Denies history of DT, seizures, ICU
admission for withdrawal, and she did not require any benzos
during hospitalization. Patient indicates willingness to cut
down. Started thiamine, MVI, folate. Counseled by Addiction
Psych about alcohol abstinence and resouces including AA, Smart
Recovery, counseling.
___
Baseline Cr 0.5-0.8, Cr rise to 1.3 on ___. Improving and
stable at 1.1. Initially suspected to be due to poor intake. S/p
albumin with downtrending Cr. Discharge Cr 1.1.
#Anemia
Presented with Hgb 7.2 (unclear baseline). Hemolysis labs neg.
Electrophoresis showed elevated reticulocyte count, Coombs was
negative. S/p 1U pRBC in ED on ___, and 1U on ___ be
anemia ___ Zieve syndrome, given the expected triad of anemia
with elevated reticulocytes, HLD + jaundice. Treatment for Zieve
syndrome is alcohol cessation and supportive care of alcoholic
hepatitis.
#Coagulopathy
Likely due to acute hepatic injury and also iso poor po intake.
S/p IV vitamin K (___).
#Prolonged QTc
___ EKG showed Qtc 473 msec.
#Hyponatremia
#Hypophosphatemia
Likely hypovolemic hyponatremia from decreased effective volume.
Also recent hx of very poor PO intake over the past ___ months.
Hypophosphatemia likely ___ poor PO. Repleted with NeutraPhos.
Na at discharge: 140.
#Cardiac murmur
Pt w/ systolic murmur on exam. TTE shows hyperdynamic
biventricular systolic function with high CO, no clinically
significant valvular disease and mild pHTN. High output syndrome
possibly secondary to anemia, though also seen in cirrhosis.
Medications on Admission:
None
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tab-cap by mouth once a day Disp #*30 Tablet
Refills:*0
3. Neutra-Phos 1 PKT PO DAILY
RX *potassium, sodium phosphates 280 mg-160 mg-250 mg 1 packet
by mouth once a day Disp #*30 Packet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
5.Outpatient Lab Work
ICD-9 571.1
Draw CBC, CMP, LFTs, INR and PTT
Please fax to Dr. ___ at ___
and Dr. ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
=======
Acute Alcoholic Liver Injury
Acute on Chronic Anemia
Secondary
========
EtOH use disorder
Hypophosphatemia
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 had not been eating very much for 2 months. You also had
become increasingly tired and fatigued, and your eyes and skin
were yellow.
WHAT HAPPENED TO ME WHILE I WAS IN THE HOSPITAL?
- You were found to have a condition called alcohol hepatitis
(liver inflammation due to alcohol consumption).
- We also found that your red blood cell count was low. We think
this is related to your liver disease. You received a blood
transfusion. We hope that this will improve as your liver gets
better.
- Your liver was monitored with daily blood lab tests.
- You had a special ultrasound picture of your heart
(echocardiogram) because you were noted to have a new heart
murmur that could be caused by heart valve problems. The
echocardiogram was normal.
- You had a procedure called an endoscopy to look at the inside
of your esophagus and stomach. We wanted to see if there were
any esophageal varices, which are veins that become bigger
because of your liver disease and can easily bleed. You have
mild varices in your esophagus that are not bleeding. This
should resolve after your liver gets better.
- You had a feeding tube placed. This is because the best
treatment for your liver disease is trying to increase the
amount of food you get each day (4000 calories). This feeding
tube will help you reach that goal.
WHAT SHOULD I DO WHEN I LEAVE?
- You must stop drinking alcohol so that your liver can improve.
- Please get your labs checked in 1 week (on ___.
- Your PCP's office in ___ would not make an appointment
until your insurance has been approved. We made an appointment
with a new PCP at ___, and are working on a follow up
appointment with the Liver doctor (___). You will have to
pay for these appointments out of pocket if your insurance has
not been approved.
- Continue the tube feeds until you see the Liver doctor: please
use one of the following schedules (whichever is more
convenient):
1. Jevity 1.5 @90mL/hr x 14 hrs per day
2. Jevity 1.5 @75 mL/hr x 16 hours per day
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10366977-DS-5 | 10,366,977 | 27,763,398 | DS | 5 | 2158-05-15 00:00:00 | 2158-05-15 13:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall onto his face
Major Surgical or Invasive Procedure:
- Open reduction internal fixation of the mandibular symphysis
fracture
- Closed reduction with maxilla-mandibular fixation of the
bilateral
condylar head fracture
History of Present Illness:
Mr. ___ is a ___ year old male with history of TBI and VP
shunt in ___ presenting now after a fall. Patient reports that
he was walking his dog when the dog starting chasing another
dog, pulling the patient and causing him to fall onto his face.
No LOC, reports significant jaw pain since. Taken to OSH where
imaging found a mandibular fracture and a left mastoid fracture.
He has also had bleeding out of his left ear that has since
slowed. Denies diplopia, dizziness, nausea, vomiting, or feeling
unsteady. Also denies use of anticoagulants.
Past Medical History:
TBI following skiing accident in ___
Past Surgical History: Right craniotomy ___, VP shunt ___,
tracheostomy ___, right femur ORIF right femur
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION (___)
Vital Signs:
Temp: 98.1 HR: 77 BP: 124/81 RR: 16 SatO2: 99% RA
GEN: ___ x 3, in mild discomfort
HEENT: No scleral icterus, mucus membranes moist, CN ___
intact, tongue swollen, small 2cm laceration overnight philtum,
hard collar in place, 3.5cm chin laceration, no cervical TTP
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: ___ deferred
Back: no step-offs, TTP , or abrasions
Ext: No ___ edema, ___ warm and well perfused
PHYSICAL EXAM ON DISCHARGE (___)
Vital Signs:
Temp: 98.3 BP: 129/82 HR: 89 RR: 18 O2 Sat: 96% on RA
Constitutional: patient lying in bed comfortably, NAD, well
developed and well nourished, AAO x 3
HEENT: right cranial deformity noted lateral and superior to
right orbit, right ear normal, left ear has dry blood in it,
EOMI and PERRL with no visual impairment noted, no evidence of
septal hematoma, epistaxis or nasal deformities noted
EOE: Abrasion of the upper lip and chin noted, Chin laceration
re-sutured after surgery as it was the site of access and
steri-strips placed over. site is hemostatic and intact. TMJ
exam limited by ___
IOE: Arch bars with wires in place. Elastics added last night
for additional stability. Occlusion intact with mandible midline
to the left 3mm. Bilateral posterior occlusion noted. No
evidence of hematoma or acute infection noted. FOM could not be
examined. Sensitivity to palpation of the upper lip
Neck: supple with FROM
CV: RRR
Resp: Normal effort breathing with equal chest rise
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: DRE deferred
Back: no step-offs, TTP , or abrasions
Extremities: No lower extremity edema noted, no weakness noted,
warm to touch and well perfused x 4
Pertinent Results:
LAB TESTS
___ 06:22AM BLOOD WBC-4.6# RBC-4.81 Hgb-14.8 Hct-44.3
MCV-92 MCH-30.8 MCHC-33.4 RDW-12.5 RDWSD-42.1 Plt ___
___ 09:58PM BLOOD WBC-12.6* RBC-4.39* Hgb-13.7 Hct-40.9
MCV-93 MCH-31.2 MCHC-33.5 RDW-12.5 RDWSD-43.0 Plt ___
___ 09:58PM BLOOD Neuts-81.9* Lymphs-12.7* Monos-4.0*
Eos-0.6* Baso-0.4 Im ___ AbsNeut-10.32* AbsLymp-1.60
AbsMono-0.51 AbsEos-0.07 AbsBaso-0.05
___ 06:22AM BLOOD Plt ___
___ 09:58PM BLOOD ___ PTT-28.3 ___
___ 06:22AM BLOOD Glucose-84 UreaN-6 Creat-0.7 Na-138 K-3.5
Cl-100 HCO3-29 AnGap-13
___ 09:58PM BLOOD Glucose-106* UreaN-10 Creat-0.8 Na-139
K-4.4 Cl-105 HCO3-26 AnGap-12
___ 06:22AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.2
IMAGING
CT HEAD (___)
IMPRESSION:
1. Bilateral comminuted fractures of the mandibular condyles.
2. Left mastoid air cell fracture with tissue emphysema
3. Fracture of the body of the mandible just to the right of
midline with mild distraction.
4. Unchanged air in the left cavernous sinus and in the sella
turcica.
CT ORBITS, SELLA and IAC (___)
IMPRESSION:
1. Acute fracture of the tympanic portion of the left temporal
bone, with
extension into the external auditory canal.
2. No temporal bone fracture on the right.
3. Comminuted fractures of the mandibular condyles bilaterally,
with complete dislocation from the mandibular fossa.
4. There is widening of the incudomalleolar joint on the left.
Recommend
clinical correlation with conductive hearing loss.
CULTURES
URINE CULTURE: PENDING
BLOOD CULTURE: PENDING
Brief Hospital Course:
The patient presented to the Emergency Department on ___.
Upon arrival to ED the patient was evaluated by ED staff and a
second read of the head CT he had was done and showed bilateral
comminuted fractures of the mandibular condyles, left mastoid
air cell fracture with tissue emphysema, fracture of the body of
the mandible just to the right of midline with mild distraction
and unchanged air in the left cavernous sinus and in the sella
turcica so OMFS was consulted for surgical repair. ___
requested a CT of the orbit, sella and iac that showed acute
fracture of the tympanic portion of the left temporal bone, with
extension into the external auditory canal, no temporal bone
fracture on the right, comminuted fractures of the mandibular
condyles bilaterally, with complete dislocation from the
mandibular fossa, widening of the incudomalleolar joint on the
left. Recommend clinical correlation with conductive hearing
loss. Given findings, the patient was admitted for surgery. The
patient was taken to the operating room for open reduction
internal fixation of the mandibular symphysis fracture and
closed reduction with maxilla-mandibular fixation of the
bilateral condylar head fracture. There were no adverse events
in the operating room; please see the operative note for
details. Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a Tylenol and
IV dilaudid for breakthrough pain and then transitioned to oral
Tylenol and oxycodone once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO for the procedure.
After surgery, the diet was advanced sequentially to a soft
regular diet, which was well tolerated. Patient's intake and
output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, 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.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen (Liquid) 1000 mg PO Q8H
RX *acetaminophen 500 mg/5 mL 10 ml by mouth every eight (8)
hours Refills:*0
2. Cephalexin 500 mg PO Q8H
RX *cephalexin 250 mg/5 mL 10 ml by mouth every eight (8) hours
Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % Mouth wash Two times per day
Refills:*0
4. Ciprofloxacin 0.3% Ophth Soln 5 DROP LEFT EAR BID
RX *ciprofloxacin HCl 0.2 % 5 drops in the ear every twelve (12)
hours Disp #*1 Bottle Refills:*0
5. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg/5 mL 5 ml by mouth every four (4) hours Disp
#*210 Milliliter Refills:*0
6. LamoTRIgine 200 mg PO BID
7. Propranolol 60 mg PO DAILY
8. RisperiDONE 1 mg PO QHS
9. TraZODone 300 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior mandible fracture
Bilateral condylar fractures
Altered occlusion
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 ___ and
underwent surgery of your mandible. You are recovering well and
are now ready for discharge. Please follow the instructions
below to continue your recovery:
Peridex mouth rinse two times per day and meticulous oral
hygiene using baby toothbrush and gentle pressure.
You may have your jaw wired shut for many reasons, including a
broken jaw or jaw surgery. The wires help hold your jaw in place
while you heal.
HOW TO CARE FOR YOUR WIRED JAW
Keep your mouth clean.
Rinse your mouth with warm salt water after eating or drinking
anything. To make salt water, mix ½ tsp of salt in one cup of
warm water.
Brush the front of your teeth with a child-sized, soft
toothbrush after you eat.
If you need to vomit, bend over and open your lips. Always
rinse out your mouth and brush your teeth after vomiting.
Take care of swelling.
Follow your health care provider's instructions about how to
help the swelling go down.
Sit up or prop yourself up with pillows behind your back to
help with swelling.
Take care of pain and discomfort.
Do not drive or operate heavy machinery while taking pain
medicine.
Use petroleum jelly on your lips to keep them from drying and
cracking.
Cover the wire with dental wax if any wires are poking into
your lips or gums.
Follow your health care provider's instructions.
Follow your health care provider's directions about what you
can and cannot eat --> Full liquid diet for next 2 weeks until
follow up when new recommendations can be made. Blended recipes
given to patient for home meal ideas
Take medicines only as directed by your health care provider.
Keep all follow-up visits as told by your health care
provider.
This is important.
Only cut wires in an emergency.
Keep wire cutters with you at all times. Use them only in an
emergency to cut the wires that hold your jaw together.
Do not cut the wires:
Even if you are tired of having your jaw wired.
Even if you are hungry.
Even if you need to vomit.
You may cut the wires that hold your jaw together only:
If you have trouble breathing.
If you are choking.
Do not cut the wires that connect to your back teeth (arch
wires). If you must cut the wires in an emergency, cut straight
across the wires that hold your mouth closed. These are the
wires
that are connected to the arch wires.
SEEK MEDICAL CARE IF:
You have a fever.
You feel nauseous or you vomit.
You feel that one or more wires have broken.
You have fluid, blood, or pus coming from your mouth or
incisions.
You are dizzy.
SEEK IMMEDIATE MEDICAL CARE IF:
You had to cut the wires that hold your jaw together.
Your pain is severe and is not helped with medicine.
You faint.
CSF leak precautions: no straining, no nose blowing, sneeze
with open mouth, no drinking from a straw
Avoid getting the left ear canal wet. Place a cotton ball in
the conchal bowl covered with Vaseline when the patient showers.
Followup Instructions:
___
|
10366982-DS-12 | 10,366,982 | 26,452,453 | DS | 12 | 2175-12-03 00:00:00 | 2175-12-03 21:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin
Attending: ___.
Chief Complaint:
Afib w/ RVR
Major Surgical or Invasive Procedure:
TEE Cardioversion ___
History of Present Illness:
Ms. ___ is a ___ woman with PMHx of endometrial
adenocarcinoma, HLD, HTN, LBP, obesity, osteoarthritis, stress
incontinence who was referred from her PCP's office for atrial
fibrillation with RVR.
Her symptoms of dyspnea and palpitations began on the ___ of
this
month. Went to three different doctors, an oncologist, a
dermatologist, and a vascular surgeon and was noted to have high
HRs and low BPs on all three visits. They did not refer her to
the hospital during those clinic appointments and advised that
she see her PCP. She went to her primary care clinic on ___
who then referred her to ___ ED for afib with RVR.
Dyspnea and palpitations would come and go but would mainly be
present on exertion and/or positional changes. Denies chest
pain,
productive cough, syncope, presyncope, vision changes, or
headaches, or pain in the arms, neck or into the back.
Has had some urinary burning for about a month, on and off. No
blood in urine. No worsening burning sensation. Does have some
urge/stress incontinence but at her baseline.
Had a bad cold in the past month and took prednisone for it. Has
since recovered from that. Denies new cough. No sore throat
currently. No nasal drainage. Also denies the following: skin
rashes, stomach pain, nausea, vomiting, diarrhea, constipation.
Per PCP note, had ___ similar episode of atrial fibrillation in
___, was treated at ___ with IV medications(record not
received). Since then, patient has been on metoprolol succinate
100mg and aspirin 325mg qd as she refused anticoagulation.
Cardiologist is Dr. ___ recommended anticoagulation with a
DOAC back in ___. No known CAD.
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
COLONIC POLYPS
OBESITY
OSTEOARTHRITIS
OTALGIA
PERIPHERAL EDEMA
PLANTAR FASCIITIS
STRESS INCONTINENCE
DIVERTICULOSIS
LOW BACK PAIN
SEBORRHEIC DERMATITIS
LUMBOSACRAL POLYRADICULOPATHIES
LEG PAIN
FECAL INCONTINENCE
ENDOMETRIAL ADENOCARCINOMA, ENDOMETRIOID TYPE, FIGO GRADE 3.
OBGYN
H/O HEPATITIS B
Social History:
___
Family History:
Mother - hematologic cancer
Father - strokes, ___ disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
T98.3 HR 119 BP 97/60 RR18 Sat94% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVP not seen at 90 degrees or at 45
degrees
HEART: irregularly irregular tachycardia, no murmurs, gallops,
or
rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, has vertical incision with incisional hernia
that is reducible, not erythematous
EXTREMITIES: no cyanosis, clubbing. trace pitting edema at
patella with increased edema distally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Exam:
===================
24 HR Data (last updated ___ @ 334)
Temp: 97.7 (Tm 98.3), BP: 107/75 - 131/70 (123-150/70-94),
HR: 74 (73-84), RR: 20 (___), O2 sat: 98% (94-98), O2
delivery:
ra, Wt: 224.21 lb/101.7 kg
I/Os= ___
Weight: 101.7<-101.1kg
Admission: 113.4kg
GENERAL: Lying in bed comfortably, NAD, AOx3
HEENT:MMM
CV: RRR, difficult to assess JVP
RESP: CTAB, no wheezing, normal WOB
MSK: trace ___ edema
NEURO: Moving all extremities
Pertinent Results:
Admission labs:
=====================
___ 12:30PM BLOOD WBC-6.8 RBC-4.40 Hgb-13.0 Hct-39.8 MCV-91
MCH-29.5 MCHC-32.7 RDW-14.6 RDWSD-48.2* Plt ___
___ 01:23PM BLOOD ___ PTT-28.4 ___
___ 12:30PM BLOOD Glucose-82 UreaN-21* Creat-0.7 Na-142
K-3.9 Cl-103 HCO3-26 AnGap-13
___ 12:30PM BLOOD ALT-33 AST-27 AlkPhos-48 TotBili-0.8
___ 12:30PM BLOOD proBNP-___*
___ 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
REPORTS
====================
___ CXR:
Low lung volumes with probable bibasilar atelectasis.
Infection, particularly within the left lung base, cannot be
completely excluded in the correct clinical setting.
___ TEE
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. The left atrial appendage
ejection velocity is normal. No spontaneous echo contrast or
thrombus is seen in the body of the right atrium/right atrial
appendage. There is no evidence for an atrial septal defect by
2D/color Doppler. There are no aortic arch atheroma with simple
atheroma in the descending aorta. The aortic valve leaflets (3)
are mildly thickened. No masses or vegetations are seen on the
aortic valve. No abscess is seen. There is trace aortic
regurgitation. The mitral leaflets appear structurally normal
with no mitral valve prolapse. No masses or vegetations are seen
on the mitral valve. No abscess is seen. There is physiologic
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. No abscess is seen. There is mild [1+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal.
___ TTE:
The left atrial volume index is normal. No left atrial
mass/thrombus seen ___ excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is ___ mmHg.
Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 50%). Right
ventricular chamber size is normal with borderline normal free
wall function. 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 estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved regional and low normal global
biventricular systolic function. No valvular pathology or
pathologic valvular flow identified.
Compared with the prior study (images reviewed) of ___,
left ventricular systolic function is now less vigorous/low
normal. The heart rate is also now slower. Is the patient now on
a negative inotrope/beta blocker?
Discharge labs:
=====================
___ 06:00AM BLOOD Glucose-103* UreaN-24* Creat-0.8 Na-144
K-4.2 Cl-100 HCO3-29 AnGap-15
___ 06:00AM BLOOD Mg-2.1
___ 08:10AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.2
Brief Hospital Course:
Patient Summary:
=======================
Ms. ___ is a ___ woman with PMHx of endometrial
adenocarcinoma, HLD, HTN, LBP, obesity, osteoarthritis, stress
incontinence who was referred from her PCP's office for atrial
fibrillation with RVR. She was found to be volume overloaded
with ~15lb weight gain over the past month and diagnosed with
Acute HFpEF. She underwent TEE cardioversion ___ and started on
apixiban. She was diuresed to dry weight of 224lb and discharged
on Furosemide 40mg daily
-CORONARIES: unknown
-PUMP: LVEF >55% in ___, TTE pending
-RHYTHM: afib s/p cardioversion to NSR
ACUTE ISSUES:
==============
#Proxysmal Atrial fibrillation
Per notes, patient initially diagnosed at ___ in ___, and
cardioverted to NSR without intervention. She had previously
been on Metop succinate 100mg, as well as aspirin 325mg given
that she did not want anticoagulation. Based on her history on
presentation, she has been in atrial fibrillation with elevated
HRs for about a week PTA. TSH wnl. She became hypotensive with
diltiazem, and metoprolol was uptitrated to Succinate 200mg
daily. Rates remained uncontrolled to 130s-150s, and thus she
underwent TEE cardivoersion on ___. CHADS-VASC 4. She was
started on Apixiban 5mg BID on discharge and ASA was
discontinued due to initiation of anticoagulation and lack of
coronary disease.
#Acute HFpEF (EF 50%)
No history of heart failure, but has had 15lb weight gain over
the past month PTA with elevated BNP 1499, ___ edema, mild
crackles at the bases, consistent with new onset heart failure
and volume overload. TTE with EF 50% with low normal global
biventricular systolic function. Heart failure likely worsened
by afib w/ RVR. Diuresed well with IV Lasix ___ BID boluses.
Discharge on PO Lasix 40mg with plan for close follow up and
daily weights by patient. ___ consider decreasing to PRN dosing
if scheduled dosing appears to be too aggressive on follow up
labs.
Discharge weight: 224
Discharge Cr: 0.8
Discharge regimen: Po Lasix 40mg
# Asymptomatic bacteriuria:
Urine culture with pan-sensitive E.coli. Previously with dysuria
but no current urinary symptoms. Given no pyuria, fever, or
systemic leukocytosis or left shift and asymptomatic, was not
treated.
CHRONIC ISSUES:
================
#Hypertension: Discontinued triamterene-HCTZ in lieu of loop
diuretic
#Lumbosacral plexopathy: history of grade 3 endometrioid
adenocarcinoma of the uterus status post total abdominal
hysterectomy, bilateral salpingo-oophorectomy and periaortic
lymphadenectomy, adjuvant radiation therapy, on pentoxifylline
and vitamin E.
#Osteoarthritis: Discontinued home Naproxen 500mg BID due to CV
risk factors. Recommended use of Tylenol for pain.
#Seborrheic dermatitis: home ketoconazole
Transitional Issues:
======================
New medication: Lasix 40mg daily, Apixiban 5mg BID
Discontinued meds: Naproxen, aspirin, triamterene-HCTZ
Changed: Metop succinate incr to 200mg
[] Follow up in 1 week with PCP for BMP and evaluation of volume
status on Lasix 40mg daily
[] Consider starting statins for primary prevention
[] Can restart aspirin as outpatient if stable on
anticoagulation, would be for primary prevention
Discharge weight: 224
Discharge Cr: 0.8
Discharge regimen: Po Lasix 40mg daily
#CODE: Full (confirmed)
#CONTACT:
Name of health care proxy: ___
Relationship: daughter
Cell phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. calcium carbonate-vitamin D3 600 mg calcium- 200 unit oral
BID
3. Ketoconazole Shampoo 1 Appl TP ASDIR
4. Ketoconazole 2% 1 Appl TP BID:PRN skin rash on face
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Naproxen 500 mg PO Q12H
8. omega ___ oil ___ oil)
100-160-1,000 mg oral TID
9. Pentoxifylline 400 mg PO TID
10. Simethicone 40-80 mg PO QID:PRN gas, adominal pain
11. Triamterene-HCTZ (37.5/25) 0.5 TABLET PO DAILY
12. Vitamin E 1000 UNIT PO DAILY
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. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Metoprolol Succinate XL 200 mg PO DAILY
RX *metoprolol succinate 200 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
4. calcium carbonate-vitamin D3 600 mg calcium- 200 unit oral
BID
5. Ketoconazole 2% 1 Appl TP BID:PRN skin rash on face
6. Ketoconazole Shampoo 1 Appl TP ASDIR
7. Multivitamins 1 TAB PO DAILY
8. omega ___ oil ___ oil)
100-160-1,000 mg oral TID
9. Pentoxifylline 400 mg PO TID
10. Simethicone 40-80 mg PO QID:PRN gas, adominal pain
11. Vitamin E 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Atrial fibrillation with rapid ventricular rate
Acute heart failure with preserved ejection fraction
Secondary diagnosis:
Asymptomtic bacteriuria
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:
Dear Ms. ___,
You were admitted to the hospital because you were found to be
in an irregular heart rhythm called atrial fibrillation, with a
fast pulse. You were also found to have significant weight gain,
and found to be in congestive heart failure. Please see below
for more information on your hospitalization. It was a pleasure
participating in your care!
We wish you the ___!
- Your ___ Healthcare Team
What happened while you were in the hospital?
- Your medications were optimized to help lower your heart rate.
- You were started on Apixiban to thin your blood as you are at
risk for stroke with the rhythm of atrial fibrillation
- You had a procedure done called Cardioversion to put your
heart back into a normal rhythm
- You received a medication in your IV (Lasix) to help take
fluid off your body, which was switched to a pill for you to
take at home
- You were improved significantly and were ready to leave the
hospital.
What should you do after leaving the hospital?
- Please take your medications as listed in the discharge papers
and follow up at the listed appointments.
- It is important that you take the Apixiban regularly even
though your heart rate is back in normal rhythm.
- As you are now on another blood thinner, we have stopped your
aspirin
- Your weight at discharge is 224 pounds. Please weigh yourself
today at home and use this as your new baseline weight
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs in a day, or 5
lbs in a week.
- We have stopped your Naproxen medication as it can have
adverse effects for the health of your heart. You can use
Tylenol as needed for pain
Followup Instructions:
___
|
10366982-DS-13 | 10,366,982 | 25,258,195 | DS | 13 | 2176-04-02 00:00:00 | 2176-04-05 05:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
gabapentin
Attending: ___.
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
Electrical cardioversion ___
History of Present Illness:
___ y/o F with PMH of AFib s/p cardioversion in ___ and again in
___, on apixiban, who presented to her primary care
doctor with ___, and sent to the ED due to AFib with
RVR.
In the ED, the patient states she developed dysuria, increased
frequency and abnormal odor 3 days ago, but that these symptoms
have since resolved. In addition, yesterday she noticed onset of
lightheadedness with positional changes and palpitations
consistent with prior episodes of afib in the past. These
symptoms are worse as of this morning, prompting her to go to
her
PCP. Of note, she was cardioverted in ___, and seems to
have
been in sinus rhythm since this time.
She denies fever, chills, headache, blurry vision, CP, SOB,
abdominal pain, constipation/diarrhea.
Initial vital signs were notable for:
97.9 125 117/69 18 96% RA
Exam notable for: Irregular rate/rhythm, trace b/l edema
Labs were notable for: Normal CBC, Chem-7, LFTs, and completely
unremarkable urinalysis
Studies performed include:
# CXR: Streaky bibasilar opacities, potentially atelectasis,
though infection isdifficult to exclude in the correct clinical
setting.
Patient was given:
___ 17:58IVFNS ( 1000 mL ordered)
Consults: None
Vitals on transfer:
97.4___ / ___ 100
Upon arrival to the floor, the patient has no acute complaints.
States that if she stands up, she feels a little
lightheaded/dizzy, but otherwise is feeling okay. Denies chest
pain, palpitations, shortness of breath.
==================
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
- AFIb, s/p successful cardioversion in ___ and ___, on
apixaban
- HFpEF
- HTN
- HLD
- OA, s/p b/l TKA
- Hx of endometrial adenocarcinoma, s/p TAH/BSO
- Diverticulosis
- Obesity
- Lumbosacral plexopathy
- Fecal/Stress Incontinence, s/p midurethral sling
- Seborrheic Derm.
Social History:
___
Family History:
Mother - hematologic cancer
Father - strokes, ___ disease
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.4, BP 90 / 60, HR 78, SpO2 100/RA
GENERAL: Alert, In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No JVD.
CARDIAC: Irregular rhythm, tachycardic. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Trace bibasilar rales
BACK: NNo CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Trace edema, worse in the RLE
SKIN: Warm. No rash.
NEUROLOGIC: AOx3.
========================
DISCHARGE PHYSICAL EXAM:
========================
Vitals:
24 HR Data (last updated ___ @ 1540)
Temp: 98.2 (Tm 98.2), BP: 96/64 (88-110/53-72), HR: 69 (67-105),
RR: 20 (___), O2 sat: 97% (96-97), O2 delivery: RA, Wt: 220.46
lb/100 kg
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: RRR. normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
lower extremity edema b/l.
Skin: WWP, no rashes, lesions, excoriations
Neuro: moving all four extremities with purpose, face
symmetrical
Pertinent Results:
ADMISSION LABS:
___ 04:15PM BLOOD WBC-6.6 RBC-4.74 Hgb-14.4 Hct-42.3 MCV-89
MCH-30.4 MCHC-34.0 RDW-14.4 RDWSD-46.7* Plt ___
___ 04:15PM BLOOD Neuts-71.5* Lymphs-17.5* Monos-8.5
Eos-1.7 Baso-0.5 Im ___ AbsNeut-4.70 AbsLymp-1.15*
AbsMono-0.56 AbsEos-0.11 AbsBaso-0.03
___ 04:15PM BLOOD Plt ___
___ 04:15PM BLOOD Glucose-94 UreaN-18 Creat-0.8 Na-145
K-3.7 Cl-104 HCO3-28 AnGap-13
___ 04:15PM BLOOD ALT-14 AST-19 AlkPhos-49 TotBili-1.3
___ 04:15PM BLOOD Lipase-23
___ 04:15PM BLOOD Albumin-3.5
___ 04:32PM BLOOD Lactate-1.8
PERTINENT INTERMITTENT LABS:
___ 05:40AM BLOOD TSH-2.9
IMAGING:
CXR ___:
Streaky bibasilar opacities, potentially atelectasis, though
infection is
difficult to exclude in the correct clinical setting.
MICRBIOLOGY:
___ 1:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood cultures ___: pending
DISCHARGE LABS:
___ 05:02AM BLOOD WBC-5.5 RBC-4.27 Hgb-13.2 Hct-38.3 MCV-90
MCH-30.9 MCHC-34.5 RDW-14.6 RDWSD-46.5* Plt ___
___ 05:02AM BLOOD Plt ___
___ 05:02AM BLOOD Glucose-100 UreaN-17 Creat-0.9 Na-144
K-4.0 Cl-107 HCO3-27 AnGap-10
___ 05:02AM BLOOD ALT-14 AST-19 AlkPhos-48 TotBili-1.0
___ 05:02AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year old woman with atrial fibrillation on
apixaban s/p cardioversion in ___ and ___, as well chronic
diastolic heart failure who presented with atrial fibrillation
in rapid ventricular rate.
#Afib with RVR:
Patient presented to PCP with palpitations and lightheadedness,
found to be in afib with RVR. Upon admission rates were ranging
120s-150s, with blood pressures in systolics high ___. There was
no clear trigger for the acute onset: no signs of heart failure
or dehydration, no electrolyte abnormalities, no infection.
Cardiology was consulted, and recommended starting her on
amiodarone and cardioversion. She underwent cardioversion on
___ and successfully converted to sinus rhythm. Per cardiology,
she will be on amiodarone 400 mg BID until ___ and then 200
mg daily. She will also decrease home metoprolol from 200 mg
daily to 150 mg daily. Apixaban was continued throughout
hospitalization.
*Pre-amiodarone LFTs were normal, as is TSH.
#Chronic diastolic heart failure:
Patient with no signs of decompensation on exam or labs. Home
Lasix was continued.
#Dysuria, resolved
Patient shared that few days prior to admission had dysuria;
this symptom resolved prior to admission and afib with RVR.
Urinalysis and culture were negative for infection.
#Sacral plexopathy
Patient uses a walker and brace at baseline. She was continued
on home Pentoxifylline.
TRANSITIONAL ISSUES:
#Discharge weight: 220 lbs
#Medication changes:
NEW MEDS:
- Amiodarone 400 mg BID until ___ and then 200 mg daily
DECREASED MEDS:
- Metoprolol succinate from 200 mg daily to 150 mg daily
#Contact: ___, daughter/HCP, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Pentoxifylline 400 mg PO TID
2. Metoprolol Succinate XL 200 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Apixaban 5 mg PO BID
5. Vitamin E 1000 UNIT PO DAILY
6. Ketoconazole 2% 1 Appl TP TID
7. Simethicone 125 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
Discharge Medications:
1. Amiodarone 400 mg PO BID
Amiodarone 400 mg BID until ___ and then 200 mg daily
RX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp
#*100 Tablet Refills:*0
2. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1.5 tablet(s) by mouth daily
Disp #*45 Tablet Refills:*0
3. Apixaban 5 mg PO BID
4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral DAILY
5. Furosemide 40 mg PO DAILY
6. Ketoconazole 2% 1 Appl TP TID
7. Multivitamins 1 TAB PO DAILY
8. Pentoxifylline 400 mg PO TID
9. Simethicone 125 mg PO DAILY
10. Vitamin E 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular rate
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 during your hospitalization at
the ___.
WHY WAS I ADMITTED?
- You were having lightheadedness and palpitations, and found to
be in atrial fibrillation with rapid rates.
WHAT WAS DONE FOR ME IN THE HOSPITAL?
- You were seen by the cardiology team.
- You were taking for a cardioversion, as you had in the past.
This was successful and put your heart back in regular rhythm.
- You were also started on a medication called amiodarone. This
is also to keep your heart in regular rhythm.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
- Please take metoprolol succinate 150 mg daily.
- Please take amiodarone 400 mg twice a day for a total of two
weeks: ___ (yesterday) through ___. Then on ___ please start
200 mg once a day.
- Please follow up with your primary care doctor and your
cardiologist.
We wish you the ___!
Warmly,
Your ___ Care Team
Followup Instructions:
___
|
10367587-DS-11 | 10,367,587 | 24,738,888 | DS | 11 | 2110-04-15 00:00:00 | 2110-04-17 10:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___.
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male with PMHx seizure, EtOH use disorder, who
presents with recurrent seizure iso Keppra nonadherence (reports
30% compliance) and was found to have transaminitis and
hepatosteatosis on US. He is aware that alcohol is likely
harming his liver and is motivated to stop drinking. He will be
discharged on naltrexone to help with alcohol cravings.
#Seizure
Mr ___ likely had a breakthrough seizure in the setting of
nonadherence with his Keppra. He reports that he takes it about
30% of the time. Pt reportedly states he has been in the ED
several times this past year for seizure suggesting his epilepsy
is not controlled. Alcohol withdrawal seizure is on the
differential but the patient had recently drank when he had his
seizure and still had a nonzero serum alcohol on presentation.
He was given a Keppra load and then started back on his home
dose.
#Transaminitis
#Steatosis
Mr ___ presented with a transaminitis of ALT=135, AST=178,
Alkphos=145.
No evidence of synthetic dysfunction. ___ DF of 0.5.
Alcoholic hepatitis was though less likely. Suspected
transamintis ___ etoh use, but AST/ALT pattern not in classic
2:1 ratio. The Tylenol level was negative. His hepatitis B and C
serologies were normal including HBV immune. There was no
evidence of hepatic encephalopathy, ascites, asterixis. He
underwent a RUQUS showing steatosis vs cirrhosis vs liver
fibrosis. His LFTs have been improving throughout his admission.
He will need a fibroscan and LFT monitoring going forward.
#Alcohol Use Disorder
He reports that he drinks ___ beers per day. Last drink on ___
at 7pm. No evidence of withdrawal during observation until ___
___. No lorazepam was needed. He is motivated to stop drinking
alcohol and understands that it is harming his liver. He wants
to try naltrexone to reduce alcohol cravings and will leave with
a 30 day supply to be followed up by his PCP.
#Macrocytic anemia
He presented with a mild anemia to Hgb=12.6 MCV 101. It is
likely ___ etoh use. He will be discharged on a multivitamin,
thiamine, and folate.
#Thrombocytopenia
Platelets 87 on presentation increasing to 104. Suspect this is
in the setting of EtOH use disorder vs liver disease.
#Insomnia
Continued home trazodone.
TRANSITIONAL ISSUES:
==================
[] Steatosis vs fibrosis vs cirrhosis on US. Radiological
evidence of fatty liver does not exclude cirrhosis or
significant liver fibrosis which could be further evaluated by
___. This can be requested via the ___
(FibroScan) or the Radiology Department with either MR
___ or US ___, in conjunction with a
GI/Hepatology consultation" *
[] consider initiation of statin for cholesterol 265,
triglycerides 217
[] Started Naltrexone for prevention of alcohol cravings.
Request PCP assistance in monitoring alcohol cessation efforts
and continuing this med.
#CODE: full code
Name of health care proxy: ___
Relationship: fiancee
Phone number: ___
Past Medical History:
Alcohol Use Disorder
Seizure disorder
Hemorrhoids
Social History:
___
Family History:
mother and uncle had seizures. Cirrhosis in aunt, who had
alcohol use disorder.
CAD/DM in both mother and father
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 98.9 84 149/97 16 95% RA
GENERAL: appears comfortable in no acute distress. Conversant,
cooperative.
HEENT: NCAT. PERRL. EOMI. Injected sclera, nonicteric. Clear OP
NECK: supple neck
CARDIAC: RRR. S1, S2. No mrg
LUNGS: CTA b/l. No crackles, wheezing, rhonchi
ABDOMEN: soft, TTP in RUQ. +BS
EXTREMITIES: WWP. No ___ edema
SKIN: No rash.
NEUROLOGIC: CN2-12 intact. No asterixes AOx3.
DISCHARGE PHYSICAL EXAM:
======================
VITALS: 24 HR Data (last updated ___ @ 1112)
Temp: 98.2 (Tm 98.5), BP: 132/91 (132-149/83-97), HR: 84
(72-84), RR: 18 (___), O2 sat: 100% (99-100), O2 delivery: Ra
GENERAL: appears comfortable in no acute distress. Conversant,
cooperative.
HEENT: PERRL. EOMI. nonicteric sclerae. Clear OP.
CARDIAC: RRR. S1, S2. No mrg
LUNGS: CTA b/l. No crackles, wheezing, rhonchi
ABDOMEN: soft, TTP in RUQ with liver palpable below the ribcage.
+BS
EXTREMITIES: WWP. No ___ edema
SKIN: No rash.
NEUROLOGIC: CN2-12 intact. No asterixis, AOx3.
Pertinent Results:
ADMISSION LABS:
=============
___ 03:15PM WBC-6.7 RBC-3.65* HGB-12.6* HCT-36.8*
MCV-101* MCH-34.5* MCHC-34.2 RDW-12.5 RDWSD-46.8*
___ 03:15PM NEUTS-79.6* LYMPHS-13.7* MONOS-5.6 EOS-0.0*
BASOS-0.6 IM ___ AbsNeut-5.31 AbsLymp-0.91* AbsMono-0.37
AbsEos-0.00* AbsBaso-0.04
___ 03:15PM PLT SMR-LOW* PLT COUNT-87*
___ 03:15PM GLUCOSE-79 UREA N-10 CREAT-0.8 SODIUM-140
POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-20* ANION GAP-22*
___ 03:15PM ALBUMIN-4.5 CALCIUM-9.5 PHOSPHATE-3.7
MAGNESIUM-1.7
___ 03:15PM ALT(SGPT)-135* AST(SGOT)-178* ALK PHOS-145*
TOT BILI-0.5
___ 03:15PM ASA-NEG ETHANOL-39* ACETMNPHN-NEG
tricyclic-NEG
DISCHARGE LABS:
=============
___ 05:55AM BLOOD WBC-6.4 RBC-3.58* Hgb-12.2* Hct-35.8*
MCV-100* MCH-34.1* MCHC-34.1 RDW-12.0 RDWSD-44.1 Plt ___
___ 05:55AM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-137
K-3.8 Cl-101 HCO3-24 AnGap-12
___ 05:55AM BLOOD ALT-89* AST-92* AlkPhos-148* TotBili-0.4
___ 05:55AM BLOOD Albumin-4.1 Calcium-9.6 Phos-4.3 Mg-1.7
MICROBIO:
========
___ 03:15PM HCV Ab-NEG
___ 03:15PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
IMAGING:
=======
LIVER OR GALLBLADDER US (SINGLE ORGAN)Study Date of ___
6:26 ___
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the
liver is smooth.
There is no focal liver mass. The main portal vein is patent
with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 8.3 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.6 cm
Left kidney: 11.9 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal
limits.
IMPRESSION:
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.
RECOMMENDATION(S):
Radiological evidence of fatty liver does not exclude cirrhosis
or
significant liver fibrosis which could be further evaluated by
___.
This can be requested via the ___ (FibroScan) or the
Radiology
Department with either MR ___ or US ___, in
conjunction with
a GI/Hepatology consultation" *
* ___ et al. The diagnosis and management of nonalcoholic
fatty liver
disease: Practice guidance from the ___ Association for the
Study of
Liver Diseases. Hepatology ___ 67(1):328-357
OTHER SELECTED RESULTS:
=====================
___ 05:45AM BLOOD Triglyc-217* HDL-83 CHOL/HD-3.2
LDLcalc-139*
Brief Hospital Course:
___ year old male with PMHx seizure, EtOH use disorder, who
presents with recurrent seizure iso Keppra nonadherence (reports
30% compliance) and was found to have transaminitis and
hepatosteatosis on US. He is aware that alcohol is likely
harming his liver and is motivated to stop drinking. He will be
discharged on naltrexone to help with alcohol cravings.
#Seizure
Mr ___ likely had a breakthrough seizure in the setting of
nonadherence with his Keppra. He reports that he takes it about
30% of the time. Pt reportedly states he has been in the ED
several times this past year for seizure suggesting his epilepsy
is not controlled. Alcohol withdrawal seizure is on the
differential but the patient had recently drank when he had his
seizure and still had a nonzero serum alcohol on presentation.
He was given a Keppra load and then started back on his home
dose.
#Transaminitis
#Steatosis
Mr ___ presented with a transaminitis of ALT=135, AST=178,
Alkphos=145.
No evidence of synthetic dysfunction. ___ DF of 0.5.
Alcoholic hepatitis was though less likely. Suspected
transamintis ___ etoh use, but AST/ALT pattern not in classic
2:1 ratio. The Tylenol level was negative. His hepatitis B and C
serologies were normal including HBV immune. There was no
evidence of hepatic encephalopathy, ascites, asterixis. He
underwent a RUQUS showing steatosis vs cirrhosis vs liver
fibrosis. His LFTs have been improving throughout his admission.
He will need a fibroscan and LFT monitoring going forward.
#Alcohol Use Disorder
He reports that he drinks ___ beers per day. Last drink on ___
at 7pm. No evidence of withdrawal during observation until ___
___. No lorazepam was needed. He is motivated to stop drinking
alcohol and understands that it is harming his liver. He wants
to try naltrexone to reduce alcohol cravings and will leave with
a 30 day supply to be followed up by his PCP.
#Macrocytic anemia
He presented with a mild anemia to Hgb=12.6 MCV 101. It is
likely ___ etoh use. He will be discharged on a multivitamin,
thiamine, and folate.
#Thrombocytopenia
Platelets 87 on presentation increasing to 104. Suspect this is
in the setting of EtOH use disorder vs liver disease.
#Insomnia
Continued home trazodone.
TRANSITIONAL ISSUES:
==================
[] Steatosis vs fibrosis vs cirrhosis on US. Radiological
evidence of fatty liver does not exclude cirrhosis or
significant liver fibrosis which could be further evaluated by
___. This can be requested via the ___
(FibroScan) or the Radiology Department with either MR
___ or US ___, in conjunction with a
GI/Hepatology consultation" *
[] consider initiation of statin for cholesterol 265,
triglycerides 217
[] Started Naltrexone for prevention of alcohol cravings.
Request PCP assistance in monitoring alcohol cessation efforts
and continuing this med.
#CODE: full code
Name of health care proxy: ___
Relationship: fiancee
Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 1000 mg PO BID
2. TraZODone Dose is Unknown PO QHS:PRN insomnia
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Naltrexone 50 mg PO DAILY
RX *naltrexone 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
5. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
6. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Seizure disorder
2. Alcohol use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you had a seizure.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- In the hospital you were given a big dose of Keppra to
increase the amount Keppra in your body quickly and then started
on what you are supposed to take at home.
- You were monitored for alcohol withdrawal, but did not require
any medicine for this.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Be sure to take your Keppra as prescribed to prevent seizures.
- You started a medicine called naltrexone to prevent alcohol
cravings. Talk with your primary care doctor about continuing
this medication.
- Continue to take all your medicines and keep your
appointments.
We wish you the best! Congratulations on getting engaged.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10367718-DS-18 | 10,367,718 | 27,311,788 | DS | 18 | 2188-06-07 00:00:00 | 2188-06-07 12:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worsening back pain with associated muscle spasms
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of HTN, diabetes, CAD with prior MI presents to the
Emergency Room for acute on chronic back pain x 5 months. It
first began after she was a passenger in the T van for the
disabled which was rear ended. She states that she has back
spasms for the past 2 days. Nothing made her pain better. Her
pain was worse with movement. + dizziness and she fell twice. No
LOC. She turns and then experiences an acute worsening of her
pain such that she loses her balance. She has not had any
urinary accidents. +
constipation since ___. No fevers or chills. She has lost 50
lbs since last year intentionally. Her back pain did wake her up
when she was asleep. No lower extremity weakness. She couldn't
walk down the two steps to leave her house. + spasms. Back pain
radiates to the leg. She thinks that her back pain may have been
exacerbating by sitting and folding papers and stuffing
envelopes but no other trauma. + LH with standing. + gait
instability during the past week. No decrease in fluid intake.
.
This is very typical of her back pain. It is lower mid thoracic
area. Denies any red flags. ? MVA in ___.
.
In ER:
Triage Vitals: 98.2, 118, 103/55, 18, 97% RA
Meds Given: Diazepam 5 mg; Acetaminophen 1000 mg; IVF 1000 mL
Morphine Sulfate 2 mg
Radiology Studies:CXR
Consults called: none
.
Labs checked and creatinine up to 3.2 up from baseline of 1.6-2.
HCT also decreased to 33.___dmitted.
.
ROS: + dizziness, visual changes with blurry vision x 1 month,
nausea, dry mouth
10-point ROS otherwise negative
Past Medical History:
1) CAD- one vessel disease (mid-LAD) s/p 3 stents placed most
recently in ___. Underwent ___ stenting ___ at the ___.
2) Diabetes mellitus type 2
3) Morbid Obesity
4) Hyperlipidemia
5) Vitiligo
6) OSA on CPAP
7) Hypertension
8) Depression
9) Chronic back pain
Social History:
___
Family History:
Mom and 2 aunts with heart disease when ___ yo. Uncle with heart
disease s/p pacemaker.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS:
PAIN SCORE
1. VS: 97.5 P 91 BP 141/88 RR 18 O2Sat 97% on RA
GENERAL: Well appearing middle aged female.
Nourishment: good
Grooming: good
Mentation
2. Eyes: [] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [+] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [X] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None
[X] Edema LLE None
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [X]WNL
[X] CTA bilaterally [ ] Rales [ ] Diminshed
6. Gastrointestinal [ ] WNL
[X] Soft [] Rebound [] No hepatomegaly [X] Non-tender [] Tender
[] No splenomegaly
[] Non distended [X] obesely distended [] bowel sounds
Yes/No [] guiac: positive/negative
RECTAL: NO saddle anesthesia. Preserved rectal tone.
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [ X]Upper extremity strength ___ and symmetrical
[
]Other:
[ ] Bulk WNL [X] Lower extremity strength ___ and symmetrica
[
] Other:
8. Neurological [X] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ X] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [X] Fluent speech
9. Integument [X] WNL
[X] Warm [X] Dry [] Cyanotic [?] Rash: patient reports area of
erythema and allodynia of the b/l inner thighs. Author cannot
appreciate reported erythema
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated
[X] Pleasant [] Depressed [] Agitated [] Psychotic
DISCHARGE PHYSICAL EXAM:
VS: T=97.6 BP=150/91 HR=101 RR=18 O2 Sat=95% on RA
Gen: Awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
CV: RR
Pulm: CTA B
Abd: Soft, NTND, positive bowel sounds
Ext: No edema or calf tenderness, full strength in lower
extremities
Psych: Affect appropriate, good insight into own health
Neuro: Speech fluent
Pertinent Results:
ADMISSION LABS:
___ 10:15PM BLOOD WBC-6.8 RBC-3.93* Hgb-11.0* Hct-33.9*
MCV-86 MCH-28.1 MCHC-32.6 RDW-15.0 Plt ___
___ 10:15PM BLOOD Glucose-202* UreaN-46* Creat-3.2*# Na-135
K-5.3* Cl-97 HCO3-25 AnGap-18
___ 12:35AM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:35AM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 12:35AM URINE RBC-1 WBC-20* Bacteri-FEW Yeast-NONE
Epi-24
___ 12:35AM URINE CastHy-27*
MICROBIOLOGY:
___ Urine Culture
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
___ CXR (PA/LAT)
IMPRESSION:
No acute findings.
___ T-Spine X-Ray
IMPRESSION:
Multilevel degenerative changes in the thoracic spine.
___ LS-Spine X-Ray
IMPRESSION:
Multilevel degenerative joint and disc disease as described,
most marked at L2-L3 and L4-L5.
MRI Lumbar Spine
1. Interval progression of multilevel lumbar spondylosis as
described.
2. Interval worsening of L2-L3 and L4-L5 spinal canal stenosis,
which are now moderate to severe, with subarticular zone recess
stenosis, also affecting traversing nerve roots.
3. Multilevel neural foraminal stenoses as described, greatest
at left L2-L3 level and right L4-L5 levels.
4. Limited imaging of kidneys again suggests a right inferior
pole at least partially cystic lesion. While this finding may
represent a renal cyst, other etiologies cannot be excluded on
the basis of this examination. Recommend clinical correlation.
If clinically indicated, further evaluation may be obtained via
renal ultrasound.
Rib Films, R:
No definite evidence of rib fracture or pneumothorax.
Brief Hospital Course:
The patient is a ___ year old female with h/o poorly controlled
DM II, last HgbA1C = 15 presenting with acute on chronic L sided
back pain s/p MVA.
BACK PAIN / DJD / RADICULOPATHY
Musculoskeletal in nature. No acute findings on plain films of
the spine or MRI of the lumbar spine; rib fracture ruled-out
with dedicated rib films. The patient was seen in consultation
by the Pain Service and is being discharged on a regimen of
oxycodone 5mg PO q6, tylenol, gabapentin 300mg PO BID,
tizanidine 2mg PO qHS, lidocaine patch, and diazepam 5mg PO q6.
Given that her pain was felt to be primarily due to muscle
spasm, injections were not thought to be beneficial at this
time. The patient wished to follow-up with her pain specialists
at ___ and indicated that she would call to schedule an
appointment.
ACUTE RENAL FAILURE on CKD
Most likely seconday to poor po intake as an outpatient. She
improved back to baseline with IV fluids initially and then PO
intake. Would consider starting an ACE-I as an outpatient.
DIABETES MELLITUS POORLY CONTROLLED WITH DIABETIC RETINOPATHY
and NEPHROPATHY
- Patient was continued on her home glargine regimen with FSBG
in the high 100's-high 200's. She should follow-up with ___
as an outpatient and consider an ACE-I as noted above.
ANEMIA:
Stable during this admission. Iron studies c/w anemia of chronic
disease, possibly due to underlying CKD
CAD / HTN
Patient continued on her home ASA, atenolol and statin. Given
her underling CKD would consider transition to metoprolol.
CONSTIPATION:
Patient was continued on an agressive bowel regimen.
Transitional Issues:
MRI of the L-spine incidentally noted a likely renal cyst with
recommendation for an outpatient ultrasound for further
characterization.
"Limited imaging of kidneys again suggests a right inferior pole
at least
partially cystic lesion. While this finding may represent a
renal cyst, other
etiologies cannot be excluded on the basis of this examination.
Recommend
clinical correlation. If clinically indicated, further
evaluation may be
obtained via renal ultrasound."
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Atenolol 25 mg PO DAILY
4. Cyclobenzaprine 10 mg PO HS:PRN qhs
5. Glargine 40 Units Breakfast
Glargine 40 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
8. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Multivitamins 1 TAB PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Glargine 40 Units Breakfast
Glargine 40 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Atenolol 25 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
8. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth Every eight hours
Disp #*60 Tablet Refills:*0
9. Bisacodyl ___AILY
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*20
Suppository Refills:*0
10. Diazepam 5 mg PO Q6H:PRN back spasm
RX *diazepam 5 mg 1 tablet by mouth q6 Disp #*30 Tablet
Refills:*0
11. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
12. Lactulose 30 mL PO TID
13. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % (700 mg/patch) 1 patch every evening Disp #*30
Patch Refills:*0
14. Tizanidine 2 mg PO QHS
RX *tizanidine 2 mg 1 tablet(s) by mouth every evening Disp #*30
Tablet Refills:*0
15. Outpatient Physical Therapy
Please refer patient to outpatient physical therapy for
therapeutic exercise, balance/fall prevention.
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar degenerative disc disease
Lumbar radiculopathy
Acute on chronic renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You presented to the hospital with worsening back pain with
associated spasms. You were seen by the Chronic Pain
physicians. You had your medications adjusted. You were seen
by the Physical Therapists as well and they recommended
outpatient physical therapy. Your acute renal failure improved
with fluids.
Please see your physicians as instructed.
Please take your medications as listed.
Followup Instructions:
___
|
10367718-DS-19 | 10,367,718 | 22,363,808 | DS | 19 | 2188-12-06 00:00:00 | 2188-12-06 19:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac cath s/p distal RCA ___
History of Present Illness:
This is a ___ with a history of CAD s/p RCA stenting in ___,
s/p 3 stents placed to LAD in ___ and ___ stenting ___ at
the ___, HTN, IDDM who presents with chest pain.
She reports around 2100 last night have chest pain and
diaphoresis at a family event after which she called ___.
She reports intense pressure, like something is sitting on her
chest, similar to prior MIs.
In the ED initial vitals were: 10 96 126/82 16 98% Nasal Cannula
EKG: showed TWI in III and flattening in aVF, that improved
'pseudonormalization on second ekg. Sinus tach at 100, NANI.
Labs/studies notable for:
Trop-T: 0.03, CK 184, MB 5
Na 134, K 4.8, Cl 99, HCO3 25, BUN 36, Cr 1.9, Glu 376
Patient was given:
___ 00:40 SL Nitroglycerin SL
___ 00:42 IV Morphine Sulfate 5 mg
___ 00:42 IV Ondansetron 4 mg
___ 01:42 IV Lorazepam 1 mg
Her symptoms did not improve despite these medications, although
nursing notes report she appeared more comfortable.
Vitals on transfer: 97 142/82 14 100% RA
On the floor, she reports continued ___ pain, although she is
talking, joking/laughing and intermittently closing eyes as if
falling asleep during discussion.
She reports chronic back pain for which she was recently started
on a new medication DICLOFENAC POT 25mg daily.
ROS:
+ HPI, also positive for back pain, 50lb intentional weight loss
over the past ___
Past Medical History:
1) CAD- one vessel disease (mid-LAD) s/p 3 stents placed most
recently in ___. Underwent ___ stenting ___ at the ___.
2) Diabetes mellitus type 2
3) Morbid Obesity
4) Hyperlipidemia
5) Vitiligo
6) OSA on CPAP
7) Hypertension
8) Depression
9) Chronic back pain
Social History:
___
Family History:
Mom and 2 aunts with heart disease when ___ yo. Uncle with heart
disease s/p pacemaker.
Physical Exam:
ADMISSION PHYSICAL EXAM
=================================
VS: 97.6 155/95 L, 162/100 R, 97, 20, 100% RA
WEIGHT: 90.7 KG
GENERAL: Does not appear in any acute distress. Intermittently
seems to fall sleep when talking.
HEENT: NCAT. + hirsute. Sclera anicteric. PERRL, EOMI. No
xanthelasma.
NECK: Supple, unable to see JVP
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.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. 2+ DP pulses
SKIN: Vitligo.
Neuro: A&Ox3, no focal deficits
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM
================================
VS: T=98.4 F BP= 144/95 HR=95 RR= 18 O2 sat= 98% RA
Wt:91.3 KG
GENERAL: Mild distress. Oriented x3. Mood, affect appropriate.
NECK: Thickened neck diameter.
CARDIAC: Tachycardia. Regular rhythm. No MRG.
HEENT: NCAT. + hirsute. Sclera anicteric. PERRL, EOMI. No
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. 2+ DP pulses.
Right>left lower extremities are tender to palpation.
SKIN: Vitligo.
Neuro: A&Ox3, no focal deficits. ___ ___ muscle strength.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
Admission Labs
=======================================
___ 12:15AM WBC-8.8# RBC-3.88* HGB-11.2 HCT-35.4 MCV-91
MCH-28.9 MCHC-31.6* RDW-14.1 RDWSD-46.9*
___ 12:15AM NEUTS-68.9 ___ MONOS-7.2 EOS-2.6
BASOS-0.5 IM ___ AbsNeut-6.04 AbsLymp-1.77 AbsMono-0.63
AbsEos-0.23 AbsBaso-0.04
___ 12:15AM GLUCOSE-376* UREA N-36* CREAT-1.9* SODIUM-134
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15
___ 05:11AM ___ PTT-32.2 ___
___ 12:15AM cTropnT-0.03*
___ 12:15AM CK-MB-5
___ 12:15AM CK(CPK)-184
___ 05:11AM CK-MB-13* cTropnT-0.14*
___ 10:50AM CK-MB-15* cTropnT-0.39*
___ 05:00PM CK-MB-10 cTropnT-0.45*
___ 09:18PM CK-MB-8 cTropnT-0.42*
Discharge Labs
=======================================
___ 04:35AM BLOOD WBC-8.2 RBC-2.64* Hgb-7.7* Hct-24.6*
MCV-93 MCH-29.2 MCHC-31.3* RDW-14.1 RDWSD-47.2* Plt ___
___ 04:35AM BLOOD Plt ___
___ 06:10AM BLOOD ___ PTT-30.9 ___
___ 04:35AM BLOOD Glucose-210* UreaN-47* Creat-1.8* Na-139
K-4.9 Cl-104 HCO3-27 AnGap-13
___ 04:35AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.9
___ 06:50PM BLOOD CK-MB-4 cTropnT-0.23*
___: CXR: In comparison with the earlier study of this
date, there is little change. Cardiac silhouette remains within
normal limits and there is no evidence of vascular congestion,
pleural effusion, or acute focal pneumonia. Left bronchial ___
remains in place.
___: TTEcho: The left atrial volume index is normal. There
is moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is 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. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Prominent LVH with normal global and regional
biventricular systolic function.
___: Cardiac Cath: Right Dominant. Was found to have 90%
stenosis to the distal RCA and had a DES placed during cath on
___. LAD 40% stenosis.
Full report pending.
___: EKG: Vent rate:99 PR:160 QRS:76 ___ segment
depression No TWI. Baseline artifact. Sinus rhythm with a rate
at the upper limits of normal. Mild Q-T interval prolongation.
Compared to the previous tracing of ___ the rate is slower.
The other findings are similar.
Brief Hospital Course:
This is a ___ with a history of CAD s/p RCA stenting in ___,
s/p 3 stents placed to LAD in ___ and ___ stenting ___ at
the ___, HTN, IDDM who presents with chest pain and found to
have distal RCA occlusion and is s/p DES.
#NSTEMI:
Patient presented with acute onset substernal chest pain and
shortness of breath and was found to have an NSTEMI on ___ with
elevated troponins that peaked at 0.39. Patient continued to
have chest pain despite nitro drip and was sent to cath lab
emergently. She had a cardiac cath which showed 90% stenosis to
the distal RCA and had a DES placed during cath on ___. She was
started on Ticagrelor 90 mg BID for 12 months and aspirin 81 mg
daily. Atenolol was stopped and patient started on metoprolol
150 mg XL.
#Acute on chronic renal injury:
Patient also had a mild ___ on CKD with a Cr. of 1.9. Creatinine
was around(1.8-2.1) throughout hospital stay and was 1.8 on
discharge; baseline creatinine was 1.6 on ___. Was stable
throughout admission. Stopped 800 mg Ibuprofen throughout
hospital stay and at discharge.
#Hyperkalemia:
Patient was also found to have hyperkalemia on the morning of
___ up to 6.1. EKG was normal. Was given calcium gluconate and
IV insulin with normalization prior to discharge. Potassium
level on discharge was 4.9.
#Insulin Dependent Diabetes
Recently seen at ___ with home regimen of lantus 40 untis
BID. A1c in ___ of 8.6. Was discharged with Lantus 40 BID.
Blood glucose remained <400 throughout hospitalization.
# Hypertension:
SBP in the 150s-160s on arrival to the floor. BP below
(165/90's) throughout hospitalization. Atenolol was stopped in
setting of CKD and metoprolol 150 mg XL started.
# Chronic back pain:
Patient with history of back injury on Percocet and
cylcobenzaprine. This was continued during hospitalization. Was
discharged refill of 10 tablets of Acetominophen-Oxycodone
(5mg-325mg) 1 tab BID PRN. Ibuprofen was discontinued.
Transitional Issues
=========================
-Discontinued atenolol 25 mg PO Daily and changed to metoprolol
to 150 mg XL
-Ticagrelor 90 BID started this hospitalization to continue for
12 months
-Aspirin 81 mg daily
-Increased Atorvastatin 40mg to Atorvastatin 80 mg Daily
-Chem-7 at next PCP appointment to follow renal function and
electrolytes
-Discontinued Ibuprofen 800 mg TID to prevent worsening kidney
failure and Ticagrelor use
-Cardiology follow up pending. Patient will be called with
appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Colchicine 0.6 mg PO PRN gout flare
4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
5. Multivitamins 1 TAB PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Cetirizine 10 mg PO DAILY
8. Cyclobenzaprine 10 mg PO HS
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
10. Diclofenac Sodium ___ 25 mg PO BID:PRN pain
11. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL)
subcutaneous AS DIRECTED
Discharge Medications:
1. TiCAGRELOR 90 mg PO BID ACS
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
2. Atorvastatin 80 mg PO QPM
3. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
4. Cetirizine 10 mg PO DAILY PRN allergies
5. Colchicine 0.6 mg PO PRN gout flare
6. Cyclobenzaprine 10 mg PO HS
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
RX *oxycodone-acetaminophen [Endocet] 5 mg-325 mg 1 tablet(s) by
mouth every 12 hours Disp #*10 Tablet Refills:*0
8. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL)
subcutaneous AS DIRECTED
9. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Non ST-elevation MI
Coronary artery disease s/p DES to distal RCA
Hypertension
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted because you had chest pain and were found a
heart attack. You had a procedure called a cardiac
catheterization to look at the blood vessels supplying blood to
your heart. You had an occlusion in one of them and had a
drug-eluting ___ placed. You were started on a medication
called Ticagrelor that you will need to take for 12 months. Do
not stop this medication until told so by a Cardiologist. It is
very important that you take this medication every day.
Please follow up with your appointments below
It was a pleasure meeting you!
Sincerely,
Your ___ Cardiology team.
Followup Instructions:
___
|
10367718-DS-22 | 10,367,718 | 20,009,197 | DS | 22 | 2191-11-06 00:00:00 | 2191-11-12 00:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ transesophageal echocardiogram
History of Present Illness:
Patient with substernal chest pain and heaviness since 8pm last
night. Started while she was washing dishes and persisted all
night. It started around ___ and has been unrelenting and
slightly worsening to ___. She tried taking nitro at home
without improvement and received nitro spray from EMS which gave
her a headache without CP relief. The pain is not exertional and
is present at rest. She characterizes it as the same as with her
prior MIs.
Also complains of right leg pain and right hip pain. Was in a
car accident in ___. Never had right hip imaged.
In the ED, For initial team there was concern for ACS vs. PE.
Patient was
notably tachycardic and markedly hypertensive but not hypoxic.
She had a positive D-dimer but ___ was negative. She could not
get a CTA due to creatinine 3.0 (up from 2.5 baseline). Her
troponin was 0.___levations on EKG. The plan was to
admit the patient to medicine for V/Q scan. While in the ED she
was signed out to Merit who started a heparin gtt. It was noted
that the patient had worsening chest pressure that became ___
in intensity. With up-trending troponin and positive D-dimer
there was concern for aortic dissection vs. NSTEMI. She was
given esmolol for BP control and nitroglycerin with notable
improvement in pain. The heparin was discontinued. After
discussion with cardiology, had a TTE in the ED without regional
wall motion abnormalities. TEE without aortic dissection. Second
troponin
negative.
- Initial vitals were: afebrile, HR 104, BP 196/108, O2 sat 99%
on RA
- Exam notable for:
A&O, NAD
CV: No murmurs.
Pulm: CTAB
Ext: 2+ pitting edema
Abd: Soft, NTND.
- Labs notable for:
Hgb 8.5
Cr 3.0
D-dimer 724
proBNP 1366
Trop 0.03 -> 0.04 -> 0.05
CK-MB 5 -> 4
-Studies notable for:
EKG: sinus tachycardia, normal axis, no ST changes, T wave
inversions in AVL
LENIs: No evidence of deep venous thrombosis in the right or
left
lower extremity
TTE:
Normal regional and global left ventricular systolic function
LVEF 69%, grade I diastolic dysfunction
Aortic valve leaflets appear structurally normal, no AS or AR
Pulmonary artery pressure could not be measured
No pericardial effusion
TEE: no evidence of aortic dissection
-Patient was given:
acetaminophen 1000 mg IV
morphine sulfate 2 mg IV x2
nitroglycerin gtt
aspirin 81 mg
insulin 25 U
carvedilol 12.5 mg PO
lidocaine patch 5%
atorvastatin 80 mg
heparin gtt
esmolol gtt
propofol for ___
On arrival to the CCU, patient interviewed and examined at
bedside. She confirmed the above history. She endorsed chest
pain
starting last night at 9pm when doing dishes that remained
constant overnight. She described pain as chest pressure
radiating to the left shoulder. Did not get worse with deep
breath. Was not diaphoretic as she was during her past MIs.
She denies headache, vision changes, shortness of breath. She
states that she takes her medications as prescribed and never
misses a dose. She denies any recent changes to her diet.
She complains of right sided hip and back pain radiating down
the
leg since a car accident in ___. She has never had imaging
of
the hip since then. She was previously on oxycodone for this
issue but it didn't help so she stopped taking it.
She also complains of a herpes outbreak on her buttocks and
request Valtrex which has helped in the past. She has been told
by different doctors that these ___ are herpes zoster vs.
herpes simplex.
Past Medical History:
HTN, HL, DM2 on insulin, CAD s/p multiple PCI, CKD, anemia,
obesity, OSA, vitiligo, and chronic back pain
Surgeries: eye surgery, wrist surgery
Social History:
___
Family History:
Family history was reviewed and is thought impertinent to
current
presentation. Positive for DM, HTN, HL, and CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: afebrile, HR 88, BP 116/85, O2 sat 100% on room air
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric.
NECK: Supple. No appreciable JVD.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No adventitious breath
sounds.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ pitting edema L>R. Right
hip
tender to palpation.
DISCHARGE PHYSICAL EXAM:
========================
VS:
24 HR Data (last updated ___ @ 1259)
Temp: 98.2 (Tm 98.4), BP: 116/65 (100-147/56-75), HR: 76
(75-88), RR: 18 (___), O2 sat: 94% (92-98), O2 delivery: Ra
GENERAL: Lying in bed comfortably, no apparent distress
CARDIAC: RRR, normal S1/S2, no murmurs
PULM: Clear to auscultation bilaterally, no wheezes or crackles
GI: Soft, nontender, nondistended
EXT: No swelling, warm and well perfused. No erythema, no edema
over the LLE. Some small scar tissue over R gluteal region. No
obvious vesicular lesions over the LLE. She has pain with
external rotation of the hip, no pain with internal rotation of
the hip. No pain with internal or external rotation of the leg.
No back pain, no radiating pain with bilateral straight leg
raise.
Pertinent Results:
ADMISSION LABS:
================
___ 03:30AM BLOOD WBC-6.2 RBC-2.90* Hgb-8.5* Hct-27.5*
MCV-95 MCH-29.3 MCHC-30.9* RDW-13.2 RDWSD-45.6 Plt ___
___ 03:30AM BLOOD Neuts-47.1 ___ Monos-13.8*
Eos-8.5* Baso-0.5 Im ___ AbsNeut-2.92 AbsLymp-1.85
AbsMono-0.86* AbsEos-0.53 AbsBaso-0.03
___ 03:30AM BLOOD ___ PTT-29.4 ___
___ 03:30AM BLOOD Plt ___
___ 03:30AM BLOOD D-Dimer-724*
___ 03:30AM BLOOD Glucose-165* UreaN-54* Creat-3.0* Na-143
K-5.1 Cl-104 HCO3-27 AnGap-12
___ 03:30AM BLOOD proBNP-1366*
___ 01:07PM BLOOD CK-MB-4 cTropnT-0.05*
IMAGING:
========
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Mild right basilar atelectasis. Suspected pulmonary
hypertension. Otherwise, no acute cardiopulmonary abnormality.
___ Imaging BILAT LOWER EXT VEINS
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ Cardiovascular Transthoracic Echo Report
CONCLUSION:
The left atrium is mildly dilated. There is normal left
ventricular wall thickness with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 69 %.
There is no resting left ventricular outflow tract gradient.
There is Grade I diastolic dysfunction. Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. The
aortic valve leaflets (3) appear structurally normal. There is
no aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The pulmonary artery systolic pressure
could not be estimated. There is no pericardial effusion.
Compared with the prior TTE ___, no major change.
FINDINGS:
LEFT ATRIUM (LA)/PULMONARY VEINS: Mildly dilated LA.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Normal RA
size.
LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity
size. Normal regional/global systolic function. No resting
outflow tract gradient. Grade I diastolic dysfunction.
RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall
motion.
AORTA: Normal sinus diameter for gender. Normal ascending
diameter for gender. Normal arch diameter.
AORTIC VALVE (AV): Normal/thin (3) leaflets. No stenosis. No
regurgitation.
MITRAL VALVE (MV): Mildly thickened leaflets. No systolic
prolapse. Mild MAC. Trivial regurgitation.
PULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation.
TRICUSPID VALVE (TV): Normal leaflets. Physiologic
regurgitation. Undertermined pulmonary artery systolic pressure.
PERICARDIUM: No effusion.
___ Cardiovascular Transesophageal Echo Report
CONCLUSION:
Overall left ventricular systolic function is normal. There are
simple atheroma in the aortic arch with simple atheroma in the
descending aorta. No aortic dissection is seen. The aortic valve
leaflets (3) appear structurally normal. No masses or
vegetations are seen on the aortic valve. No abscess is seen.
There is mild [1+] aortic regurgitation. The mitral valve
leaflets appear structurally normal with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
No abscess is seen.
IMPRESSION: No evidence of aortic dissection. Simple atheroma in
the aortic arch and descending aorta. Mild aortic regurgitation.
Normal left ventricular systolic function.
Brief Hospital Course:
ear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had chest pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your blood pressures were very high, so we gave you
medications through the IV to help lower them.
- You were in the cardiac intensive care unit (CCU) because of
the medications you required.
- We did an transthoracic echocardiogram (TTE) of your heart,
which showed that it is pumping normally.
- We did a transesophageal echocardiogram (TEE) to look at your
larger arteries and confirm there was no tear.
- We did a pharmacological perfusion study of your heart, which
showed no areas concerning for blockage.
- We took xrays of your hip, knee and ankle. The wet read showed
no fractures.
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
Did the patient have a TIA or stroke (ischemic or hemorrhagic)
diagnosed during this admission?:No
Will this patient be discharged on an opioid pain
medication?:No
Final Diagnosis:PRIMARY:
=========
# HYPERTENSIVE EMERGENCY
# NSTEMI
# ___ ON CKD
# RIGHT HIP PAIN
# HERPES ZOSTER
SECONDARY:
===========
# CORONARY ARTERY DISEASE
# TYPE 2 DIABETES
Recommended Follow-up:PRIMARY CARE
Name: ___.
When: ___ at 10:15am
Location: THE ___
Address: ___, ___
Phone: ___
CARDIOLOGY FOLLOW UP
Department: CARDIAC SERVICES
When: ___ at 9:15 AM
With: ___
Building: ___
Campus: ___ Best Parking: ___
NEPHROLOGY FOLLOW UP
Department: ___
When: ___ at 1:20 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
*** You have also been placed on a waitlist if a sooner
appointment becomes available. ***
Pending Results at Discharge:Labs
___ 00:41 VOIDED SPECIMEN (urine)
Pending Results ___ ___
Key Information for Outpatient Providers:ASSESSMENT AND PLAN:
=====================
___ with DMII, HTN, HLD, CAD s/p DES, who presented with
hypertensive emergency.
=============
ACUTE ISSUES:
=============
# Hypertensive emergency
# Hypertension
Presented with BP 196/108 of unclear etiology; patient reported
taking her medications and no change in diet but multiple recent
stressors including her mother's death. Normal TSH and renal
doppler in ___ normal. Initially admitted to CCU for esmolol
drip, blood pressures also titrated with nitro drip. Once weaned
off drips she was transferred to the floor where her blood
pressures were controlled with oral medications.
# NSTEMI
# Coronary artery disease NSTEMI likely type II; secondary to
demand ischemia in setting of hypertensive emergency. Nuclear
stress test showed no evidence of focal ischemia with normal
left ventricular cavity size with EF of 49%.
# Right lower extremity pain
Ms. ___ described pain in R gluteal region, right knee
(anterior/posterior), foot and ankle with a S1 dermatomal
distribution consistent w/ post-herpetic neuralgia. However, she
describes pain in this region since motor vehicle accident in
late ___. She had no pain on straight leg exam; so, unclear
whether pain w/ element of lumbar radiculopathy. However, recent
trauma to the right hip and tenderness to palpation on exam. We
continued her home Flexeril. Wet read of her hip, knee and ankle
x-ray showed no evidence of fracture.
# Herpes zoster
Patient complaining of outbreak of herpes zoster on buttocks.
Similar to previous episodes. Has a culture confirmed Zoster
outbreak in ___ in the lower back and has used Valtrex in the
past. She has ___ erythematous papules with one small possible
pustule in general S1 dermatome. She states that her stinging
pain occurred with her rash that appeared two days ago prior her
admission. She was started on local zoster precautions and
Valtrex x 7 days, renally dosed.
# DMII
She was given glargine 25u in AM and started on ISS in the
hospital
Transitional Issues:
====================
[] Patient instructed to obtain repeat labs on ___. Please
follow up chem-10 to ensure renal function stable. Discharge Cr
3.7, K 5.3. Will need ongoing follow up with outpatient
nephrology.
[] Recommend Shingrix vaccine given recent episode of Shingles.
[] Pain control: Pain was poorly controlled on oxycodone,
Tylenol, capsaicin cream. Recommend follow-up with her pain
management doctor for titration of her chronic pain medications.
#CODE: Full code, confirmed
#CONTACT/HCP: daughter ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO DAILY
2. Glargine 25 Units Breakfast
3. Torsemide 10 mg PO EVERY OTHER DAY
4. Cyclobenzaprine 10 mg PO BID:PRN pain
5. Carvedilol 12.5 mg PO BID
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Capsaicin 0.025% 1 Appl TP QID:PRN pain
RX *capsaicin 0.025 % Appl on affected area Daily Refills:*0
4. ValACYclovir 1000 mg PO DAILY Duration: 3 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth Daily Disp #*2
Tablet Refills:*0
5. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
6. Glargine 25 Units Breakfast
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO DAILY
9. Cyclobenzaprine 10 mg PO BID:PRN pain
10. Torsemide 10 mg PO EVERY OTHER DAY
11.Outpatient Lab Work
Dx: CKD IV (I12.9)
Please obtain Chem-10
FAX TO: ATTN Dr. ___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=========
# HYPERTENSIVE EMERGENCY
# NSTEMI
# ___ ON CKD
# RIGHT HIP PAIN
# HERPES ZOSTER
SECONDARY:
===========
# CORONARY ARTERY DISEASE
# TYPE 2 DIABETES
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had chest pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your blood pressures were very high, so we gave you
medications through the IV to help lower them.
- You were in the cardiac intensive care unit (CCU) because of
the medications you required.
- We did an transthoracic echocardiogram (TTE) of your heart,
which showed that it is pumping normally.
- We did a transesophageal echocardiogram (TEE) to look at your
larger arteries and confirm there was no tear.
- We did a pharmacological perfusion study of your heart, which
showed no areas concerning for blockage.
- We took xrays of your hip, knee and ankle. The wet read showed
no fractures.
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:
___
|
10367718-DS-23 | 10,367,718 | 22,264,834 | DS | 23 | 2192-03-20 00:00:00 | 2192-03-20 11:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Coronary artery bypass grafting x 3 with the left
internal mammary artery to the left anterior descending artery
and reverse saphenous vein graft to the obtuse marginal artery
and the posterior descending artery.
History of Present Illness:
Ms. ___ is a pleasant ___ year old woman with a history of
coronary artery disease status post multiple myocardial
infarctions and stents. Her history is also significant for
chronic kidney disease, diabetes mellitus, hyperlipidemia, and
hypertension. She presented with hypertension, chest pain,
headache, blurry vision, dizziness/lightheadedness, and
generalized weakness. She was admitted for hypertensive
emergency and ruled in for NSTEMI. Cardiac catheterization
demonstrated three-vessel coronary artery disease. Cardiac
surgery consulted
for coronary artery bypass graft evaluation.
Past Medical History:
Chronic Kidney Disease (baseline Cre 2.9-3.4)
Coronary Artery Disease
Diabetes Mellitus Type II, on Insulin
Diabetic Retinopathy
Hyperlipidemia
Hypertension
Leg Pain, chronic right
Legally Blind, right eye
Non-ST Elevation Myocardial Infarction
Normocytic Anemia
Obstructive Sleep Apnea
Vitiligo
Social History:
___
Family History:
Patient reports family history of DM, HTN, HL, and CAD.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
===============================
BP: 112/66. HR: 86. RR: 18. O2 sat: 96% O2 RA.
Height: 60 in Weight: 197 lbs
General: Pleasant woman, WDWN, NAD
Skin: Warm, dry, intact
HEENT: NCAT, PERRLA, EOMI, OP benign
Neck: Supple, full ROM
Chest: Lungs clear bilaterally
Heart: Regular rate and rhythm, no murmur appreciated
Abdomen: Protruberant, normal BS, non-tender, non-distended
Extremities: RLE tender to palpation. Warm, well-perfused, no
edema.
Varicosities: Superficial varicosities L>R
Neuro: Grossly intact
Pulses:
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: none appreciated
DISCHARGE PHYSICAL EXAM
=======================
Physical Examination:
General: NAD
Neurological: A+O x3 [x] non-focal [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: Decreased at the bases bilaterally [x] No resp
distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema trace
Left Lower extremity Warm [x] Edema trace
Pulses:
DP Right: + Left:+
___ Right: + Left:+
Radial Right: Left:
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] Prevena off - mild erythema along border of
incision improving, no drainage/collection. Sternum stable [x]
Lower extremity: Right [] Left [x] CDI [x]
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 07:52PM BLOOD WBC-5.5 RBC-2.94* Hgb-8.4* Hct-28.1*
MCV-96 MCH-28.6 MCHC-29.9* RDW-15.0 RDWSD-52.7* Plt ___
___ 07:52PM BLOOD Glucose-83 UreaN-57* Creat-3.5* Na-144
K-5.1 Cl-106 HCO3-26 AnGap-12
___ 08:14AM BLOOD ALT-10 AST-23 AlkPhos-87 TotBili-0.2
___ 07:52PM BLOOD CK-MB-8 proBNP-___*
___ 07:52PM BLOOD cTropnT-0.08*
___ 08:14AM BLOOD Albumin-3.1* Calcium-8.7 Phos-4.9* Mg-1.8
___ 09:16PM BLOOD %HbA1c-7.0* eAG-154*
Head CT ___
1. No acute intracranial process.
2. Stable global involutional changes and probable chronic
sequela of small vessel ischemic disease.
Cardiac Catheterization ___
LMCA: no significant disease.
LAD: severe proximal stent restenosis to 80% at the origin.
There is 50% mid.
LCX: 40% proximal, 50% mid stent restenosis, 70% distal edge
restenosis, 70-80% diffuse OM1 with several smaller branches
demonstrating subtotal occlusion.
RCA: 95% mid and widely patent distal stent.
Transesophageal Echocardiogram ___
PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm.
Left Atrium ___ Veins: No spontaneous echo contrast
or thrombus in the ___.
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
Normal RA size. No spontaneous echo contrast or thrombus is seen
in the RA/RA appendage. No atrial septal defect by 2D/color flow
Doppler.
Left Ventricle (LV): Normal cavity size. Normal regional &
global systolic function Normal ejection fraction.
Right Ventricle (RV): Normal free wall motion.
Aorta: Normal ascending diameter. Normal descending aorta
diameter. No dissection. Simple atheroma of ascending aorta.
Complex (>4mm) arch atheroma. Complex (>4mm) descending
atheroma.
Aortic Valve: Mildly thickened (3) leaflets. Mild leaflet
calcification. No stenosis. Trace regurgitation.
Mitral Valve: Mildly thickened leaflets. Minimal leaflet
calcification. No systolic prolapse. No stenosis. Mild annular
calcification. Trace regurgitation. Central jet.
Pulmonic Valve: Normal leaflets. Mild regurgitation.
Tricuspid Valve: Normal leaflets. Mild-moderate [___]
regurgitation.
Pericardium: No effusion.
POST-OP STATE: The post-bypass TEE was performed at 16:28:00.
Atrial paced rhythm.
Support: Vasopressor(s): none.
Left Ventricle: Similar to preoperative findings. Global
ejection fraction is normal.
Right Ventricle: No change in systolic function.
Aorta: Intact. No dissection.
Aortic Valve: No change in aortic valve morphology from
preoperative state.
Mitral Valve: No change in mitral valve morphology from
preoperative state.
Tricuspid Valve: No change in tricuspid valve morphology vs.
preoperative state.
CXR: IMPRESSION:
The right IJ central line tip is again seen within the right
atrium. There are low lung volumes. There is a left
retrocardiac opacity and likely bilateral pleural effusions.
The pulmonary edema is mildly improved. There are no
pneumothoraces.
Discharge Labs:
___ 05:21AM BLOOD WBC-9.7 RBC-3.10* Hgb-8.8* Hct-29.4*
MCV-95 MCH-28.4 MCHC-29.9* RDW-14.3 RDWSD-48.9* Plt ___
___ 05:21AM BLOOD Glucose-125* UreaN-72* Creat-4.0* Na-143
K-5.1 Cl-98 HCO3-32 AnGap-13
___ 05:21AM BLOOD Mg-2.2
Brief Hospital Course:
She underwent routine preoperative testing and evaluation. She
remained hemodynamically stable. Renal was consulted for
recommendations regarding acute on chronic kidney injury, likely
due to CIN. Supportive care was given, no need for hemodialysis.
Of note: Her baseline creatnine is documented to be =4. Patient
was taken to the operating room on ___ and underwent
coronary artery bypass grafting x 3. Please see operative note
for full details. She tolerated the procedure well and was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
Postoperatively she had a coagulopathy requiring transfusion
of three packed red blood cells. She weaned from sedation,
awoke neurologically intact and was extubated on POD 1. She was
weaned from inotropic and vasopressor support. Beta blocker was
initiated and she was diuresed toward her preoperative weight.
Lasix drip was initiated. Postoperatively her creatnine peaked
at 5.9. She weaned off the Lasix drip to bolus dosing and
eventually transitioned to PO Torsemide. Patient remained
hemodynamically stable and was transferred to the telemetry
floor for further recovery. Chest tubes and pacing wires were
discontinued per protocol without incident. Home flexeril
resumed for chronic leg spasms and oxycodone was resumed for
pain (patient takes Percocet at home). Keflex was started for
erythema surrounding sternal incision borders, patient remained
afebrile with normal WBC. No drainage or appreciable fluid
collection, sternum stable. She was evaluated by the physical
therapy service for assistance with strength and mobility. Her
renal functions slowly improved and she eventually transitioned
and responded well to her home Demedex dose. By the time of
discharge on POD 11 her creatnine was 4.0, she was ambulating
with assistance, her wound was healing, and pain was controlled
with oral analgesics. She was discharged to ___ in
good condition with appropriate follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Torsemide 10 mg PO EVERY OTHER DAY
5. amLODIPine 10 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Glargine 30 Units Breakfast
8. Docusate Sodium 100 mg PO BID
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Cyclobenzaprine 10 mg PO BID:PRN muscle spasm
12. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO BID:PRN
BREAKTHROUGH PAIN
13. Senna 17.2 mg PO QHS
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
wheezing/shortness of breath
2. Cephalexin 500 mg PO Q8H Duration: 7 Days
3. Lactulose 30 mL PO DAILY
4. Metoprolol Tartrate 50 mg PO TID
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
6. Potassium Chloride 20 mEq PO Q12H
7. Ranitidine 150 mg PO DAILY
8. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
9. Acetaminophen 1000 mg PO Q6H
10. Atorvastatin 80 mg PO QPM
11. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
12. Torsemide 40 mg PO DAILY
13. Aspirin EC 81 mg PO DAILY
14. Cyclobenzaprine 10 mg PO BID:PRN muscle spasm
15. Docusate Sodium 100 mg PO BID
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. Senna 17.2 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, mild erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
tr edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10367718-DS-24 | 10,367,718 | 25,984,649 | DS | 24 | 2192-05-13 00:00:00 | 2192-05-13 18:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ pmhx of CAD s/p multiple PCI & recent CABG ___
(LIMA-LAD,
SVG-OM, SVG-RPDA), CKD (b/l Cr 2.9-3.4), HTN, HLD, OSA who
presented to ED for back spasms pain control and developed chest
discomfort in the ED with TWI on ECG.
She was doing well from prior CABG. No CP, dyspnea,
palpitations,
orthopnea, PND, lightheadedness, weight gain. Exercising,
dieting
well, losing weight since CABG. Came with 2 wks acute on chronic
severe back pain/spasms. Flexeril was previously tried without
relief in a prior ED visit.
While in the ED she was treated with trigger point injection in
the ED after which she noticed pain began to radiate to left
side
of chest under bra line.
ECG: lateral TWI new compared to prior ECG but stable over
course
of ED time
Trop: 0.08 -> 0.08 -> 0.09 -> 0.10
Cr: 3.5 (b/l 2.9-3.4)
Cardiology saw the patient, recommended stress given risk
factors.
Was planned for ED Obs w/nuc stress but given delay of nuclear
stress and rising trop patient being admitted to medicine.
___ was consulted, on their assessment, patient reported back
pain and chest discomfort had resolved. Chest discomfort lasted
~1hr after trigger point injection and resolved on its own. Back
pain per patient resolved only after oxycodone PO. She strongly
insists morphine has no effect.
On arrival to the the floor, pt reiterates that chest pressure
started after the trigger point injection and felt like it
originated from her back and wrapped to the front of her chest.
She described it as a "brick". She reports that that chest
pressure has improved but is still present. No back pain. She
reports that oxycodone is the only thing medication that makes
her back pain tolerable, she says she has a pain clinic
appointment on ___.
Denies dyspnea on exertion, palpitations, fever, chills, abd
pain, change in LLE, orthopnea or PND.
Does endorse mild dizziness.
REVIEW OF SYSTEMS:
Positive per HPI. All of the other review of systems were
negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes Mellitus Type II, on Insulin c/b nephropathy
- Hypertension
- hyperlipidemia
- Obstructive Sleep Apnea
- Chronic Kidney Disease (baseline Cre 2.9-3.4) ___ diabetic
- Normocytic Anemia
2. CARDIAC HISTORY
- CABG: 3vCABG on ___ (LIMA-LAD, rSVG-OM, and rSVG-RPDA)
- PERCUTANEOUS CORONARY INTERVENTIONS: RCA stent ___, ___
stent ___, ___ 3 to LAD ___, ___ ___ last cath
___ showing patent LAD, RCA, and LCx stent, with distal
90% RCA treated with dES x1)
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
-Leg Pain, chronic right
-Legally Blind, right eye
-Vitiligo
Social History:
___
Family History:
Multiple family members with cardiac disease as well as cancer -
too many for her to enumerate
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: Afebrile, HR 90, BP 144/69, RR 16 93% RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: no LAD, JVD2-3cm above clavical
CV: RRR, S1/S2, no murmurs, gallops, or rubs. Midline sternotomy
scar healing well, has 2 scabs midline and inferior end no
drainage or tenderness.
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding,
EXTREMITIES: no cyanosis, clubbing, or trace LL edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no lesions, no rashes
DISCHARGE PHYSICAL EXAM:
======================
VS 98.___ ___
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: no LAD, JVD flat
CV: RRR, S1/S2, no murmurs, gallops, or rubs. Midline sternotomy
scar healing well, has 2 scabs midline and inferior end no
drainage or tenderness.
PULM: CTAB, no wheezes, rales, rhonchi,
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding,
EXTREMITIES: no cyanosis, clubbing, or trace LL edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Pertinent Results:
ADMISSION LABS:
==============
___ 10:00PM cTropnT-0.08*
___ 05:50PM GLUCOSE-80 UREA N-75* CREAT-3.5*# SODIUM-142
POTASSIUM-5.4 CHLORIDE-109* TOTAL CO2-18* ANION GAP-15
___ 05:50PM estGFR-Using this
___ 05:50PM CK(CPK)-81
___ 05:50PM cTropnT-0.08*
___ 05:50PM CK-MB-5 proBNP-3636*
___ 05:50PM WBC-5.3 RBC-3.20* HGB-9.5* HCT-31.2* MCV-98
MCH-29.7 MCHC-30.4* RDW-16.0* RDWSD-57.5*
___ 05:50PM NEUTS-55.1 ___ MONOS-9.7 EOS-7.8*
BASOS-0.6 IM ___ AbsNeut-2.90 AbsLymp-1.39 AbsMono-0.51
AbsEos-0.41 AbsBaso-0.03
___ 05:50PM PLT COUNT-213
___ 04:00PM URINE HOURS-RANDOM
___ 04:00PM URINE UHOLD-HOLD
___ 04:00PM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 04:00PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
___ 04:00PM URINE RBC-6* WBC-13* BACTERIA-FEW* YEAST-NONE
EPI-4 TRANS EPI-<1
___ 04:00PM URINE MUCOUS-RARE*
INTERVAL LABS:
===============
___ 05:50PM BLOOD CK-MB-5 proBNP-3636*
___ 05:50PM BLOOD cTropnT-0.08*
___ 10:00PM BLOOD cTropnT-0.08*
___ 02:27AM BLOOD cTropnT-0.09*
___ 06:35AM BLOOD CK-MB-4 cTropnT-0.10*
___ 09:20PM BLOOD CK-MB-4 cTropnT-0.10*
___ 07:49AM BLOOD CK-MB-3 cTropnT-0.08*
DISCHARGE LABS:
===============
___ 07:25AM BLOOD Glucose-124* UreaN-64* Creat-3.6* Na-139
K-4.9 Cl-105 HCO3-21* AnGap-13
___ 07:25AM BLOOD Calcium-9.6 Phos-4.7* Mg-2.6
IMAGING:
========
___ Nuclear stress test:
IMPRESSION: 1. Moderate fixed inferior wall defect. 2. Mildly
decreased left
ventricular ejection fraction. Normal left ventricular cavity
size
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Appropriate hemodynamic response to the Regadenoson infusion.
Nuclear
report sent separately.
___ CXR:
IMPRESSION: No acute cardiopulmonary abnormality.
MICROBIOLOGY:
=============
___ 4:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
TRANSITIONAL ISSUES:
==================
[] Discharge weight: 178.35 lbs
[] Discharge diuretic: Home Torsemide 40mg PO daily
[] Discharge Cr: 3.6 (s/p nuc stress ___
[] Stress test was done revealing: No acute ischemia
[] Patient DC'd with short course of Oxycodone 5mg please
continue to counsel regarding opioid use and importance of
having a single provider for narcotics. MassPMP reviewed.
[] Please ensure patient has follow up with Pain clinic
[] Please continue to titrate or discontinue cyclobenzaprine and
gabapentin
[] Patient discharged on calcitriol, while confirming PAML pt
reports that she was not taking at home. This was started on ___
per nephrology
[] Please evaluate if patient would benefit from a replacement
CPAP for OSA
___ pmhx of CAD s/p multiple PCI & recent CABG ___
(LIMA-LAD, SVG-OM, SVG-RPDA), CKD (b/l Cr 2.9-3.4), HTN, HLD,
OSA who presented to ED for back spasms pain control and
developed chest discomfort in the ED with TWI on ECG.
# CORONARIES: s/p CABG
# PUMP: EF >55%
# RHYTHM: NSR
ACTIVE ISSUES:
============
# Chest pain
# CAD s/p CABG
Seems more likely MSK, possibly related to trigger point
injection particularly given time course relation. Trops are
quite flat peaked at 0.1 for Cr 3.5, with MB never elevated. EKG
with new TWI in lateral leads. However, given risk factors, she
was admitted for nuc stress. Continued home medications metop,
amlodipine, and torsemide 40mg PO daily and ASA/statin. Nuclear
stress test done and revealed Moderate fixed inferior wall
defect; Mildly decreased left ventricular ejection fraction.
Normal left ventricular cavity size.
# Back Spasm
Chronic issue, per patient PO oxy and cyclobenzaprine is only
fix. IV morphine did nothing. She feels trigger point injection
also not helpful. Prior skin rxn to lidocaine patch. Also
previously tried on vallium without success. Managed with oxy 5
and APAP while admitted. Held home cyclobenzaprine and
gabapentin, however may resume at discharge if helpful.
Discharged with short course of Oxy 5 mg, MassPMP reviewed.
# CKD baseline Cr 2.9-3.4
Roughly at her baseline. Is still making urine. Cr on admission
3.5 and on discharge 3.2. Continued home calcitriol and
torsemide.
# U/A
Patient given initially started on CTX ?probably for U/A, given
absence of sxs, bland U/A, neg cx will discontinued further
antibiotics.
# PAML
She is taking some medications not a directed (denies taking
KCL,
taking gabapentin as prn, denies taking calcitriol despite
recent
refill). Also has oxycodone, usually as Percocet, though at
times
as oxycodone alone. By MassPMP there is not a regular interval
of
prescription ___ between refills) but otherwise no suspicious
filling pattern. Oxy ___ daily prn seems reasonably close to
outpt dosing.
CHRONIC ISSUES:
==============
# DM: ISS
#Normocytic anemia: CTM
#HTN: Meds as above
#OSA: Not on home CPAP, used one prior but broke and unable to
get a replacement
# CODE: Full presumed
# CONTACT: HCP:
___, Daughter
Phone number: ___
Cell phone: ___
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Cyclobenzaprine 10 mg PO BID:PRN muscle spasm
5. Torsemide 40 mg PO DAILY
6. Metoprolol Tartrate 50 mg PO TID
7. Calcitriol 0.25 mcg PO 3X/WEEK (___)
8. amLODIPine 10 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN Pain
- Moderate
12. Gabapentin 300 mg PO BID:PRN pain
13. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth twice a day as needed
Disp #*8 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 [GentleLax] 17 gram/dose 17 g by
mouth daily as needed Disp #*1 Bottle Refills:*0
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides 8.6 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever
5. amLODIPine 10 mg PO DAILY
6. Aspirin EC 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Calcitriol 0.25 mcg PO 3X/WEEK (___)
9. Cyclobenzaprine 10 mg PO BID:PRN muscle spasm
10. Gabapentin 300 mg PO BID:PRN pain
11. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
12. Metoprolol Tartrate 50 mg PO TID
13. Multivitamins 1 TAB PO DAILY
14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
15. Torsemide 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
back pain and non-cardiac chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having back pain then developed chest pain
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We monitored your heart enzymes
- You had a stress test to see if your heart function changes
with stress, this was normal
- Your back and chest pain improved and you were ready to go
home.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs from your discharge weight of
178.35 lbs.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, chest pain, abdominal
distention, or shortness of breath at night.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10367793-DS-8 | 10,367,793 | 24,876,044 | DS | 8 | 2194-06-01 00:00:00 | 2194-06-03 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:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old healthy man presents with fever, productive cough,
and dyspnea on exertion. Symptoms began 5 days ago. Associated
vomiting and central chest pain with coughing. Significant
anorexia and night sweats. No nasal congestion, sinus pressure,
headache, or sore throat. Denies unintentional weight loss,
hemoptysis. Traveled to ___ ___ years ago, otherwise no
travel outside of country. No h/o incarceration or known TB
exposure. HIV negative in ___. No known sick contacts.
History of intermittent smoking as a teenager, no smoking
currently. No history of asthma. No history of pneumonia in
past.
In the ED, initial vital signs were 102.3 98 146/85 20 97% RA.
Labs notable for WBC 21.4 (81% PMN), lactate 2.7 (improved to
1.0 with 2L fluids), normal chem 7, UA without signs of UTI.
CXR showed multifocal consolidating pneumonia. Received
levofloxacin 750mg, azithromycin 500mg x1 and 250mg x1,
acetaminophen and albuterol/ipratropium nebulizers. He was kept
in ED observation overnight, but became tachypneic when walking
short distances, so he was admitted. Vitals prior to transfer:
100 82 131/79 16 97%.
Upon arrival to the floor, patient is slightly dyspneic, but
satting well (99%) on room air.
Review of Systems:
(+) per HPI
(-) per HPI, otherwise denies abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Obesity
Social History:
___
Family History:
His father died in his ___ with HIV. His mother died at age ___,
cardiac arrest, in the hospital from knee surgery. He has had
one brother murdered. He has three daughters, one of which had
rhabdomyosarcoma resected at age ___ and another who developed
chronic lung disease as an infant. No h/o CAD/MI, DM2, other
malignancies, or sudden death.
Physical Exam:
Admission:
Vitals- 98.5 154/90 89 16 99% RA
General- Alert, oriented, respirations unlabored
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- diffuse crackles posteriorly, occasional rhonchi,
occasional expiratory wheeze anteriorly
CV- RRR, no M/R/G
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge:
Vitals- 98.9 Tm 100 120/60 p75 R16 100RA
General- Alert, oriented, respirations unlabored
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- diffuse crackles posteriorly, occasional rhonchi and
wheezing CV- RRR, no M/R/G
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission:
___ 10:15PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-6.0 LEUK-NEG
___ 10:15PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 10:15PM URINE MUCOUS-MOD
___ 09:43PM LACTATE-2.7*
___ 09:15PM GLUCOSE-172* UREA N-10 CREAT-0.9 SODIUM-135
POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-23 ANION GAP-20
___ 09:15PM estGFR-Using this
___ 09:15PM WBC-20.5*# RBC-4.67 HGB-14.0 HCT-41.9 MCV-90
MCH-30.0 MCHC-33.5 RDW-13.5
___ 09:15PM NEUTS-85.5* LYMPHS-6.6* MONOS-6.0 EOS-1.5
BASOS-0.3
___ 09:15PM PLT COUNT-266
Discharge:
___ 06:50AM BLOOD WBC-17.4* RBC-4.12* Hgb-12.2* Hct-37.1*
MCV-90 MCH-29.6 MCHC-32.9 RDW-14.0 Plt ___
___ 06:50AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-140 K-3.9
Cl-103 HCO3-25 AnGap-16
___ 06:38AM BLOOD Lactate-1.0
CPK ISOENZYMES proBNP
___ 07:49 541
HIV SEROLOGY HIV Ab
___ 07:49 NEGATIVE
Micro:
___ 3:30 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0550.
PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
Clinical correlation and additional testing suggested
including
culture and detection of serum antibody.
___ 10:15 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ URINE URINE CULTURE-NEGATIVE
Imaging:
Radiology Report CHEST (PA & LAT) Study Date of ___ 8:38 ___
IMPRESSION:
Multifocal consolidative opacities concerning for multifocal
pneumonia.
Followup radiographs after treatment are recommended to ensure
resolution of these findings.
Radiology Report CHEST (PA & LAT) Study Date of ___ 10:00
AM
CHEST, PA and lateral.
COMPARISON: ___. Comparison is made with the prior
chest x-ray and this shows increased in opacification in both
the right upper lobe and the left lung. Costophrenic angles
remain sharp.
IMPRESSION:
Worsening pneumonia.
Brief Hospital Course:
___ year old healthy man presents with fever, productive cough,
and dyspnea, found to have multifocal consolidative pneumonia.
# Legionella pneumonia: Patient presented with five days of
dyspnea. Chest x ray on ___ showed multifocal consolidative
opacities concerning for multifocal pneumonia. Patient met SIRS
criteria (temp >100.4, HR >90, leukocytosis) but with normal
oxygen saturation. Community acquired pathogens (most likely
S.pneumo) initially suspected. Influenza less likely given
incidence has dropped with the finishing season (also he is ___
days from symptom onset which places him out of the window for
treatment). Patient had no known TB exposure risk factors, but
was checked for immunocompromised state given severity of
pneumonia and ___ age. HIV antibody was negative. Notably he
does not have underlying lung disease (no COPD/asthma). Sputum
culture had extensive contamination with upper respiratory
secretions. A urine legionella antigen was check and positive.
Patient was started on levofloxacin 750mg for a 5 day course.
He was also given albuterol and ipratropium nebulizer for
wheezing on exam and subjective dyspnea. He was given mucinex
as needed for cough and tylenol as needed for fever. Dept
public health notified of positive legionella by the lab.
# Obesity/Metabolic: Elevated blood glucose on testing, needs
repeat HbA1C as an outpatient and well as ongoing dietary and
exercise counseling.
Transitional Issues:
- Recommend repeat CXR to ensure resolution in several weeks
- Recommend repeat HbA1C
- Patient will complete course of levofloxacin
- Blood cultures pending
- Urine legionella positive and Dept Public health notified
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Ibuprofen 400 mg PO Q8H:PRN pain/fever
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 4 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
2. Calcium Carbonate 500 mg PO DAILY
3. Ibuprofen 400 mg PO Q8H:PRN pain/fever
4. Multivitamins 1 TAB PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain or fever
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
6. Guaifenesin ER 600 mg PO Q12H
RX *guaifenesin 600 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: pneumonia
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
with a pneumonia and started on antibiotics. You will need to
complete a course of antibiotics as prescribed. Recommend an
x-ray to make sure it has completely resolved in 6 weeks.
Medication changes:
Please finish course of Levofloxacin
Followup Instructions:
___
|
10367793-DS-9 | 10,367,793 | 29,183,099 | DS | 9 | 2199-10-01 00:00:00 | 2199-10-01 15:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right open ankle fracture dislocation, left tibial shaft
fracture, right elbow soft tissue wound, right ___ metacarpal
base fracture
Major Surgical or Invasive Procedure:
___ for ORIF of the right ankle fracture, ORIF and external
fixation of the left tibial plateau fracture, prophylactic
anterior and lateral left lower extremity fasciotomy and wound
vacuum placement, on ___ for right ___ fracture ORIF,
and
___ for Remove ex fix, I and D, ORIF tibia, STSG left leg
History of Present Illness:
___ male with no medical history presented after a motorcycle
accident. Patient reported he was cut off while driving a
motorcycle at unknown speed, was thrown from his motorcycle
while helmeted, striking the ground. Noted immediate pain in
his right arm, right leg, left leg. Denied numbness, weakness,
tingling in any extremity. Denied loss of consciousness,
abdominal pain. No dizziness or syncope.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
VSS
General: Well-appearing, breathing comfortably
MSK:
-LLE: leg swollen, vac removed; dressings intact, STSG site
c/d/i; fires ___ actively; sensation is intact to
DPN/SPN/saphenous/sural/tibial distributions, exposed toes warm
with brisk capillary refill
-RLE: short leg splint intact; fires ___ within splint;
sensation intact over exposed toes; brisk capillary refill to
exposed toes
Pertinent Results:
See OMR for all lab and imaging results
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a Right open ankle fracture dislocation, left tibial
shaft fracture, right elbow soft tissue wound, right ___
metacarpal base fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF of the right ankle fracture, ORIF and external
fixation of the left tibial plateau fracture, prophylactic
anterior and lateral left lower extremity fasciotomy and wound
vacuum placement, on ___ for right ___ fracture ORIF, and
___ for Remove ex fix, I and D, ORIF tibia, STSG left leg,
which the patient tolerated well. For full details of the
procedures please see the separately dictated operative reports.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient was given 1 unit of pRBCs on ___ with following
stabilization of crits to discharge. 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
platform weight bearing in the right upper extremity, non weight
bearing in the left lower extremity and right lower extremity,
weight bearing as tolerated in the left upper extremity, and
will be discharged on Lovenox 30mg twice daily for DVT
prophylaxis. The patient will follow up with Dr. ___ Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 975 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. Enoxaparin Sodium 30 mg SC Q12H
5. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*45 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY constipation
7. Senna 17.2 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right open ankle fracture dislocation, left tibial shaft
fracture, right elbow soft tissue wound, right ___ metacarpal
base fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - may require assistance or aid
(walker or cane).
Discharge Instructions:
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Platform weight bearing right upper extremity; non weight
bearing left lower extremity and right lower extremity; weight
bearing as tolerated left upper extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add Oxycodone 5mg as needed for increased pain. Aim to
wean off this medication in 1 week or sooner. This is an
example on how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox 30mg twice daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
Platform weight bearing right upper extremity; non weight
bearing left lower extremity and right lower extremity; weight
bearing as tolerated of left upper extremity
functional mobility
patient/caregiver education
balance training
___
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
10367989-DS-19 | 10,367,989 | 28,108,922 | DS | 19 | 2142-03-20 00:00:00 | 2142-03-20 16:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
R PCN
L PCNU
History of Present Illness:
___ yo man with severe BPH and a chronic indwelling foley,
atrial fibrillation on Coumadin, CKD with recent baseline
3.0-3.4, frequent UTIs, gout, who presents from rehab for
worsening ___ and hypokalemia.
Patient was recently admitted to ___ ___ during
that admission he presented for hematuria and was found to have
VRE bacteremia which was felt to be due to urinary source. On
admission there he was noted to have ___ with Cr 4.8 on
admission. He had imaging there which showed bilateral
hydronephrosis. During the admission he was also noted to have a
gout flair and was started on prednisone. On discharge from
___ his Cr 3.4 and BUN was 107. He was discharged to rehab
where his toresemide and metolazone were restarted. There his
labs were monitored and he was found to have a Cr of 3.9 and BUN
of 145 and potassium of 3.0. Due to this he was sent to the ED.
In the ED his vitals were T-max 98.4, heart rate 70, blood
pressure 102/55, respiratory rate 18 satting 98% on room air.
Labs were sent which were remarkable for creatinine of 3.8 a BUN
of 143, white blood cell count of 6.6, potassium of 3.5, UA sent
from his chronic indwelling Foley showed 45 white blood cells.
He was started on ceftriaxone for presumed UTI and given 40 of
potassium. He underwent a CT of his head which showed no acute
intracranial process. He underwent a CT of his abdomen which
showed bilateral severe hydronephrosis and hydroureter without
obstructing stones asymmetric thickening of the posterior
lateral
lateral wall with a prominent area up along the posterior wall
of
the bladder measuring 9 x 4 x 7 concerning for a bladder mass.
He was subsequently admitted to medicine for further care.
On arrival to the floor the patient is a poor historian but
denies any urinary frequency or burning. He states he has been
doing very well at rehab and was looking forward to going home.
He is oriented to himself but not place or year.
14 point ROS reviewed and negative except HPI
Past Medical History:
Urinary obstruction attributed to presumed BPH
Atrial fibrillation
CKD IV
HFrEF
Tracheomalacia
DM2, no longer needing meds i.s.o worsening CKD
HLD
HTN
Gout
Frequent UTI
positive PPD
chronic thrombocytopenia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
VS: ___ ___ Temp: 97.7 PO BP: 125/63 HR: 64 RR: 16 O2 sat:
100% O2 delivery: Ra
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self only
On discharge
96.2 141 / 80 75 16 100 RA
Gen: Thin male, NAD, comfortably lying flat
+ wasting above scapula
Lung: Very faint rales at bases
CV: Irregular
Abd: Soft, nabs, nt/nd
Ext: NO edema
Neuro: Oriented to person, year is "___", unable to tell me date
or name of President.
+ R and L PCN tubes draining clear urine
Pertinent Results:
**************
LABS
**************
ADMISSION LABS
___ 08:45PM BLOOD WBC-6.6 RBC-2.61* Hgb-8.0* Hct-25.0*
MCV-96 MCH-30.7 MCHC-32.0 RDW-15.9* RDWSD-54.5* Plt ___
___ 08:45PM BLOOD Glucose-170* UreaN-143* Creat-3.8*
Na-134* K-3.5 Cl-86* HCO3-28 AnGap-20*
___ 08:45PM BLOOD ALT-19 AST-26 AlkPhos-150* TotBili-0.4
___ 08:45PM BLOOD Albumin-3.1* Calcium-8.7 Phos-4.6* Mg-1.9
___ 08:58PM BLOOD Lactate-1.6 K-3.2*
**************
IMAGING
**************
CT ABD/PELVIS W/O ___
1. Bilateral severe hydroureteronephrosis likely due to
malignant obstruction at the level of the bilateral UVJ.
Suspect large bladder mass along the posterior wall for which
ultrasound may be performed to further assess.
2. Sclerotic region within the T11 vertebral body is potentially
concerning for osseous metastasis.
3. Severe cardiomegaly.
4. Normal appendix.
MRI PELVIS ___
1. Large mass, likely arising from the prostate, invading the
urinary bladder anteriorly and the anterior wall of the rectum
posteriorly, with extension up to the bilateral lateral pelvic
side walls, measuring up to 10.4 cm in maximum dimension
concerning for a prostate neoplasm. Given the large size, a
sarcoma is in the differential.
2. Bilateral pelvic sidewall lymph nodes with abnormal
morphology
are suspicious for metastatic involvement.
3. Extensive osseous metastases are seen in the pelvic bones as
described above.
4. Scout images demonstrate severe bilateral
hydroureteronephrosis.
**************
MICRO
**************
BCx ___ (one of one bottle)
VIRIDANS STREPTOCOCCI
CEFTRIAXONE----------- 0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 2 R
PENICILLIN G---------- 0.12 S
VANCOMYCIN------------ 0.5 S
ABIOTROPHIA/GRANULICATELLA
BCx ___: NO GROWTH x2
Urine cultures of his bilateral PCNs ___: NO GROWTH
The telemetry captured no pushbutton activations. It showed a
slow
backgroundand occasional bursts of generalized slowing
throughout, indicating a widespread encephalopathy. The
recording cannot specify the etiology, but metabolic
disturbances, infections, and medications are among the most
common causes. There were no areas of prominent focal slowing,
but encephalopathies may obscure focal findings. There were no
epileptiform features or electrographic seizures.
C. difficile PCR (Final ___:
Reported to and read back by ___ @ ___ ON ___
- ___.
POSITIVE. (Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of
C. difficile and detects both C. difficile infection
(CDI) and
asymptomatic carriage. Therefore, positive C. diff PCR
tests
trigger reflex C. difficile toxin testing, which is
highly
specific for CDI.
C. difficile Toxin antigen assay (Final ___:
NEGATIVE. (Reference Range-Negative).
PERFORMED BY ___.
This result indicates a low likelihood of C. difficile
infection
(CDI).
Discharge Labs
___ 04:13AM BLOOD WBC-5.8 RBC-2.32* Hgb-7.1* Hct-22.1*
MCV-95 MCH-30.6 MCHC-32.1 RDW-18.7* RDWSD-62.6* Plt ___
___ 04:13AM BLOOD Glucose-92 UreaN-65* Creat-3.3* Na-139
K-6.0* Cl-107 HCO3-18* AnGap-14
Brief Hospital Course:
TRANSITIONAL ISSUES:
___ w/ chronic urinary obstruction w/ b/l hydro (now w/
indwelling Foley), CKD IV (recent baseline Cr 3.0-3.4), HFrEF
(EF 35-40%), a-fib (on warfarin), admitted w/ ___, possibly due
to some combination of over-diuresis and chronic ureteric
obstruction. He is s/p L PCNU and R PCN, which have been c/b
significant hematuria but since resolved. Imaging shows a large
pelvic tumor invading the bladder and rectum and with numerous
bony mets to the pelvis. PSA is 400, so this is presumed to be
metastatic prostate cancer. Also with Strep viridans bacteremia
(oral source?), for which he is on CTX. Hospital course also
marked by delirium.
# Hematuria
# Acute blood-loss anemia
# Anemia of CKD
Chronic anemia progressively worsening even prior to onset of
hematuria, probably mostly from his CKD. Hgb had been hovering
around 6.9-7.1 during his admission.
After his PCNs he has been having significant hematuria. He
has been transfused 3u pRBCs on ___ and ___. Renal US
reassuring that there is no perinephric hematoma. Started on
CBI, then stopped ___. He had continued bleed from tubes,
especially Right, which ___ believed that the bleeding was likely
from clots, not active bleeding from the kidney. Hematuria did
resolve.
He failed capping trial x 3, discussed with ___, and this was
felt to be due to likely bladder outlet obstruction from
enlarged prostate. Will leave both PCN tubes uncapped.
Hematocrit is 22 on discharge. At this point, anemia likely
driven by anemia of renal disease and marrow suppression given
infection, malignancy.
# ___ on CKD V
# Obstructive uropathy
# Hypovolemia
He appeared over-diuresed on arrival; diuretics were held
but his PO intake has been poor enough that he has not
auto-corrected to euvolemia. Cr has improved somewhat with 3L of
IV fluid given cautiously over several days and with holding
torsemide and metolazone.
He also has progressive and chronic bilateral hydronephrosis
(which did not normalize with indwelling Foley), likely due to
his large pelvic tumor). Bilateral PCNs placed in ___ on ___.
After his PCNs, Cr did not initially improve, but then had slow
improvement to 3.3. His creatinine in ___ was 1.7
# Chronic systolic CHF:
Previously had severe cardiomyopathy with EF 20% attributed to
medication non adherence. With medical therapy his EF improved
to 35-40%. He had been on spironolactone previously. His
diuretics had been steadily increased as an outpatient. He
seems euvolemic here currently. Dry wt is around 135.
Continued hydral and nitrate. Throughout inpatient stay
torsemide and metolazone were held, and discharge weight was
130, so will continue to hold diuretics.
# Atrial Fibrillation
CHA2DS2-VASc is 4. CHADS2 is 3, suggesting he fits well within
the BRIDGE trial and bridging anticoagulation would be of no
benefit. Discussed with wife possibility that risks (bleeding)
and benefits (CVA prevention) with use of warfarin, and she felt
that she would prefer avoiding risk of bleeding so warfarin held
for now. Restart in the future can be considered should HCP
favor taking recurrent risk of hematuria.
#METASTATIC PROSTATE CANCER
MRI shows "large mass, likely arising from the prostate,
invading the urinary bladder anteriorly and the anterior wall of
the rectum posteriorly, with extension up to the bilateral
lateral pelvic side walls, measuring up to 10.4 cm in maximum
dimension, concerning for a prostate neoplasm." This appears to
be metastatic to regional lymph nodes and to the pelvis. PSA is
400, so the pelvic mass is almost certainly prostate cancer.
Most recent cystoscopy was less than six months ago and was
negative for malignancy, suggesting the mass does not arise from
the bladder. Case discussed with urology resident and medical
oncology fellow, who both feel that a PSA that high obviates the
need for biopsy.
Wife is in agreement that treatment is worth pursuing, given
tolerable side effect profile. Patient started on casodex and
will follow up with heme/onc as outpatient.
# Viridans Strep Bacteremia:
Initial blood cx with viridans strep and Abiotrophia
defectiva. Seen by ID who think this may be real, not just a
contaminant. They were concerned for an oral source, but dental
exam and Panorex were reassuring. I would also consider a
urogenital source, given comorbidities as above. CTX 2g daily; 4
wk course per ID team through ___
Per ID note:
___: BCx positive for strep viridans and
Abiotrophia/Granulicatella
___: BCxs cleared
___: Started on ceftriaxone, D1
___: TTE w/o evidence of endocarditis
PICC placement: pending
___: last day of ceftriaxone
For monitoring, please check the following labs within one week
and fax to ___ clinic
CEFTRIAXONE: CBC with differential, BUN, Cr, AST, ALT,
Total Bili, ALK PHOS
___ CLINIC - FAX: ___
# C Diff: Developed diarrhea and now C diff positive. He is
clinically
stable without signs of toxicity, overall improved after the
start of vanco.
- Initiated PO vanco 125mg QID, d1 = ___, would treat until
antibiotic course is over on ___
# Delirium: Patient with paranoia, visual hallucinations, ___
and ___. Started trazodone every evening on 730 with good
effect. He has dementia at baseline. EEG showed diffuse
slowing.
# 2 episodes of brief unresponsiveness: RN witnessed patient
with lower lip "drop" followed by five seconds of a blank stare,
after which he was alert, and at his baseline. Wife also saw
patient experience a five second of unresponsiveness Discussed
with neurology and EEG was performed to r/o partial seizures and
no seizure activity seen on EEG.
# Goals of care: Discussed at length with ___, who agrees
that his confusion,
delirium is worse than prior, and that he has a ___ year old
everything" and she agrees he is unlikely to recover. She
stated that he should be a DNR/DNI, will not escalate care to
ICU. When his condition deteriorates further, she would like to
pursue a hospice approach. In the meantime, will continue
present plan of care, including antibiotics, treatment with
casodex for prostate cancer, and, hospitalization.
Patient appears very eager to be out of the hospital, however,
and had tears of joy on hearing he would be discharged.
Nearly one hour spent on coordination of care on day of
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Omeprazole 20 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. Finasteride 5 mg PO DAILY
5. Isosorbide Dinitrate 20 mg PO BID
6. Torsemide 100 mg PO DAILY
7. HydrALAZINE 50 mg PO BID
8. Warfarin 2.5 mg PO DAILY16
9. MetOLazone 5 mg PO DAILY
10. PredniSONE 10 mg PO DAILY
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
12. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
13. Calcitriol 0.25 mcg PO DAILY
Discharge Medications:
1. Casodex (bicalutamide) 50 mg oral DAILY
2. CefTRIAXone 2 gm IV Q 24H
To finish on ___. Polyethylene Glycol 17 g PO DAILY
4. TraZODone 50 mg PO QHS
give at 730 ___
5. Vancomycin Oral Liquid ___ mg PO QID
To finish on ___. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Atorvastatin 20 mg PO QPM
8. Calcitriol 0.25 mcg PO DAILY
9. Finasteride 5 mg PO DAILY
10. HydrALAZINE 50 mg PO BID
11. Isosorbide Dinitrate 20 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute kidney injury
Chronic kidney disease stage IV
Chronic systolic CHF
Severe BPH with chronic Foley catheter
Metastatic prostate cancer
urinary obstruction
acute blood loss anemioa
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Confused - always.
Discharge Instructions:
You were admitted for evaluation of kidney failure. You were
seen by the urology team and the nephrology team. You were
evaluated for obstruction in your kidney system or heart failure
causing your kidney injury Nephrostomy tubes were placed In
addition, you were found to have prostate cancer likely
contributing to your symptoms. You had bleeding and required
blood transfusion. Because of your bleeding, we held your
warfarin. You were found to have a blood stream infection and
you will need to complete one more weeks of antibiotics. You
also were diagnosed with C diff infection and will complete
treatment with oral vancomycin.
It is very important that you follow up with a urology and
oncologist and a nephrologist for ongoing care
Please taka all medications as prescribed and keep all follow up
appointments.
Followup Instructions:
___
|
10368327-DS-20 | 10,368,327 | 22,627,761 | DS | 20 | 2152-09-13 00:00:00 | 2152-09-14 07:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Diovan / lisinopril
Attending: ___.
Chief Complaint:
Weakness, inability to transfer
Major Surgical or Invasive Procedure:
Placement of left upper extremity graft for hemodialysis.
Tunnel line catheter placement
History of Present Illness:
___ with hx of DM, HTN, HLD, PVD s/p right BKA, ___ (EF 25% on
ECHO from ___ presenting with weakness x2days. Pt noted that
he was unable to get up and transfer from bed to his wheelchair
two days ago when the ___ came to visit him. The ___ referred
him to the ED because of his weakness and inability to transfer.
Per pt report, he has never had this kind of weakness before,
but it has been improving since arrival to the ED. He denies
ever having any chest pain or shortness of breath along with
this weakness. Denies any fevers, chills, night sweats. No
N/V/D, no joint pain or muscle aches. He had a BKA surgery done
in ___ due to PVD leading to gangrene in his right foot.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +HLD, +HTN
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none known
-PACING/ICD: none known
3. OTHER PAST MEDICAL HISTORY:
#DM2 c/b retinopathy making him blind
#PAD s/p R BKA for RLE gangrene: BKA at ___ ___.
Previously treated with multiple angioplasties in RLE.
#hx diabetic foot ulcer with osteomyelitis s/p R ___ hallux
debridement/resection
#glaucoma
#CKD (III-IV) c/b renal osteodystrophy, anemia
#prostate cancer: Dx ___, with Dr. ___. Followed
by Dr. ___ in Urology. Seen ___ in ___ clinic to
discuss stereotactic XRT.
#anemia
#diabetic retinopathy, blind
#DLBCL s/p CHOP: ___
#HFrEF: ___ hospitalization for decompensated CHF at
which time proBNP was 17191 and patient had small NSTEMI
#CAD: Unknown anatomy. Declined cath previously because of renal
failure.
-NSTEMI in ___ complicated by cardiogenic shock with some
left-sided heart failure, ejection fraction in the 40-45% range
-NSTEMI ___ ___epression on EKG in ED in V2-V4 and
CKMB 13, TnT 2.65 that was managed medically
PAST SURGICAL HISTORY:
-___ RLE PTA & stent to distal SFA, PTA TP trunk & ___ ___
-R BKA at ___ ___
Social History:
___
Family History:
- Mother with DM, died at ___
- Father with htn but lived to ___
- Sister with htn, ruptured cerebral aneurysm, CAD
- 1 brother deceased in ___ (unclear etiology)
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T= 97.8, HR 95, 151/92, RR 18, 100% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI, normocephalic, atraumatic
Neck: supple, no JVD
CV: regular rate and rhythm, normal S1, S2, no m/r/g
Lungs: CTAB, no wheezing, rales, rhonchi, crackles
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally, right BKA
Neuro: moving all extremities grossly, A&O x4
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1, 104-109/53-60, HR 72-77, RR ___, 94-95% RA.
I/O: ___ since MN, 680/270 over past 24h
Wt: ___.1kg <- 64.0kg <- 65.4
General: NAD, comfortable, pleasant, thin and frail elderly male
Neck: supple, no JVD at 45 degrees
CV: RRR, normal S1, S2, no mururs, clicks, rubs, gallops, no
S3/S4
Lungs: CTAB, no wheezing, rales, rhonchi
Abdomen: soft, NT/ND
Ext: no lower extremity edema, right BKA, LUE graft in place,
left upper extremity graft site c/d/i w/o erythema or tenderness
but does have moderate swelling
Neuro: moving all extremities
Pertinent Results:
ADMISSION LABS:
___ 02:10PM BLOOD WBC-2.5* RBC-3.91* Hgb-13.0* Hct-44.0
MCV-113* MCH-33.4* MCHC-29.7* RDW-18.9* Plt ___
___ 02:10PM BLOOD Neuts-71.4* Lymphs-17.8* Monos-6.9
Eos-3.5 Baso-0.4
___ 02:10PM BLOOD Plt ___
___ 02:10PM BLOOD Glucose-205* UreaN-47* Creat-3.4* Na-138
K-6.5* Cl-108 HCO3-22 AnGap-15
___ 03:26PM BLOOD K-5.2*
CARDIAC ENZYMES:
___ 08:37AM BLOOD proBNP-GREATER THAN 70,000
___ 08:37AM BLOOD cTropnT-0.08*
___ 06:00PM BLOOD cTropnT-0.08*
CHEMISTRY:
___ 05:48AM BLOOD Albumin-2.6* Calcium-7.9* Phos-4.0 Mg-2.2
___ 03:00PM BLOOD Calcium-8.0* Phos-3.9 Mg-2.0
___ 03:05PM BLOOD Calcium-8.0* Mg-2.0
___ 05:55AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2
___ 06:00AM BLOOD Calcium-8.2* Phos-4.6* Mg-2.3
___ 09:30AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.1
___ 02:10PM BLOOD Glucose-205* UreaN-47* Creat-3.4* Na-138
K-6.5* Cl-108 HCO3-22 AnGap-15
___ 04:36AM BLOOD Glucose-71 UreaN-52* Creat-3.8* Na-138
K-3.8 Cl-104 HCO3-24 AnGap-14
___ 05:20AM BLOOD Glucose-64* UreaN-63* Creat-4.3* Na-137
K-3.6 Cl-98 HCO3-32 AnGap-11
___ 06:00AM BLOOD Glucose-202* UreaN-89* Creat-5.2* Na-139
K-3.6 Cl-92* HCO3-33* AnGap-18
___ 09:30AM BLOOD Glucose-143* UreaN-63* Creat-4.4* Na-136
K-3.8 Cl-94* HCO3-33* AnGap-13
CBC W/ DIFF:
___ 02:10PM BLOOD WBC-2.5* RBC-3.91* Hgb-13.0* Hct-44.0
MCV-113* MCH-33.4* MCHC-29.7* RDW-18.9* Plt ___
___ 04:36AM BLOOD WBC-2.5* RBC-3.03* Hgb-10.0* Hct-33.1*
MCV-109* MCH-33.0* MCHC-30.2* RDW-18.8* Plt Ct-82*
___ 03:05PM BLOOD WBC-2.7* RBC-3.28* Hgb-10.8* Hct-34.8*
MCV-106* MCH-33.0* MCHC-31.1 RDW-18.2* Plt Ct-97*
___ 06:00AM BLOOD WBC-4.4 RBC-2.91* Hgb-9.6* Hct-29.9*
MCV-103* MCH-32.9* MCHC-32.0 RDW-16.9* Plt ___
___ 09:30AM BLOOD WBC-3.7* RBC-2.90* Hgb-9.4* Hct-30.9*
MCV-107* MCH-32.5* MCHC-30.5* RDW-17.0* Plt ___
___ 02:10PM BLOOD Neuts-71.4* Lymphs-17.8* Monos-6.9
Eos-3.5 Baso-0.4
___ 08:37AM BLOOD Neuts-71.3* Lymphs-16.0* Monos-9.1
Eos-3.1 Baso-0.6
___ 11:00AM BLOOD Neuts-87.6* Lymphs-5.4* Monos-6.0 Eos-0.8
Baso-0.3
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-3.7* RBC-2.43* Hgb-8.0* Hct-25.5*
MCV-105* MCH-33.0* MCHC-31.5 RDW-17.2* Plt ___
___ 06:10AM BLOOD ___ PTT-34.1 ___
___ 06:10AM BLOOD Glucose-97 UreaN-48* Creat-4.5* Na-137
K-4.7 Cl-98 HCO3-29 AnGap-15
___ 06:10AM BLOOD Calcium-7.9* Phos-3.6 Mg-2.2
IMAGING:
ECHO ___: The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is severe global left ventricular hypokinesis (LVEF = ___.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Doppler parameters are most
consistent with Grade II (moderate) left ventricular diastolic
dysfunction. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction.
Moderate right ventricular systolic dysfunction. Mild mitral
regurgitation. Mild to moderate tricuspid regurgitation. Pleural
effusions.
CT ABDOMEN PELVIS ___: FINDINGS:
LOWER CHEST: There are very large bilateral layering
nonhemorrhagic pleural effusions with adjacent compressive
atelectasis of the lungs. Please see the CT chest report from
the same day for full details of the lungs.
ABDOMEN: Evaluation the abdomen is limited given the lack of IV
contrast. With this limitation in mind, no focal liver lesions
are noted. The spleen is normal in size. Both kidneys are normal
in size. The adrenal glands are within normal limits.
Pericholecystic fluid is noted, but likely due to generalized
fluid overload. Calcifications of the splenic artery as well as
moderate calcifications of the aorta particular at the distal
aspects and through to the bifurcation are noted. Oral contrast
is administered to the patient and flows freely through the
bowel. The patient is status post resection of the right lower
quadrant mass and within the confines of a noncontrast study,
there does not appear to be any recurrence in this area.
No lymphadenopathy is identified.
PELVIS: There is a moderate amount of free fluid within the
pelvis,
nonhemorrhagic. A Foley catheter is in the bladder. The rectum
appears normal.
No pelvic lymphadenopathy is identified.
BONES AND SOFT TISSUES: No suspicious bony lesions are seen.
Calcification of the intervertebral disc at the T10-T11 level is
noted. There is extensive generalized anasarca. A lipoma is
noted near the patient's right flank.
IMPRESSION:
1. Large bilateral pleural effusions, generalized anasarca and
free fluid in the pelvis. This may reflect fluid overload or
malnutrition /hypoalbuminemia ,renal or hepatic compared
2. Limited study without IV contrast, but no evidence of
lymphadenopathy or recurrence of the right lower quadrant mass.
VENOUS DUPLEX ___:
FINDINGS: On the right, the cephalic and basilic veins were
patent. The
cephalic vein was small with a distal IV present. Measurements
were 0.13 to 0.24 cm. The basilic vein was patent and larger
with measurements of 0.22 cm.
On the left, the cephalic and basilic veins were patent. The
cephalic vein was larger with similar measurements of 0.16 to
0.26 cm. The basilic vein was slightly larger with measurements
of 0.23; however, it was small distally with measurements of
0.13 cm.
The right and left brachial and radial arteries were patent.
There was a
duplicated brachial artery system bilaterally. Significant
calcifications
were noted.
IMPRESSION: Patent but small upper extremity veins and
arteries. Significant calcifications were noted in the
arteries.
CXR ___
As compared to the previous radiograph, no relevant change is
noted.
Bilateral pleural effusions with mild to moderate pulmonary
edema. Subsequent areas of atelectasis at both the left and the
right lung bases. The left border of the heart is unremarkable,
the right border cannot be exactly determine given coexisting
pleural effusion. A non characteristic scarring in the right
upper lobe is unchanged.
Brief Hospital Course:
___ with hx of DM, HTN, HLD, PVD s/p right BKA, sCHF (EF 25% on
ECHO from ___ presenting with acute decompensation of his
chronic systolic congestive heart failure with EF 25%,
complicated by ESRD now s/p HD initiation with improved volume
status.
#Acute decompensated sCHF (EF 25%) likely ___ to longstanding
hypertension. Patient presented initially with weakness and
inability to transfer, found to have decompensation of his sCHF.
He was 67kg on admit with a dry weight of 59kg to 60kg. He was
initially treated with agressive IV boluses of lasix with
moderate success. Due to his history of CKD and overall low
urine output despite IV lasix, he was subsequently placed on a
lasix gtt and dobutamine gtt which increased his urine output
substantially. He was effectively diuresed on the lasix and
dobutamine gtt and both drips were weaned off as patient
approached euvolemia. He still necessitated frequent IV boluses
with lasix even after the dobutamine gtt was discontinued. He
was eventually weaned off the lasix gtt and started on PO
torsemide and metolazone. Again due to pt's worsening renal
disease, nephrology was consulted and recommended initiation of
hemodialysis for further long-term fluid management. Pt received
LUE graft placed by transplant surgery and has gone through 3
sessions of HD. His LUE graft infiltrated on ___ and he
received a tunneled HD line on ___ to use for HD. He will have
further evaluation on HD access and the graft when he follows up
with transplant surgery on ___. He will be discharged to a ___
facility and will continue to recieve HD three times weekly and
the torsemide and metolazone were both discontinued. During his
admission we also increased his Hydralazine to 100mg TID and his
imdur to 120mg daily for management of his HTN as well as his
sCHF. He will also be discharged on Atorvastatin 80mg and daily
aspirin 81mg.
#CKD/ESRD: patient has history of chronic kidney disease
secondary to his longstanding diabetes and hypertension. He is
still able to make urine but his output declined during
admission. The nephrology team was consulted and recommended
starting hemodialysis for further fluid management for his sCHF
and for his CKD. He initially received a LUE graft for HD but
the graft infiltrated on ___. He had a tunneled HD catheter
placed on ___ and will have further evaluation of his LUE graft
use when he follows up with Dr. ___ transplant surgery on
___. He will be followed up by Dr. ___ in nephrology after
discharge. Patient had a PPD placed on ___ which was read
as negative and he also received a HepB vaccination in
preparation for initiating outpatient hemodialysis. He was
started on nephrocaps and will need close management of his
potassium and phosphate levels.
#UTI: patient had foley catheter placed initially in the ED for
urine output monitoring. He subsequently had an episode of fever
and a positive UA. His foley was discontinued and a condom
catheter was placed instead. Given his gender and recent foley
placement, patient was started on 1g IV rocephin Q24hrs and was
treated for a total of 7d for a complicated UTI. Patient
remained afebrile and did not have any further urinary symptoms.
#DM: patient has history of poorly controlled diabetes. During
this admission he was placed on sliding scale insulin. Patient
was stable on this insulin regimen and no further adjustments
were made.
#HTN: history of HTN, patient was not started on any ACE
inhibitors or ARBs due to his worsening renal function on admit.
Patient was already on hydralazine and imdur at home but the
doses were increased for both of these medications. He is to be
discharged on 100mg of hydralazine TID and 120mg of Imdur daily.
Patient remained normotensive throughout his admission and his
blood pressure was stable in light of hemodialysis.
#Pancytopenia: Mr. ___ also presented with pancytopenia
on admit. The hematology/oncology team was consulted and
recommended further outpatient evaluation. They recommended
weekly CBC with diff lab draws and the results are to be faxed
to Dr. ___ who ___ see Mr. ___ in clinic on
___.
# Transitional issues:
- WEEKLY CBC with differential, results faxed to Dr. ___
___ at ___ hematology-oncology (Fax #: ___
-Continue dialysis MWF through tunnel line until transplant
surgery follow up to determine re-initiation through LUE AVG
-Dry weight 65-66kg without prosthesis
-Please follow up with Dr. ___ in nephrology
-___ follow up with Dr. ___ in heart failure clinic
-Please follow up with Dr. ___ transplant surgery
-Please follow up with Dr. ___ in hematology/oncology
-Complete hepatitis B vaccine series (FIRST VACCINE GIVEN
___
-Patient still needs suspension stockings for his prosthetic leg
-Code status: DNR/DNI
-Emergency contact: Sister ___ - ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. HydrALAzine 50 mg PO TID
6. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Tamsulosin 0.8 mg PO HS
9. Vitamin D 1000 UNIT PO DAILY
10. Amiodarone 200 mg PO DAILY
11. Metoprolol Succinate XL 150 mg PO DAILY
12. Lantus Solostar (insulin glargine) 6 units subcutaneous qam
13. Torsemide 80 mg PO DAILY
14. HydrOXYzine 10 mg PO BID:PRN itching
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Metoprolol Succinate XL 150 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Tamsulosin 0.8 mg PO HS
8. Vitamin D 1000 UNIT PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN Pain
RX *oxycodone 10 mg 1 tablet(s) by mouth EVERY 4 HOURS Disp #*18
Tablet Refills:*0
11. HydrOXYzine 10 mg PO BID:PRN itching
12. Lantus Solostar (insulin glargine) 6 units subcutaneous qam
13. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
14. HydrALAzine 100 mg PO TID
15. Senna 8.6 mg PO BID:PRN constipation
16. Lidocaine Jelly 2% 1 Appl TP Q6H:PRN Rectal pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: acute decompensation of systolic congestive
heart failure (EF ___, end-stage renal disease.
Secondary diagnosis: type II diabetes, hypertension, diabetic
retinopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___. You were admitted for weakness and shortness
of breath due to your heart failure and kidney disease. We gave
you medications to remove fluid from your lungs to help you
breathe better. We also had a line placed in your chest for you
to receive hemodialysis. At this time we have treated your heart
failure and started hemodialysis for your kidney disease. We are
sending you to a rehab facility for further care before you go
home.
Sincerely,
Your ___ Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10368516-DS-12 | 10,368,516 | 23,997,654 | DS | 12 | 2127-05-31 00:00:00 | 2127-05-31 16:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizure, AVM
Major Surgical or Invasive Procedure:
___: Diagnostic Angiogram confirming left frontal AVM.
History of Present Illness:
___ yo M s/p new onset seizure activity. He states that he
was out to lunch with his boss, when his right arm became
"tight"
and he started to fall, he was caught by his boss and lowered to
the ground. He denies heatstroke, but endorses loss of
consciousness. Per reports, he had a tonic clonic seizure. He
denies loss of bowel or bladder control. He was brought to an
OSH
where he had another seizure, that was broke by 2mg Ativan IV.
He
was given 1500mg Keppra IV.
A MRI was obtained and he was noted to have a AVM. He was
transferred to ___ for Neurosurgical evaluation.
Past Medical History:
None
Social History:
___
Family History:
Denies any related family hx
Physical Exam:
On admission:
===============
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally EOMs intact
Tongue: R swelling, no lacerations or bleeding noted
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. Mild dysarthria due to tongue swelling.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline with mild fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch and propioception
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Handedness Right
On discharge:
==============
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 4-3mm
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Angio Groin Site: [x]Soft, no hematoma [x]Palpable pulses
Pertinent Results:
Please refer to ___ for pertinent lab and imaging results.
Brief Hospital Course:
Mr. ___ was transferred from an OSH s/p tonic-clonic seizure
found to have AVM on MRI. He was admitted to neurosurgery for
ongoing management.
#seizures
Patient was placed on seizure precautions and continued on
Keppra 500mg BID for seizures management. He was evaluate by the
MERIT service for right tongue swelling due to biting during his
seizure. He was given chloraseptic spray with good effect.
#AVM
Patient was admitted to ___ for close neurological monitoring.
He underwent diagnostic angio which confirmed MRI findings of
left frontal AVM. For more procedural details please refer to
formal op report in OMR. Patient was transferred to the PACU
after angio and then to the floor for further care. Patient
remained stable and neurologically intact for the remainder of
his admission. On POD patient was mobilized. Dressing was
removed and patient was cleared for discharge home on ___ with
planned follow up for outpatient surgical planning to resect
AVM.
Medications on Admission:
No home medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
Please take this medication to prevent constipation while taking
narcotic pain meds.
4. LevETIRAcetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*62 Tablet Refills:*3
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Do not drive while taking this medication. ___ request Partial
Fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left Frontal Arterio-Venous Malformation (AVM)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Activity
- ___ may gradually return to your normal activities, but we
recommend ___ take it easy for the next ___ hours to avoid
bleeding from your groin.
- Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
- ___ make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
- Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
- Do not drink alcohol. Alcohol consumption can increase your
blood pressure, which can lead to complications such as bleeding
from ___ AVM.
- Due to seizure activity, by law, ___ are not allowed to drive
until ___ have been seizure free for 6 months.
- ___ make take a shower.
Medications
- Resume your normal medications and begin new medications as
directed.
- ___ may use Acetaminophen (Tylenol) for minor discomfort if
___ are not otherwise restricted from taking this medication.
- Please do NOT take any blood thinning medication (Aspirin,
Plavix, Coumadin, Ibuprofen) until cleared by the neurosurgeon.
- ___ have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication until follow-up. It is important that ___ take this
medication consistently and on time.
Care of the Puncture Site
- Keep the site clean with soap and water and dry it carefully.
- ___ may use a band-aid if ___ wish.
What ___ ___ Experience:
- Mild tenderness and bruising at the puncture site (groin).
- Soreness in your arms from the intravenous lines.
- Fatigue is very normal.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the puncture
site.
- Fever greater than 101.5 degrees Fahrenheit
- Constipation
- Blood in your stool or urine
- Nausea and/or vomiting
Call ___ and go to the nearest Emergency Room if ___ 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:
___
|
10370124-DS-22 | 10,370,124 | 25,452,178 | DS | 22 | 2135-04-14 00:00:00 | 2135-08-14 20:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
clindamycin / metronidazole / Bactrim / Penicillins / Haldol
Attending: ___.
Chief Complaint:
Suicidal ideation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of anxiety/depression, self harm, multiple psych admits,
paranoia, prior sexual abuse p/w active SI and PE on imaging in
ER. States that has been feeling more hopeless lately in setting
of her obesity, giving up her son for adoption and her older son
cutting himself. She tried cutting her L wrist today and states
that she also attempted to stand in front of a speeding car,
however car stopped. She feels paranoid, however denies any
auditory or visual hallucinations.
In the ED, initial vitals were:
Pain ___ 135/80 16 100% RA
Pt was initially being considered for admission at a psychiatric
facility, but there was a report of an untreated PE. Patient
reported she was diagnosed with PE at ___ a few months ago, was
started on coumadin and lovenox, but never filled it. Every time
she has been hospitalized, they restart anticoagulation, but she
has not filled it. Though she does say that at a clinic visit
last week they did convince her to start the coumadin b/c she is
having DOE.
In ER she had no CP, not tachycardic, not hypoxic. ER spoke with
PCP ___ at ___ in ___ - ___ at 300 ___
for collateral information: *spoke with nurse practitioner: has
never had coumadin on her medication list. Has no documentation
of PE on problem list. There is a record at ___ of
coumadin in ___ ER tried to get info from ___, but unable to
get through (on hold for prolonged period of time). Given lack
of clarity of diagnosis, got CTA which showed likely acute on
chronic components of PE, also with PA dilatation concerning for
possible submassive physiology. As pt will require TTE and
anticoagulation, is psychotic and will not be a reliable
outpatient bridge, was admitted to medicine. 100 mg of lovenox
first dose given in ED.
Vitals prior to transfer were: Pain 0 98.1 66 104/61 16 95% RA
Upon arrival to the floor, pt endorses some central chest
tightness and ___ pain, but no other complaints. Denies HA,
dizziness, SOB, abdom pain, N/V/D.
Past Medical History:
Anxiety
Depression
Psychotic disorder NOS (?paranoid schizophrenia)
Obesity
Sexual Assault
Social History:
___
Family History:
nc
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8 114/76 72 18 100%RA
General: Alert, oriented, no acute distress, flat affect
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley
Ext: R wrist with several superficial lacerations. no bleeding.
Psych: active SI. no HI. no auditory/visual hallucinations.
=
================================================================
DISCHARGE EXAM PHYSICAL EXAM:
Vitals: 98.1 103-131/60s-90s ___ 18 95-100%RA
General: Alert, oriented, no acute distress, flat affect
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, crackles
Abdomen: Soft, non-tender, non-distended, bowel sounds present
GU: No foley
Ext: R wrist with several superficial lacerations. no bleeding.
Psych: active SI. no HI. no auditory/visual hallucinations.
Pertinent Results:
ADMISSION LABS:
======================
___ 10:38PM BLOOD WBC-9.6 RBC-3.93 Hgb-12.5 Hct-37.5 MCV-95
MCH-31.8 MCHC-33.3 RDW-13.2 RDWSD-46.2 Plt ___
___ 10:38PM BLOOD Neuts-25.0* Lymphs-65.8* Monos-4.7*
Eos-3.8 Baso-0.6 Im ___ AbsNeut-2.39 AbsLymp-6.30*
AbsMono-0.45 AbsEos-0.36 AbsBaso-0.06
___ 10:38PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
Ovalocy-1+ Burr-OCCASIONAL
___ 10:38PM BLOOD Plt Smr-NORMAL Plt ___
___ 04:50PM BLOOD ___ PTT-31.3 ___
___ 10:38PM BLOOD Glucose-100 UreaN-10 Creat-0.8 Na-139
K-4.5 Cl-103 HCO3-24 AnGap-17
___ 06:17PM BLOOD D-Dimer-806*
___ 10:38PM BLOOD cTropnT-<0.01 proBNP-PND
___ 10:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:20PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 09:20PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-7
___ 09:20PM URINE Mucous-RARE
___ 09:20PM URINE Hours-RANDOM
___ 09:20PM URINE Hours-RANDOM
___ 09:20PM URINE UCG-NEGATIVE
___ 09:20PM URINE Gr Hold-HOLD
___ 09:20PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG oxycodn-NEG mthdone-POS
IMAGING:
=================
TTE ___
The left atrium is normal in 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
(?#) appear structurally normal with good leaflet excursion.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Preserved biventricular systolic function. No
clinically significant valvular disease. Indeterminate pulmonary
artery systolic pressure.
___ LUMBOSACRAL XR:
IMPRESSION:
No definite fracture.
___ CTA CHEST
IMPRESSION:
1. Segmental and subsegmental PE in the right lower lobe of
unclear
chronicity. Correlate with prior imaging.
2. Focal dilatation of the right ventricular outflow tract with
mild
cardiomegaly.
3. No acute aortic abnormality.
4. Nodular appearance of the inferior most portion the left
thyroid lobe, not fully characterized.
Brief Hospital Course:
___ hx of anxiety/depression, self harm, multiple psych admits,
paranoia, prior sexual abuse p/w active suicidal ideation (ran
infront of a speeding vehicle) and found to have pulmonary
embolism of unclear duration on imaging in ER.
.
# PULMONARY EMBOLISM: Low Risk
Seen on CTA on this admission, but known to all caretakers that
she had PE in the past as well. It was unclear whether her
pulmonary embolism is acute or chronic, and patient has prior
history of PE. She never filled her warfarin script in the past,
likely secondary to poor understanding of need for medication.
- Her troponins were negative, her BNP was 100, and orthostatic
vital signs were normal. Her EKG showed some right heart strain
(T wave inversions in V1-V4), unclear if this is acute or
chornic given that previous EKGs showed T wave inversions in
V1-V3. She was initially treated with lovenox and transitioned
to apixiban. She had a TTE that was within normal limits. She
was medically optimized for transfer to the Psychiatry service.
-- CONTINUE apixiban 10mg twice daily for 7 days (___) and
then 5mg twice daily for 6 months ___ - ___ for
treatment of pulmonary embolism. Day 1 apixiban: ___
-- Will need PCP follow up to continue Apixaban
-- She had ___ workup at ___ and ___ recommended
to follow up with PCP in regards to that information
.
# Suicidal ideation: She ran infront of a speeding vehicle, car
stopped
-- During her stay she had a 1:1 sitter and was ___ for
active suicidal ideation.
- She was discharged to ___ Inpatient Psychiatry Service
- See her medication list for relevant Psychiatric medications,
per Psychiatry recommendations
.
# Hx of sexual assault:
Patient states that she completed 28 days of HIV prophylaxis a
few months ago following a sexual assault. She clined STD
testing including HIV and declined social work consult.
.
TRANSTIIONAL ITEMS:
-- Follow up PE Therapy as above
-- Follow up with PCP about further ___ evaluation
-- Other follow up per Psychiatry
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 2 mg PO BID anxiety
2. ChlorproMAZINE 150 mg PO BID
3. CloniDINE 0.2 mg PO TID
4. Methadone 95 mg PO DAILY
5. Promethazine 50 mg PO Q8H
6. Gabapentin 600 mg PO TID
7. Lactulose ___ mL PO DAILY
8. Baclofen 10 mg PO BID
9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
10. Senna 8.6 mg PO Frequency is Unknown constipation
11. Nicotine Polacrilex 2 mg PO Q1H:PRN nicoteine withdrawal
12. Docusate Sodium 100 mg PO Frequency is Unknown
Discharge Medications:
1. Apixaban 10 mg PO BID
2. ALPRAZolam 2 mg PO BID anxiety
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. ChlorproMAZINE 150 mg PO BID
5. CloniDINE 0.2 mg PO TID
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Gabapentin 600 mg PO TID
8. Lactulose ___ mL PO DAILY
9. Methadone 95 mg PO DAILY
10. Nicotine Polacrilex 2 mg PO Q1H:PRN nicoteine withdrawal
11. Promethazine 50 mg PO Q8H
12. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnoses:
Suicidal ideation
Pulmonary embolism, without tissue necrosis or cardiac damage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you. You were admitted to the
hospital for suicidal ideation and coincidentally found to have
a pulmonary embolism (blood clot in your lungs). This blood
clot is causing you to be short of breath. You were treated
with anti-coagulation (blood thinner) called apixiban. Please
take this medication as perscribed.
Please take good care of yourself
Your ___ Team
Followup Instructions:
___
|
10370141-DS-20 | 10,370,141 | 26,538,764 | DS | 20 | 2172-05-01 00:00:00 | 2172-05-01 15:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pulmonary embolism
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with PMHx distal right femur osteosarcoma
s/p
resection/reconstruction ___ s/p 4 cycles adria/cis who
presents for incidental pulmonary embolism found on routine
staging CT chest.
He was just discharged on ___ after his ___ cycle of adria/cis.
He had routine imaging at that time on ___ that showed a
pulmonary embolus involving a right lower lobe segmental
pulmonary artery (although not specifically a protocolled CTA
chest). He was called and told to come to the ED for initiation
of anticoagulation with lovenox given need for case management
assistance in acquiring this medication and ___ translation
with lovenox teaching. He notes a new nonproductive cough
yesterday. He denies CP/SOB/DOE/numbness/weakness/
N/V/D/F/C/lower extremity edema.
IN ER, Vitals: Afebrile, mild tachycardia, vital signs stable
Exam: Normal cardiopulm exam and breathing comfortably. No lower
extremity edema. Has lateral incisional scar on RLE non tender
to palpation w/o palpable cord. Guaiac negative.
EKG: HR 80, NS NA NI no ST or TW changes concerning for
ischemia.
He was started on Heparin gtt and admitted to OMED.
On floor, he appears comfortable. Discussed with patient with
help from ___ Interpreter ___. Patient says he was
asked to come to ER because his CT chest showed a blood clot. He
understands that he needs to be on a blood thinner for this. He
has no chest pain or SOB. He complains of right lower extremity
'discomfort' but no pain since surgery in RLE.
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel habits, hematochezia, or melena.
GU: No dysuria or change in bladder habits.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- ___: Initially presented with knee pain and
difficulty ambulating
- ___: CT and MRI knee suspicious for malignancy with chest
CT with multiple subcm nodules
- ___: CT-guided core needle biopsy showed osteosarcoma,
mixed osteoblastic and chondroblastic, high grade (___)
- ___: Bone scan showed uptake in the right femur mass
without other areas of uptake
- ___: Resection of right knee mass with reconstruction,
femoral rotation hinge, allograft, gastrocnemius flap ___
___
- ___: Restaging CT showed increased lung nodule to 5cm,
new partially calcified soft tissue nodules
- ___: C1D1 cisplatin / Adriamycin (___)
- ___: 2.3cm and 8mm partially calcified right RP nodule
- ___: Admission to ___ for nausea/vomiting
- ___: C2D1 cisplatin 75% (dose reduced for nausea) /
Adriamycin (___)
- ___: Admission for C3D1 cisplatin (75%) / adriamycin
- ___: Admission for C4D1 cisplatin (75%) / adriamycin
- ___: Self-adminstered Neulasta
PAST MEDICAL HISTORY:
Osteosarcoma, as above
Social History:
___
Family History:
No family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VITAL SIGNS: 98.0 PO 121 / 74 98 18 99 RA
GEN: Man in no acute distress, resting comfortably
HEENT: NCAT, MMM, alopecia, posterior OP clear
NECK: supple, no LAD
CV: RR, NL S1S2 no S3S4 MRG. No parasternal heave. No JVD.
PULM: CTAB. No wheezes or crackles
ABD: BS+, soft, NTND
LIMBS: No edema, clubbing, or tremors. Right lower extremity
with surgical scares, some tenderness over anterior tibia, no
warmth or erythema. No calf tenderness. Able to ambulate
independently.
SKIN: WWP, no rash
NEURO: grossly intact
DISCHARGE PHYSICAL EXAM:
=======================
VITAL SIGNS: 98.4 91 / 54 76 18 100 RA
General: NAD
HEENT: NCAT, MMM, EOMI, PERRL, posterior OP clear, no sinus
tenderness
Neck: supple, no LAD
CV: RRR
Lungs: CTAB
Abd: soft, nt, nd +BS
Extrem: Right lower extremity with surgical scares, some
tenderness over anterior tibia, no warmth or erythema. No calf
tenderness. Able to ambulate independently.
Skin: WWP, no rash
Neuro: grossly intact
Pertinent Results:
ADMISSION LABS:
===============
___ 07:15PM BLOOD WBC-8.7 RBC-2.68* Hgb-8.8* Hct-25.9*
MCV-97 MCH-32.8* MCHC-34.0 RDW-18.3* RDWSD-62.4* Plt ___
___ 07:15PM BLOOD Neuts-68.2 Lymphs-10.1* Monos-19.1*
Eos-0.5* Baso-0.5 NRBC-0.2* Im ___ AbsNeut-5.91
AbsLymp-0.87* AbsMono-1.65* AbsEos-0.04 AbsBaso-0.04
___ 07:15PM BLOOD ___ PTT-29.2 ___
___ 07:15PM BLOOD Glucose-99 UreaN-15 Creat-0.7 Na-137
K-4.4 Cl-104 HCO3-24 AnGap-13
DISCHARGE LABS:
===============
___ 05:07AM BLOOD WBC-9.1 RBC-2.67* Hgb-8.5* Hct-25.6*
MCV-96 MCH-31.8 MCHC-33.2 RDW-18.2* RDWSD-63.9* Plt ___
___ 05:07AM BLOOD Glucose-85 UreaN-14 Creat-0.8 Na-138
K-4.4 Cl-103 HCO3-23 AnGap-16
___ 05:07AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.0
MICROBIOLOGY:
============
NONE
STUDIES/REPORTS:
===============
___ CT ABD & PELVIS W/ CONTRAST
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest
performed on the same day for description of the thoracic
findings.
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 shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: 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 is diffusely distended with
contrast and food products. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There are a few densely calcified mesenteric
lymph nodes, likely sequela of prior infection. There is no
pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The tip of a right knee reconstruction with
femoral rotational hinge is noted in the proximal right femur.
IMPRESSION:
1. No evidence of metastatic disease in the abdomen or pelvis.
2. Please refer to the same day CT Chest exam for full
description of
intrathoracic findings.
___ CT CHEST W/ CONTRAST
FINDINGS:
The thyroid is unremarkable. There is no axillary,
supraclavicular
adenopathy. A right chest wall Port-A-Cath ends at the
cavoatrial junction. There are unchanged prominent but non
pathologically enlarged mediastinal lymph nodes measuring up to
10 mm in the pretracheal station. Heart size is normal. There
is no pericardial effusion. There is no thoracic aortic
aneurysm. There is no significant atherosclerosis. The main
pulmonary trunk is not dilated. Although not protocol for the
evaluation of pulmonary artery embolism, there is a filling
defect in the right lower lobe segmental pulmonary artery
(series 6, image 205). There are no significant coronary artery
calcifications.
The airways are patent to the subsegmental level bilaterally.
There are
multiple calcified pulmonary nodules, unchanged from prior.
These are seen on (series 6, image 71, 129, 177, 209, 225, 183,
___. The most suspicious nodules include those with
soft tissue components for example in the left upper lobe
measuring 6 mm (series 5, image 21 and in the right upper lobe
measuring 7 mm (series 5, image 26). There is no focal lung
consolidation. There is no pleural effusion or pneumothorax.
Thoracic esophagus is unremarkable. Please see dedicated
abdominal and pelvic CT for further details on intra-abdominal
structures.
OSSEOUS STRUCTURES/SOFT TISSUES: There are no suspicious bony
lesions. There are no soft tissues abnormalities.
IMPRESSION:
1. Multiple unchanged calcified pulmonary nodules, suspicious
for metastatic disease. No new nodules.
2. Pulmonary embolus involving a right lower lobe segmental
pulmonary artery.
___ CT HEAD W/O CONTRAST
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift
of normally midline structures, or evidence of acute major
vascular territorial infarction. Ventricles and sulci are normal
in overall size and configuration. The imaged paranasal sinuses
are clear. Mastoid air cells and middle ear cavities are well
aerated. The bony calvarium is intact.
IMPRESSION:
No acute intracranial process.
Brief Hospital Course:
Mr. ___ is a ___ year old ___ male with history of
distal right femur osteosarcoma s/p resection and reconstruction
___ and likely pulmonary metastatic disease who is s/p 4
cycles of doxorubicin/cisplatin (___) who was admitted for
treatment of incidentally found pulmonary embolism seen on
outpatient staging imaging. He was initially started on a
heparin drip which was transitioned to lovenox prior to
discharge. He should continue lovenox indefinitely pending
outpatient oncology follow-up.
TRANSITIONAL ISSUES:
===================
- Continue lovenox 60mg q12h indefinitely for treatment of PE
- Continued outpatient management of osteosarcoma (CT torso
showed stable metastatic disease of lungs)
#CODE: Full (presumed)
#COMMUNICATION: Patient
#EMERGENCY CONTACT HCP: girlfriend in ___, phone
number is ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Enoxaparin Sodium 60 mg SC Q12H
Start: Today - ___, First Dose: First Routine
Administration Time
RX *enoxaparin 60 mg/0.6 mL 1 syringe SC every twelve (12) hours
Disp #*30 Syringe Refills:*1
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Embolism
Metastatic Osteosarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your stay at ___. You
were admitted for a blood clot in your lung. You were started on
a blood thinner called lovenox, and should continue taking this
medication twice a day indefinitely.
You should follow up with your outpatient oncologist as
scheduled.
Wishing you well,
Your ___ Team
Followup Instructions:
___
|
10370161-DS-13 | 10,370,161 | 25,518,737 | DS | 13 | 2202-06-18 00:00:00 | 2202-06-18 20:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Cipro Cystitis / Keflex
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ male with cerebral palsy who presents with
foot swelling and hand swelling. Patient was sent from nursing
home also with reports of a fever of 101 °F. He reports new
bilateral lower extremity swelling, new right upper extremity
swelling. Patient reports chronic neck pain and headache. He
denies chest pain, difficulty breathing, abdominal pain, or
other
complaints.
The patient was admitted to the ___ ED, had infectious work-up
which was negative, CTA chest which was negative, and normal
labs. While the patient was initially tachycardic, the
patient's
tachycardia improved with IV fluids, and he was deemed to be
safely discharged from medical perspective. However, the
patient
did not want to go back to the current rehab facility because of
lack of cleanliness and substandard care per patient and
healthcare proxy. Case management has been looking for a new
rehab facility, and the patient has been admitted to await
placement.
Of note, the patient was recently admitted in early ___ of
this year generalized weakness, specifically in his upper
extremity. MRI of cervical spine showed that there was
narrowing
of the cervical canal and that was a source of his weakness. He
was discharged to ___ and rehab.
Notable work-up in the ED:
The patient had creatinine 1.3, normal WBC, hemoglobin 11.2, BNP
46, all other labs were within normal limits. UA did not show
any evidence of infection. D-dimer was 1104, CTA negative.
Given prolonged search for rehab bed patient admitted to
medicine
while awaiting insurance authorization.
Past Medical History:
- Cerebral palsy
- Hypertension
- Hyperlipidemia
- Diabetes, type 2
- Elevated PSA
- Recurrent urethritis/prostatitis
- Gout
- Illiteracy
- H/o septic knee arthritis s/p debridement and abx
Social History:
___
Family History:
Extensive hypertension history. One uncle with prostate cancer.
Physical Exam:
ADMISSION EXAM:
___ Temp: 98.2 PO BP: 145/87 HR: 87 RR: 17 O2 sat: 95%
O2 delivery: Ra
GEN: well appearing, NAD
HEENT: MMM
CV: RRR nl s1/s2 no mrg
PULM: CTA b/l no wrc
GI: Obese, S, mildly distended, non-tender
EXT: WWP, L ankle warm, tender, erythematous, swollen
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 2333)
Temp: 98.2 (Tm 98.9), BP: 136/87 (123-137/74-90), HR: 81
(73-83), RR: 18 (___), O2 sat: 99% (97-100), O2 delivery: RA
GEN: well appearing, NAD
HEENT: MMM
CV: RRR nl s1/s2 no mrg
PULM: CTA b/l no wrc
GI: Obese, S, mildly distended, non-tender
EXT: WWP, L ankle and R knee are tender and mildly swollen, L
knee also tender. Notable white scaling on soles of feet
bilaterally
Pertinent Results:
ADMISSION LABS:
___ 12:00AM PLT COUNT-169
___ 12:00AM NEUTS-57.6 ___ MONOS-17.5* EOS-1.7
BASOS-0.2 IM ___ AbsNeut-3.14 AbsLymp-1.22 AbsMono-0.95*
AbsEos-0.09 AbsBaso-0.01
___ 12:00AM WBC-5.4 RBC-3.95* HGB-11.2* HCT-34.9* MCV-88
MCH-28.4 MCHC-32.1 RDW-13.5 RDWSD-43.8
___ 12:00AM ALBUMIN-3.9 URIC ACID-8.3*
___ 12:00AM proBNP-46
___ 12:00AM LIPASE-26
___ 12:00AM ALT(SGPT)-11 AST(SGOT)-11 ALK PHOS-92 TOT
BILI-0.4
___ 12:00AM GLUCOSE-124* UREA N-20 CREAT-1.3* SODIUM-139
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-13
___ 03:58AM URINE RBC-2 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-2
___ 03:58AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 03:58AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:00AM D-DIMER-1104*
PERTINENT LABS:
___ 05:39AM BLOOD CRP-31.1*
DISCAHRGE LABS:
___ 05:10AM BLOOD WBC-5.6 RBC-3.49* Hgb-10.0* Hct-31.6*
MCV-91 MCH-28.7 MCHC-31.6* RDW-13.7 RDWSD-45.3 Plt ___
___ 05:10AM BLOOD Glucose-116* UreaN-16 Creat-0.9 Na-141
K-3.9 Cl-103 HCO3-27 AnGap-11
___ 05:10AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.8
MICRO:
___ 3:58 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
___ b/l ___
IMPRESSION:
Interval resolution of deep vein thrombosis in bilateral lower
extremities
with no evidence of deep venous thrombosis in the right or left
lower
extremity veins.
___ R knee plain film
IMPRESSION:
Degenerative disease as described. Unchanged linear ossific
density in the suprapatellar space, thought to represent a loose
body. Chondrocalcinosis.
___ L ankle plain film
IMPRESSION:
Soft tissue swelling at the left ankle without fracture or
dislocation.
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY:
=======================
Patient is a ___ male with a history of cerebral palsy,
admitted for new bilateral lower extremity swelling, concern for
fever, found to have tachycardia, now afebrile, normal heart
rate.
TRANSITIONAL ISSUES:
====================
[] Patient initially admitted with concern for gout given
history of uric acid crystals on arthrocentesis. Patient was
treated with steroid burst 40mg x 5d and discharged on
prednisone taper: 20mg x3d (___), 10mg x3d (___).
[] Should consider initiating allopurinol for gout prophylaxis
in outpatient setting.
[] Patient also diagnosed with tinea pedis on feet bilaterally.
Should continue topical terbinafine BID x 1 week (___). Can
consider longer course if not resolved.
[] Gabapentin was uptitrated given suspect neuropathic component
of pain. Discharged on gabapentin 200mg qAM and qHS. Can
uptitrate (potentially TID dosing) as tolerated.
[] Consider topical voltaren for degenerative joint disease in
knees and ankles.
ACTIVE ISSUES:
==============
# Gout
# Polyarthritis
# Neuropathic pain
Patient presented with polyarthritis with h/o gout (has crystals
on arthrocentesis from ___ and elevated uric acid. Unlikely
septic arthritis given no leukocytosis and patient remained
afebrile. Patient received 5d of prednisone 40mg daily but did
not note significant improvement. Currently undergoing
prednisone taper as above. Plain films demonstrated soft tissue
swelling in L ankle, degenerative disease and chondrocalcinosis
in R knee. Of note prior admissions notable for possible
neuropathy from thalamic infarct. Overall suspect his
presentation is multifactorial secondary to degenerative
disease, possible gout flare and maybe hyperalgesia from tinea
pedis as below. Patient treated with standing Tylenol, capsaicin
cream, and uptitrated gabapentin to 200mg qAM and QHS for
neuropathic component. Can uptitrate gabapentin to TID dosing in
outpatient setting.
#Tinea pedis
Concern for fungal infection on feet, maybe making patient
hyperalgesic, given he is complaining of neuropathic pain as
above. Patient receiving topical terbinafine BID x 1 week.
#Rehab placement
On ___, rehab notes that the insurance authorization declined,
and that the patient will need to be admitted to the medicine
service. Case management will continue to work on obtaining
appropriate placement for this patient. ___ recommended rehab.
#Cervical Stenosis
#Subacute to Chronic Bilateral, Proximal UE weakness (R>L)
Recent hospitalization notes, the patient had presented with
worsening weakness in the upper extremities. Underwent cervical
spine MRI which demonstrated narrowing of the cervical canal,
this is felt to be the source of his weakness. Regarding his
chronic lower extremity weakness, patient was seen by neurology
who felt that his exam had clinically improved since ___. His blood serological work-up was negative.
___ ___ Edema
Per last hospitalization records, this patient had lateral lower
externally ultrasound which showed improvement of DVTs from
prior. Continued home apixaban.
#hx Ataxia
#Dysmetria
Continued home thiamine
#Normocytic anemia
The patient's baseline hemoglobin runs from ___. Stable during
admission.
#L hand pain
Patient reports frostbite in ___, was treated with topical
but has never felt quite right and requesting topical treatment
again. Unremarkable on exam. Pain medications as above.
CHRONIC/STABLE PROBLEMS:
========================
#Prostate Cancer
Prev with ___ score of 4+3. Had cyberknife tx in ___. Was
supposed to be on tamoxifen and bicalutamide through ___ but
patient had stopped ___ possible contribution to myopathy.
Patient was discharged from ___ hospitalization on Tamsulosin
0.4mg qhs and subsequently f/u with rad onc where PSAs were
significantly decreased (1.8 on ___ down from 8.4 in ___. Continued home Tamsulosin.
#HTN
Previously on chlorthalidone 25mg, but nothing currently as he
has been well controlled in recent months. Continued to monitor.
#T2DM
Previously on metformin, now diet controlled. A1c ___ 5.8.
Continued to monitor.
#Hx DVT
Improved from prior, patient continued on apixaban while
in-house. Continued to monitor.
# CODE: Full with limited trial
# CONTACT:
Name of health care proxy: ___
Relationship: Niece
Phone number: ___
Date on form: ___
Proxy form in chart: ___
Filed on Date: ___
Comments: Alt HCP: ___, brother ___
Greater than 30 minutes spent providing discharge services for
this patient
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
3. lidocaine 5 % topical DAILY
4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
5. Apixaban 5 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 200 mg PO QHS
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Tamsulosin 0.4 mg PO QHS
11. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Capsaicin 0.025% 1 Appl TP TID
2. PredniSONE 10 mg PO DAILY
Take 2 tablets (20mg) qd for 2 days (___)
Take 1 tablet (10mg) qd for 3 days (___)
Tapered dose - DOWN
3. Terbinafine 1% Cream 1 Appl TP BID
4. Acetaminophen 1000 mg PO Q8H
5. Gabapentin 200 mg PO BID
6. Apixaban 5 mg PO BID
7. Atorvastatin 40 mg PO QPM
8. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
9. FoLIC Acid 1 mg PO DAILY
10. lidocaine 5 % topical DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. Tamsulosin 0.4 mg PO QHS
14. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
#Gout
#Polyarthritis
#Neuropathic pain
#Tinea pedis
#cervical stenosis
#subacute to chronic bilateral proximal UE weakness
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 ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you had a fever.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were diagnosed with gout in your knee and ankle, and you
received steroids to treat this.
- Your medications were altered to better control your pain,
especially your neuropathic pain.
- You were started on a topical cream to treat a fungal
infection in your feet.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below,
please call your primary care doctor or go to the emergency
department immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10370471-DS-16 | 10,370,471 | 26,104,193 | DS | 16 | 2165-12-23 00:00:00 | 2165-12-25 19:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ HTN presents for evaluation of worsening hypertension,
patient states that she was recently admitted to ___ for
uncontrolled hypertension. She endorses a sensation of head/eye
"throbbing" when her BP is high, but denies any HA, vision
changes, weakness in any of the extremities. States that while
admitted she had multiple changes to medication regimens, and
discharged on labetalol, amlodipine, clonidine. These have
subsequently been changed to labetalol and losartan. Over past
few days has had ongoing issues with BP control, seen by ___ at
home and had intermittenly low and high BPs. States that when BP
low she feels globally weak.
In the ED, initial vitals were: 97.3 63 ___
She was given 10mg IV hydralazine and her SBP dropped to 128.
Past Medical History:
HTN
Type 2 Diabetes (diet controlled)
Hypercholesterolemia
Cateracts
Glaucoma
Social History:
___
Family History:
Denies thyroid disease. Paternal cousin alive and healthy at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.1 67 161/74 18 97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD, no carotid bruit
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5 64 153/68 18 99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD, no carotid bruit
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
ADMISSION LABS
___ 03:25PM BLOOD WBC-7.4 RBC-4.42 Hgb-13.3 Hct-40.0 MCV-91
MCH-30.2 MCHC-33.4 RDW-12.9 Plt ___
___ 03:25PM BLOOD Neuts-64.8 ___ Monos-5.1 Eos-3.5
Baso-0.5
___ 03:25PM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-136
K-4.3 Cl-97 HCO3-27 AnGap-16
___ 03:25PM BLOOD Calcium-9.9 Phos-3.4 Mg-2.4
___ 06:50AM BLOOD TSH-4.0
REPORTS
___ EKG
Sinus rhythm. Minor lateral ST-T wave abnormalities. No previous
tracing
available for comparison.
___ CXR
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
___ with HTN and multiple recent admissions for hypertensive
urgency/emergency presenting to ___ with hypertensive
emergency, transferred for blood pressure management.
# Hypertensive urgency: Patient has mild symptoms (head
throbbing / dizziness) w/o clear evidence of end-organ damage.
Lateral ST-segment depressions, could indicate ischemia;
however, no prior EKGs to compare. SBP dropped from 230s to 130s
with 1 dose of 10mg IV hydralazine. Etiology is unclear at this
time, but acute worsening of her hypertension may have been
related to rebound effect after discontinuing clonidine. TSH was
normal. She was successfully weaned off clonidine without
rebound hypertension. Home losartan and labetalol were resumed.
Blood pressures were generally well-controlled with a maximum
SBP of 180. The patient was slightly symptomatic with a mild
tremor and her usual auditory symptoms at the time of this
pressure, but was otherwise asymptomatic throughout this
admission.
TRANSITIONAL ISSUES
#Hemorrhoids - patient complains of hemorrhoids and endorses
constipation and straining. Consider further counseling on
dietary fiber, daily fiber supplementation with metamucil or
citrucel with the addition of stool softeners or laxitives as
needed.
#Tinnitus: Seems to be related to hypertensive episodes. Outside
imaging reportedly showed vertebral artery stenosis, which could
be contributing. She was referred to neurology for further
evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 200 mg PO BID
2. Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. Labetalol 200 mg PO BID
2. Losartan Potassium 25 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*3
4. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 caps by mouth at bedtime Disp
#*60 Capsule Refills:*3
5. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive emergency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you were having symptoms from
a very high blood pressure. We controlled your blood pressure
and monitored you in the hospital. We determined that part of
the reason for your very high pressure was recently stopping
clonidine, which can cause rebound hypertension in some patients
when discontinued. We put you on a very low dose of clonidine
and weaned you off while restarting your other home blood
pressure medications, labetalol and losartan. You tolerated this
well with well controlled blood pressures and no symptoms. You
should continue these medications. We would recommend that you
limit your home blood pressure checks to once per day, unless
you are having symptoms consistent with very high blood
pressures and you are considering going to the hospital. We
expect your blood pressure to fluctuate throughout the day. Our
primary goal is to have it under reasonable control most of the
time and to keep it from going so high that you have symptoms.
Monitoring beyond this at home is counterproductive as the
anxiety associated with more frequent blood pressure checks and
the concern over how to proceed with a non-ideal reading could
certainly be enough to increase your blood pressure in and of
itself. Discuss your daily blood pressures with your PCP and
discuss any changes with him or her. Also discuss any symptoms
of hypertension you are having and any medication side effects
as well. If you are having symptoms such as those that brought
you to the hospital, headache, vision changes, weakness,
confusion or difficulty speaking, contact your doctor or return
to the hospital, particularly if you find that your blood
pressure is also elevated above 180 systolic.
Best wishes.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10370502-DS-21 | 10,370,502 | 29,192,243 | DS | 21 | 2155-01-16 00:00:00 | 2155-01-17 13:58:00 |
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:
Bilateral adnexal masses, fevers
Major Surgical or Invasive Procedure:
CT-guided drainage of bilateral tubo-ovarian abscesses
History of Present Illness:
___ yo G0 transferred from ___ with bilateral adnexal
masses and persistent fevers. Patient reports for approximately
past two months has had fevers and abdominal pain. Reports high
fevers at home starting beginning of ___. Initially no other
symptoms other than fevers and body aches. Was evaluated by PCP
and had "multiple blood tests" done. Reports continued to have
almost daily fevers since that time. Has been taking ibuprofen
amost daily for fevers. Reports started to develop diffuse lower
abdominal pain associated with fevers several weeks prior. PCP
ordered pelvic ultrasound which was done on ___ and revealed
bilateral pelvic masses right 9.2x5.6x5cm and left sided
13.1x12x10.6cm. An MRI was performed on ___ and revealed a
10.3x8.7x7.8cm complex left adnexal mass, 4.5cm right adnexal
mass. CT scan was done at ___ on ___ which showed
bilateral adnexal masses with spetations and an air filled
portion of right sided loculation adnexal masses measuring 15cm
together. Patient transferred to ___ for further management
given concern of air in mass and possible fistula with bowel.
Patient reports decreased appetite for past two months, stools
softer more frequent. Denies any nausea, vomiting, blood in
stools. Reports periods normal.
Past Medical History:
OB/GYN Hx:
- G0
- LMP ___
- Reports periods q29-30days, x5days, reports cramping pain with
periods
- Denies any history of abnormal Pap
- Denies any history of STI, pelvic infections
- Denies any history of fibroids, ovarian cysts
PMHx:
- Denies
- Denies HTN, asthma, clotting disorders
PSHx:
- Denies
Medications:
- ibuprofen PRN
Allergies:
- NKDA
Social History:
___
Family History:
- Denies any history of breast, colon, uterine or ovarian cancer
- Denies any history of clotting disorders, HTN, asthma
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally, normal work of
breathing
Abd: soft, appropriately tender, nondistended, three lower
abdominal drains without evidence of skin infection continuing
to drain small amounts of yellow-colored material, no
rebound/guarding
___: nontender, nonedematous
Pertinent Results:
___ CT-Interventional Procedure: Successful CT-guided
placement of 2 ___ pigtail catheters into the right lower
quadrant and left lower quadrant tubo-ovarian abscesses. Samples
sent for microbiology evaluation.
___ Abscess culture: Mixed bacterial flora including
pseudomonas aeruginosa (rare growth, pan-sensitive), bacteroides
fragilis (moderate growth, + beta-lacatamase), prevotella
(moderate growth, - beta-lactamase)
___ Blood culture: no growth
___ CT Pelvis:
1. Bilateral adnexal collections with pigtail catheters an
appropriate
position.
2. The left adnexal collection was aspirated to completion
based on the
images from the prior CT interventional procedure. However, in
the intervening days, the collection has reaccumulated.
3. Possible fistula between the sigmoid colon in the left
adnexal collection is identified.
___ Blood culture: no growth
___ CT-Interventional Procedure:
1. Successful CT guided exchange of left adnexal catheter.
2. Successful placement of additional right adnexal pigtail
catheter as
described above.
3. Limited preprocedure CT demonstrates enteric contrast within
the left
adnexal collection, confirming the presence of a fistula with
the sigmoid
colon. The left adnexal collection contains dense material,
compatible
with enteric contrast from the colonic fistula identified on the
prior CT.
___: Duplex left upper extremity: Nonocclusive thrombus
within the left basilic vein, surrounding the PICC
___: CT Abdomen/Pelvis:
1. 2 right-sided and 1 left-sided transabdominal drains within
significantly smaller adnexal collections. 6 x 6.5 cm left
adnexal collection, just inferior and anterior to the left
pigtail drain and 4 x 4.1 cm right anterolateral collection
anterolateral to the lower right-sided pelvic drain, in addition
to a smaller 1.6 x 2 cm adjacent collection. These collections
demonstrate T1 hyperintensity and T2 shading on the prior MRI,
compatible with patient's known endometriomas.
2. Small right larger than left pleural effusions.
Brief Hospital Course:
Ms. ___ was admitted to the gynecologic oncology service
at the ___ after transfer from
___ on ___ for bilateral pelvic masses,
fever, and pain.
On hospital day #1, she underwent CT-guided drainage of
bilateral collections with drainage of foul-smelling material
and she was started on gentamycin and clindamycin for suspected
tubo-ovarian abscesses bilaterally.
On hospital day #3,she was transitioned to ceftriaxone and
flagyl after consultation with Infectious Disease given gram
stain and drain output concerning for feculent material.
Infectious disease was consulted; the patient was started on IV
ceftriaxone/flagyl then transitioned to meropenem.
On hospital day #4, Ms. ___ had a fever to ___ and her
antibiotics were then changed to meropenem. She underwent a
repeat CT of her abdomen and pelvis which revealed
re-accumulation of the abscesses bilaterally to their
pre-drainage size as well as contrast extravasation from the
sigmoid colon to the left tubo-ovarian abscess. Colorectal
surgery was consulted and recommended repeat drain placement and
conservative management. The patient then underwent CT-guided
exchange of the previous 2 drains with larger drains and
placement of a third drain by interventional radiology. Enteric
contrast from her previous CT scan was aspirated from the left
adnexal collection, confirming the presence of a colonic
fistula.
On hospital day #6, Ms. ___ received 2 units of packed
red blood cells as well as vitamin K for a hematocrit of 20.6
and INR of 1.8. There was no evidence of bleeding and she had an
appropriate rise in her hematocrit and improvement in her INR.
On hospital day #9, Ms. ___ experienced numbness and
tingling in her left upper extremity. Ultrasound revealed a
non-occlusive basilic vein thrombosis around her PICC. The PICC
was removed and she was continued on prophylactic lovenox.
Repeat imaging on hospital day #10 showed interval improvement
in drainage of bilateral adnexal collections without active
drainage of enteric contrast into the collection.
During her admission, Social Work was consulted for assessment
and support in coping with this unexpected hospitalization and
diagnosis. The patient was found to have adequate social support
and coping mechanisms for self care and was given resources for
further support as an outpatient.
By hospital day #11, she was afebrile with stable vital signs,
tolerating oral intake and ambulating independently. Her
infectious disease doctors agreed with ___ to oral
ciprofloxacin and flagyl and the gynecology oncology team, in
conjunction with the colorectal surgery service, felt the
patient was safe for discharge home with continued antibiotics
and close outpatient followup. She was then discharged home in
stable condition with home nursing services and close outpatient
followup scheduled.
Medications on Admission:
ibuprofen prn
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*1
2. Ciprofloxacin HCl 750 mg PO/NG Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every 12 hours
Disp #*20 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*40 Tablet Refills:*1
4. Lorazepam ___ mg PO QHS:PRN insomnia
Do not drive while using this medication.
RX *lorazepam 1 mg 1 tablet by mouth at bedtime Disp #*5 Tablet
Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
do not drive or drink alcohol, causes sedation
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
bilateral tubo-ovarian abscesses
left tubo-ovarian abscess with colonic fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
.
You were admitted to the gynecologic oncology service with
bilateral adnexal masses, pain, and fever. You were found to
have bilateral tubo-ovarian abscesses, one of which connected
with your colon. Interventional radiology placed tubes into the
abscesses to drain and these were later replaced with larger
drains. You were given antibiotics which you will continue when
you go home. You have recovered well after this procedure, and
the team feels that you are safe to be discharged home close
outpatient followup. Please follow these instructions:
.
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen in 24 hrs.
* No strenuous activity until cleared by your physician.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Followup Instructions:
___
|
10370642-DS-9 | 10,370,642 | 28,038,797 | DS | 9 | 2129-01-10 00:00:00 | 2129-01-10 18:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex
Attending: ___
___ Complaint:
Hypoxia, unresponsive
Major Surgical or Invasive Procedure:
Endotracheal tube exchange (___)
Bronchoscopy (___)
Chest tube placement (___)
History of Present Illness:
Patient is a ___ year old man with history of cerebral palsy,
aspiration pneumonia, bronchopulmonary dysplasia, and asthma who
presented as a transfer form ___ for hypoxia
and unresponsiveness.
The patient's mother provides history with a ___
interpreter. She reports the patient was in his usual state of
health on ___ and when he went to sleep at around 2AM on
___. He reportedly ate Flan before he went to sleep. His
mother found him the morning of ___ and he appeared blue in
the skin with black fingernails. She called EMS. He was found
unresponsive at home by EMS with SaO2 into ___. He was taken to
OSH, where he was intubated and labs showed: WBC 12.4, lactate
0.9, BNP 81, trop 0.1. He was given Vanc/Zosyn/Levo, and
transferred to ___.
Of note, the patient
In the ED, initial vitals: HR 133, BP 118/42, RR 22, O2 100% on
0.7 FiO2
- Labs were notable for: ABG with 7.27/86/45/41. Lactate 2.0.
EKG showed sinus tachycardia.
- Imaging: CXR showing near complete opacification of right lung
concerning for multifocal pneumonia
On arrival to the MICU, the patient is intubated and sedated.
REVIEW OF SYSTEMS:
(+) Per HPI (-) Otherwise
Past Medical History:
Bronchopulmonary dysplasia
Asthma
Cerebral palsy
Hypertension
Scoliosis
Inguinal hernia repair
Social History:
___
Family History:
Hypertension in mother. No known history of lung disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: 99.7 ___ 22 97% 0.7 FiO2
GENERAL: Intubated and sedated
HEENT: AT/NC. Pupils pinpoint.
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, breath sound noted bilaterally. Greater on left than
right. Bilateral mechanical breath sounds.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: Sedated. Not responding to commands.
DISCHARGE PHYSICAL EXAM
=======================
VITALS: T 98.5 HR 110s-130s BP 120s-140s/70s RR ___ O2 94-100%
on 2L NC
GENERAL: Alert and oriented, conversational
HEENT: AT/NC. PERRL.
NECK: Non-tender supple neck
CARDIAC: Tachycardic, regular rhythm, no m/r/g
LUNGS: CTAB
ABDOMEN: Non-distended, non-tender
EXTREMITIES: No cyanosis, clubbing or edema
NEURO: Alert and oriented
Pertinent Results:
ADMISSION LABS
==============
___ 07:30PM BLOOD WBC-10.5* RBC-3.83* Hgb-11.5* Hct-38.6*
MCV-101* MCH-30.0 MCHC-29.8* RDW-12.6 RDWSD-46.5* Plt ___
___ 07:30PM BLOOD Neuts-86.7* Lymphs-2.4* Monos-10.3
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.08* AbsLymp-0.25*
AbsMono-1.08* AbsEos-0.00* AbsBaso-0.01
___ 07:30PM BLOOD ___ PTT-29.5 ___
___ 07:30PM BLOOD Glucose-92 UreaN-15 Creat-0.5 Na-144
K-4.0 Cl-97 HCO3-34* AnGap-17
___ 07:30PM BLOOD ALT-124* AST-82* AlkPhos-51 TotBili-1.0
___ 07:30PM BLOOD Lipase-21
___ 07:30PM BLOOD cTropnT-<0.01
___ 07:30PM BLOOD Albumin-3.7 Calcium-8.5 Phos-1.0* Mg-1.3*
___ 04:47PM BLOOD Type-ART PEEP-8 FiO2-100 pO2-45* pCO2-86*
pH-7.27* calTCO2-41* Base XS-8 AADO2-575 REQ O2-96
___ 04:47PM BLOOD Lactate-2.0
NOTABLE LABS
============
___ 11:29PM BLOOD Type-MIX pO2-48* pCO2-44 pH-7.54*
calTCO2-39* Base XS-12
___ 08:11AM BLOOD Type-MIX Temp-37.5 pO2-44* pCO2-70*
pH-7.32* calTCO2-38* Base XS-6 Intubat-INTUBATED
___ 07:54PM BLOOD Lactate-2.7*
___ 08:11AM BLOOD Lactate-0.9
MICROBIOLOGY
============
Blood Culture, Routine (Final ___:
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
OF TWO COLONIAL MORPHOLOGIES.
Isolated from only one set in the previous five days.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 7:45 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
**FINAL REPORT ___
IMAGING/STUDIES
===============
CXR ___
1. Near complete opacification of the right lung and patchy
left basilar
opacity concerning for multifocal pneumonia. There may be a
layering right pleural effusion.
2. Tip of the endotracheal tube is difficult to visualize due
to overlying bilateral ___ rods, but may be slightly low
lying, terminating approximately 2.7 cm from the carina.
3. Enteric tube in standard position.
CT Head ___
1. No evidence of acute intracranial process.
2. Age advanced involutional changes.
3. Extensive opacification of the paranasal sinuses, mastoid air
cells, and middle ear cavities, as described above.
DISCHARGE LABS
==============
___ 01:39AM BLOOD WBC-7.4 RBC-3.85* Hgb-11.3* Hct-36.8*
MCV-96 MCH-29.4 MCHC-30.7* RDW-13.2 RDWSD-46.7* Plt ___
___ 01:39AM BLOOD ___
___ 01:39AM BLOOD Glucose-120* UreaN-10 Creat-0.4* Na-138
K-4.0 Cl-100 HCO3-24 AnGap-18
___ 01:39AM BLOOD ALT-76* AST-53* AlkPhos-70 TotBili-0.3
___ 01:39AM BLOOD Calcium-9.7 Phos-4.7* Mg-1.6
Brief Hospital Course:
Mr. ___ is a ___ year old man with cerebral palsy,
bronchopulmonary dysplasia on 3L home O2, aspiration pneumonia
and asthma who was found unresponsive and hypoxic, found to have
multifocal pneumonia, intubated and started on vanc/zosyn/levo
at OSH, transferred to ___ ED and then admitted to ICU with
course complicated by ET tube dysfunction with exchange, left
tension PTX s/p chest tube placement.
At ___, he was treated for aspiration pneumonia with
vanc/cefepime/flagyl for total 7 day course. The day after
admission he had cuff leak and rupture, and his ET tube was
exchanged. Also found to have large L pneumothorax which was
decompressed with chest tube placement. Extubated ___ and
reintubated for hypoxia and tachypnea, then successfully
extubated ___ to high flow nasal cannula. Continued to have
significant airway secretions requiring aggressive pulmonary
toilet and chest ___ with home vest. Returned to home 3L nasal
cannula and was stable for several days prior to discharge.
During hospitalization developed mild pancreatitis, with
intermittent epigastric tenderness and elevated lipase, up to
1400. Was hemodynamically stable, alert and in no distress, with
no leukocytosis or hemoconcentration. Liver US was only
remarkable for gallbladder polyp, triglycerides were 200. He was
held two additional days for tachycardia over the weekend until
___, and once the team was able to get in touch with his PCP
and cardiologist on ___ to learn that this was baseline for
him, he was deemed safe to go home and discharged on ___.
Continued to look well and was tolerating and oral diet well for
several days prior to discharge.
#Acute mixed hypoxic/hypercarbic respiratory failure:
Found unresponsive with O2 sats in ___ at home, intubated at OSH
on ___. He was initially ventilated at tidal volume 350
that was decrased to Vt at 6cc/kg IBW at 280 and then to 250 to
due peak pressures greater than 15. He was treated for
pneumonia, thought to be secondary to aspiration, and
pneumothorax as below. He was given MDI inhalers. He was
continued on CMV ventilation. During his first ICU day his
course was complicated by a cuff leak and cuff malfunction.
Anesthesia was consulted and cook catheter was placed and ETT
was exchanged on ___. Patient was paralyzed from ___ with
improvement in hypoxemia. He also completed treatment for VAP.
Despite these treatments, he failed extubation and was
reintubated ___, likely due to muscular weakness and RLL
collapse. Extubated ___ and stable on home O2 requirement of 3L
NC.
#Multifocal pneumonia:
He was initially started on clindamycin for aspiration pneumonia
and broadened to vancomycin, cefepime, flagyl after worsening of
pulmonary infiltrates. Bronchoscopy performed that showed
diffuse airway irritation without evidence of mucous plugging.
Ultrasound performed on ___ showed evidence of lung collapse vs.
consolidation. VAP treatment with Cefepime, Vancomycin, Flagyl
___ vanc, cefepime (___). Also received methylpred
32mg IV for airway edema (___).
#LEFT Tension pneumothorax:
The patient was found to have a left pneumothorax on CXR
following ETT exchange on ___. Blood pressure dropped to
___. He was started on levophed for blood pressure support
and surgery was consulted. A left chest tube was placed on ___
and placed to suction. Etiology of the pneumothorax was unclear,
possibly from a ruptured bleb. This resolved on serial chest
x-rays and the chest tube was removed on ___.
#Pancreatitis: Resolved
Lipase 1350 with intermittent epigastric abdominal tenderness,
fulfilling 2 of 3 criteria; however lipase now down trending.
Etiology unclear. RUQUS w/o cholelithiasis, triglycerides 200.
Risperidone and seroquel can cause pancreatitis, and was
receiving high doses of seroquel recently. Continues to do well
clinically. Tolerating PO.
#Sinus tachycardia:
Continued sinus tachycardia ranging up to 130s, still on ___,
despite diltiazem 90mg q6h. On dilt 360 mg ER daily at home,
back on that ___ AM. Afebrile and no other infectious symptoms,
does not appear volume depleted (tried giving 1L fluid which had
no effect). TSH 2.3. TTE done to eval for RV strain, which was
unremarkable. Ultimately, once the weekend passed and we could
contact his PCP, they confirmed that he has baseline tachycardia
and that this is why he is on dilt
CHRONIC ISSUES:
======================
#Asthma:
Fluticasone INH BID and albuterol-ipratropium MDI were given. He
was discharged with a prescription for a home nebulizer and 3%
saline nebs to help the patient with secretion management.
#Hypertension:
Antihypertensives were held in the setting of hypotension
following tension pneumothorax and were eventually re-started
(clonidine, lisinopril, and diltiazem).
TRANSITIONAL ISSUES:
- Patient started on 3% saline nebulizer
- 4mm gall bladder polyp seen on US, should have further work-up
#Communication: ___ ___ (mother)
#Code: Full (confirmed)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
2. Vitamin C (ascorbate Ca-multivit-min;<br>ascorbate
calcium;<br>ascorbic acid (vitamin C);<br>vit c-ascorbate
Ca-ascorb sod) 1,000 mg oral ASDIR
3. budesonide 0.5 mg/2 mL inhalation BID
4. carboxymethylcell-glycerin(PF) 0.5-0.9 % ophthalmic ASDIR
5. CloNIDine 0.1 mg PO BID
6. Diltiazem Extended-Release 360 mg PO DAILY
7. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q4H:PRN
8. Lisinopril 20 mg PO QAM
9. Lisinopril 10 mg PO QPM
10. Polyethylene Glycol 17 g PO DAILY
11. RisperiDONE 0.5 mg PO QAM
12. RisperiDONE 1.5 mg PO QHS
13. TraZODone 125 mg PO QHS
14. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Sodium Chloride 3% Inhalation Soln 5 mL NEB TID
RX *sodium chloride 3 % 5 mL INH three times a day Disp #*45
Vial Refills:*0
2. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
3. budesonide 0.5 mg/2 mL inhalation BID
4. carboxymethylcell-glycerin(PF) 0.5-0.9 % ophthalmic ASDIR
5. CloNIDine 0.1 mg PO BID
6. Diltiazem Extended-Release 360 mg PO DAILY
7. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation Q4H:PRN
8. Lisinopril 20 mg PO QAM
9. Lisinopril 10 mg PO QPM
10. Polyethylene Glycol 17 g PO DAILY
11. RisperiDONE 0.5 mg PO QAM
12. RisperiDONE 1.5 mg PO QHS
13. TraZODone 125 mg PO QHS
14. Vitamin C (ascorbate Ca-multivit-min;<br>ascorbate
calcium;<br>ascorbic acid (vitamin C);<br>vit c-ascorbate
Ca-ascorb sod) 1,000 mg oral ASDIR
15. Vitamin D ___ UNIT PO 1X/WEEK (MO)
16.Nebulizer
ORDER: Nebulizer machine | DIAGNOSIS: Asthma | ICD10: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Hypoxemic respiratory failure
Multifocal pneumonia
Toxic metabolic encephalopathy
Left tension pneumothorax
Secondary diagnoses:
Cerebral palsy
Bronchopulmonary dysplasia
Asthma
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 pleasure caring for you at ___
___!
Why you were admitted:
- You were unresponsive and weren't breathing
What happened in the hospital:
- You were found to have a pneumonia
- You had a breathing tube placed to help your breathing
- Your left lung had a tear that required placing a tube in your
chest to drain air
- You were treated with antibiotics for your pneumonia
What you should do at home:
- Continue taking your home medications as prescribed
- Continue using your vest as needed for cough or mucous in your
chest
Thank you for allowing us to be involved in your care, we wish
you all the best!
-Your ___ Healthcare Team
Followup Instructions:
___
|
10370676-DS-12 | 10,370,676 | 23,026,978 | DS | 12 | 2145-09-16 00:00:00 | 2145-09-17 06:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / lisinopril / alendronate sodium
Attending: ___.
Chief Complaint:
Syncope, fall with possible headstrike
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F from ___ with a past medical history significant for
borderline diabetes (diet controlled), hypertension; urinary
proteinuria and history of hepatic schistosomiasis status post
treatment with praziquantel presenting for concern for altered
mental status.
Per Adult Day Care (Phone ___ ___ adult health care)
Bus picked up patient who lives alone at apartment, sitting by
herself for breakfast which is her normal. Nurse said patient
wasn't feeling well, almost passed out sitting down vital signs
87/40's hypotensive and confused at the time, + headstrike, +
LOC. She did not take her meds this AM.. Found sitting on floor
with cup of water spilled. Incontinence of urine at baseline per
report. Usually A&O3x at baseline, able to perform ADLs.
In the ED, initial VS were 97.6 57 128/66 20 99% RA
Exam notable for A&O1X, TTP left posterior scalp and left
shoulder, benign HEENT, Neuro and Abdominal exams
Labs showed UA, Chem7, CBC wnl, Trops & BNP negative
Imaging showed CT head/spine neg for acute intracranial
process/cervical spine fracture, nl CXR, nl L shoulder x-ray
Received nothing in the ED.
Transfer VS were 98.9 HR 71 BP 144/66 RR 18 98 RA
Decision was made to admit to medicine for further management of
altered mental status.
On arrival to the floor, patient walking around, in no acute
distress, examined with ___ speaking Medicine resident (Dr.
___. She reports discomfort over left rib area, that
she has had intermittently for "months", she reports she felt it
today. She says she was eating at the apartment with friends,
when she got up, and then doesn't remember falling, remembers
getting up and feeling fine. She denies any prodromal effects.
She may have had a history of vertigo, said she has had ringing
in the ear in the past, but currently denies vertiginous
symptoms.
She denies any confusion, but feels she has been more forgetful.
She denies sick contacts, any cough, fevers/chills, abdominal
pain, urinary pain, trouble breathing.
She denies taking any medications regularly, only takes calcium.
She does not take any cardiac medications, does not know of any
cardiac history aside from having palpitations in past that
resolved on its own. She reports occasional dizziness, denies
currently, states sometimes she is dizzy which improved with
sleeping. She has a diffuse posterior headache, likely from
fall, she denies new vision changes (+blurry vision that she
wears bifocals for).
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Schistosomiasis
Positive QuantiFERON testing -- declined INH and B6, does not
have evidence of active TB on chest x-ray or by symptomatology
as of ___
Cleared hepatitis B--Positive histoplasma serologies
Social History:
___
Family History:
Father had chronic cough, unknown history of TB.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
VS: 98.9F BP 180/83 HR 64 RR16 98RA
112 lbs
GENERAL: NAD, walking around, conversational in ___
HEENT: AT/NC, EOMI, no clear signs of trauma, PERRL, anicteric
sclera, pink conjunctiva, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD , full ROM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
CHEST: no tenderness over chest, no palpable thrills, no signs
of trauma
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, scar from prior C/S presnt, +BS, nontender
in all quadrants, no rebound/guarding,
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: Alert and oriented x2 (off on year, initially said ___,
then said ___, states she is in ___ CN II-XII
intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
LABS: Reviewed in ___, See attached
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ BP 132-178/71-92 HR ___ RR16 98RA, weight 112 lbs
Tele: alarms for irregular rhythm HR ___, appears to be
atrial bigeminy
GENERAL: NAD, walking around, conversational in ___
HEENT: AT/NC, EOMI, no clear signs of trauma, possible slight
swelling in posterior head, tender to palpation, no palpable
fluctuance, PERRL, anicteric sclera, pink conjunctiva, MMM, good
dentition
NECK: nontender supple neck, no LAD, no JVD , full ROM
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
CHEST: no tenderness over chest, no palpable thrills, no signs
of trauma
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distended, scar from prior C/S presnt, +BS, nontender
in all quadrants
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: Alert and oriented x3 CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION and DISCHARGE LABS:
===============================
___ 11:30AM BLOOD WBC-6.8 RBC-3.80* Hgb-12.0 Hct-35.8
MCV-94 MCH-31.6 MCHC-33.5 RDW-12.3 RDWSD-42.5 Plt ___
___ 05:56AM BLOOD WBC-8.5 RBC-4.34 Hgb-13.4 Hct-41.2 MCV-95
MCH-30.9 MCHC-32.5 RDW-12.4 RDWSD-43.4 Plt ___
___ 11:30AM BLOOD Neuts-65.3 ___ Monos-6.8 Eos-2.5
Baso-0.6 Im ___ AbsNeut-4.44 AbsLymp-1.64 AbsMono-0.46
AbsEos-0.17 AbsBaso-0.04
___ 11:30AM BLOOD Glucose-148* UreaN-15 Creat-0.6 Na-139
K-3.9 Cl-107 HCO3-27 AnGap-9
___ 05:56AM BLOOD Glucose-107* UreaN-15 Creat-0.9 Na-143
K-3.4 Cl-109* HCO3-25 AnGap-12
___ 11:30AM BLOOD ___ PTT-28.4 ___
___ 11:30AM BLOOD cTropnT-<0.01 proBNP-142
___ 05:56AM BLOOD CK-MB-2 cTropnT-<0.01
IMAGING:
=========
___ CT head:
There is no evidence of acute hemorrhage, edema, mass effect, or
loss of gray/ white matter differentiation. Foci of low density
in the supratentorial white matter are nonspecific but likely
sequela of mild chronic small vessel ischemic disease in this
age group. Ventricles and sulci are mildly prominent due to
age-related parenchymal volume loss.
There is no evidence of fracture. There is mild mucosal
thickening in the maxillary sinuses, ethmoid air cells, and
inferior frontal sinuses, and minimal mucosal thickening along
the anterior wall of the right sphenoid sinus. Mastoid air
cells and middle ear cavities are well aerated. The orbits are
unremarkable.
___ CT spine:
1. No evidence for a fracture. No acute subluxation.
2. Multilevel degenerative disease.
___ Glenohumeral Xray:
No fracture or dislocation is detected involving the
glenohumeral or AC joint. There is moderate acromioclavicular
joint degenerative change. No suspicious lytic or sclerotic
lesion is identified. No periarticular calcification or
radio-opaque foreign body is seen. The partially visualized left
lung is clear.
___ CXR: Lung volumes are low. The cardiomediastinal
silhouette and pulmonary vasculature are unremarkable given low
lung volumes. There is bibasilar linear atelectasis. An
unchanged calcified granuloma is seen at the right apex.
Brief Hospital Course:
___ with hx of osteoarthritis and HTN who had a syncopal episode
upon standing after eating a meal, with loss of consciousness
and question of headstrike.
#Syncope: Patient was reportedly sitting and eating, when she
lost consciousness and fell to the ground, reported headstrike,
and then patient was able to stand up on own but was confused
per nursing staff. Per report, patient had initial SBP in ___
after event, but was normotensive to hypertensive in the ED and
during her hospital stay. Possible etiologies included reflex
mediated (eating/post prandial, perhaps overflow incontinence in
history) vs orthostasis (15mmHg drop in SBP upon standing, no HR
increase, asymptomatic) vs cardiac etiology (reports a history
of "palpitations"). Telemetry demonstrated mostly sinus rhythm
and episodes of atrial bigeminy. The latter was not believed to
be a contributor to her syncope. She had a non focal
neurological exam with no focal source of infection - afebrile,
bland UA, clear CXR, no leukocytosis. EKG was without ischemic
changes, and she had negative troponin x2 and BNP wnl. She was
discharged and recommended close PCP ___.
#Fall: History was not entirely clear, but there was concern for
headstrike especially given patient complaining of
headache/scalp pain. Endorsed TTP of posterior scalp and left
shoulder. CT head/C-spine negative for bleed, spinal fractures.
L shoulder plain film with no evidence of fractures/dislocation.
#Hypertension: Patient reported to be initially hypotensive, but
in the ED and throughout her stay she exhibited mostly
hypertension with SBP up to 180s at times. She was started on
Losartan 25 mg briefly (given report of cough to ACE-I), but was
not discharged on it given orthostasis.
#Chest Pain: Patient reported left sided pain, underneath her
left rib area, no EKG changes, pain resolved with pain control
and topical analgesic.
#Cleared hepatitis B--Positive histoplasma serologies. She needs
f/u screening progress for HCC.
TRANSITIONAL ISSUES:
- Patient needs screening for HCC.
- Please consider adding an anti-hypertensive medication.
- Can consider ___ of Hearts or Holter monitor if concern
persists for an arrhythmia as the cause of her syncopal episode.
CODE: Full (confirmed)
EMERGENCY CONTACT HCP: ___, Dongchong, Daughter (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1000 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 1000 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Syncope
Secondary Diagnosis:
- Atrial Bigeminy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted on ___ after a syncopal episode (loss
of consciousness). We performed tests to ensure that you did not
have an abnormal heart rhythm or other dangerous etiologies as
the cause of this. We did not find anything concerning but
recommend that you follow up closely with your primary care
doctor nevertheless.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10371476-DS-15 | 10,371,476 | 25,234,771 | DS | 15 | 2176-01-12 00:00:00 | 2176-01-12 18:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Seroquel
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of multiple GI surgeries, now
presenting with persistent abdominal pain s/p ERCP with stent
placement. She has had recurrent abdominal pain and "issues"
over the past year. She went to ___ for initial
evaluation of abdominal pain and was found to have a UTI. She
had a subsequent evaluation with EGD/ERCP with stent placement.
She was reportedly found to have pancreatitis and treated with
bowel rest. She had minimal improvement during this
hospitalization. She was eventually discharged yesterday but
pain has persisted and she is unable to care for her children at
home, so she is presenting now for further evaluation.
In the ED, initial VS were: 98.2 87 125/85 18 97%. Exam notable
for moderate tenderness to palpation to RUQ. LFTs and lipase
normal with only mild ALT elevation. Given recent stent
placement, CT abd/pelvis done and only showed lymphandenopathy
with stent in place. She was given 1L NS, ondansetron, and
morphine with minimal improvement. With her persistent pain and
intolerance to PO, she is being admitted for pain control and
observation.
On arrival to the floor, pt feels well. She has no complaints
aside from constipation and decreased po intake.
Past Medical History:
- ulcers and gastritis
- congenital abnormalities "heterotaxy syndrome"
- lap band removed due to complications
- cholecystectomy
- pancreatitis
- malrotation corrected age ___
- asplenic (congenital)
- hysterectomy for bleeding, cysts
- pregnancy
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION AND DISCHARGE
VS - 98.0 125/82 99 18 96/RA wt 76.8kg
GENERAL - well-appearing obese female in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/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 - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
LABS: see below
Pertinent Results:
ADMISSION AND DISCHARGE LABS
___ 04:30PM BLOOD WBC-11.8* RBC-4.49 Hgb-13.3 Hct-39.8
MCV-89 MCH-29.7 MCHC-33.4 RDW-12.5 Plt ___
___ 04:30PM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-142 K-3.5
Cl-105 HCO3-26 AnGap-15
___ 04:30PM BLOOD ALT-51* AST-38 AlkPhos-99 TotBili-0.2
___ 06:05AM BLOOD Calcium-9.1 Phos-5.7* Mg-2.0
___ 04:30PM BLOOD Albumin-4.1
U/A - SpecGr 1.020, pH 5.5, Leuk Sm, Bld Neg, Prot Tr, RBC 3,
WBC 5, Bact Few, Yeast None, Epi 1
___ Lipase 40
IMAGING
1. No acute intrapelvic process.
2. Post-operative anatomy compatible with history of heterotaxy
and
malrotation.
3. Several nodular enhancing soft tissue densities at the celiac
axis
measuring up to 1.5 cm in short axis. These may represent lymph
nodes of
unknown significance. In addition, thes could represent an
atypical location
of splenosis. Given the patient's altered anatomy, the celiac
axis is
adjacent to the splenic tail. No normal spleen is visualized.
Brief Hospital Course:
BRIEF HOSPITAL COURSE + ACTIVE ISSUES
___ year old female with history of multiple abdominal surgeries
and recent ERCP with stent placement, presenting with worsening,
persistent RUQ abdominal pain.
Patient with normal CT scan and reassuring labs. She is
hemodynamically stable and her exam is not concerning for an
acute abdomen. Exam negative for any discomfort. Lipase is
normal. Counseled about gradual relief of pain as pancreatitis
resolves. She was monitored over course of morning and afternoon
of ___ with improving abdominal pain. Was continued on home
medications in-house, and we ensured bowel movement and regular
diet prior to discharge.
INACTIVE ISSUES
# Continued on outpatient psychiatric medications. Medications
reconcilled with pharmacy.
TRANSITIONAL ISSUES
- f/u ERCP in 8 weeks for stent removal
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Clonazepam 1 mg PO BID
4. Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg Oral
daily
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Venlafaxine XR 150 mg PO DAILY
7. BuPROPion 200 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
RX *oxycodone-acetaminophen 5 mg-500 mg 1 capsule(s) by mouth q8
Disp #*21 Capsule Refills:*0
3. Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg Oral
daily
4. BuPROPion 200 mg PO DAILY
5. Clonazepam 1 mg PO BID
6. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Venlafaxine XR 150 mg PO DAILY
10. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
11. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8 Disp #*90 Tablet
Refills:*0
12. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a ___ Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Post procedural abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing us for your care. You were admitted for
abdominal pain. We performed blood tests look for dangerous
causes of pain and there were no concerning findings. A CT scan
was done and showed changes consistent with your previous
surgeries, but nothing dangerous.
Given your recent ERCP, it is likely that this is residual pain
from that procedure. Your lipase, a marker for pancreatitis, is
normal.
We have made no changes to your medications.
Followup Instructions:
___
|
10371476-DS-16 | 10,371,476 | 23,127,830 | DS | 16 | 2176-02-01 00:00:00 | 2176-02-01 16:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Seroquel
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ pt is s/p lap choly ___ years ago with history of multiple
GI surgeries, who had persisitent abd pain and underwent ERCP
with stent placement 3 weeks ago at ___ complicated by
post-ERCP pancreatitis. The patient is unsure what the thought
process behind the last ECP and stent placement was. Since she
was discharged from ___ 2 weeks ago, she has continued to
have sharp, constant RUQ pain with radiation around her side.
The patient has associated nausea and poor PO intake, but no
vomiting. The patient also notes that she has been moving her
bowels more frequently and having loose stool and foul-smelling
gas. The patient notes ? low grade fevers and some diaphoresis,
but no sick contacts. The patient has not tried taking anything
at home for the pain.
In the ED, initial VS were: 98.9 109 140/98 16 99%. Patient with
leukocytosis to 15K. CT abdomen did not show an acute process.
The patient was admitted for infectious workup and pain control.
On arrival to the floor, the patient is comfortable.
Past Medical History:
- ulcers and gastritis
- congenital abnormalities "heterotaxy syndrome"
- lap band removed due to complications
- cholecystectomy
- pancreatitis
- malrotation corrected age ___
- asplenic (congenital)
- hysterectomy for bleeding, cysts
- pregnancy
Social History:
___
Family History:
noncontributory
Physical Exam:
admission exam:
VS - Temp 97.4F, BP 128/88, HR 98, R 18, O2-sat 98% RA
GENERAL - slighly uncomfortable due to pain
HEENT - PERRLA, EOMI, sclerae anicteric, dry mucus membranes
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - soft, nondistended, normal BS, slight TTP in RUQ along
lower ribs, + Hepatomegaly
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
discharge exam:
VS - 99.3 (2400) 97.6 ___ 20 97%CPAP/RA
GENERAL - NAD. Somnolent, says she is tired after long night.
HEENT - NCAT, EOMI, sclerae anicteric, MMM
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, nondistended, normal BS, slight TTP in RUQ along
lower ribs
EXTREMITIES - WWP, no c/c/e
NEURO - A&Ox3
Pertinent Results:
admission labs:
___ 08:15PM BLOOD WBC-15.2*# RBC-4.23 Hgb-12.9 Hct-37.6
MCV-89 MCH-30.5 MCHC-34.2 RDW-12.7 Plt ___
___ 08:15PM BLOOD Glucose-104* UreaN-10 Creat-0.5 Na-137
K-4.1 Cl-100 HCO3-26 AnGap-15
___ 08:15PM BLOOD ALT-33 AST-27 AlkPhos-121* TotBili-0.2
___ 08:15PM BLOOD Albumin-3.9
studies:
___
FINDINGS: The visualized lung bases are clear. The heart is
normal in size without pericardial effusion. Incidental note is
made of azygos continuation of the inferior vena cava.
A midline liver is present, compatible with patient's history of
heterotaxy. The liver is diffusely hypoattenuating suggestive
of hepatic steatosis with no focal lesions. The hepatic
vasculature is patent. The patient is status post
cholecystectomy. A biliary stent is unchanged in position,
extending from the left-sided biliary ducts into the duodenum
with minimal pneumobilia. The anatomic relationships of the
porta hepatis are distorted but unchanged. The pancreas is
small and atypically positioned. The spleen is absent. Mildly
enhancing soft tissue densities at the celiac axis are again
noted measuring up to 2.5 cm density, which is grossly stable.
The bilateral adrenal glands and kidneys are unremarkable.
There is stable appearance of post-operative anatomy compatible
with history of heterotaxy and malrotation. No bowel
obstruction or bowel wall thickening is seen. No free air or
ascites is present. There is no intra-abdominal fluid
collection.
The abdominal aorta is unremarkable. Incidental note is made of
a left renal vein draining into the hemiazygos vein, which
courses into the chest.
The uterus is not well seen. The urinary bladder, rectum and
sigmoid colon are within normal limits. The right adnexa is
unremarkable by CT. The left adnexa contains a 3.6 x 2.6 cm
oval hypodensity (2:68) with simple internal fluid density,
compatible with a simple ovarian cyst. There is no free pelvic
fluid or inguinal/pelvic lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions
are detected.
IMPRESSION:
1. No intra-abdominal fluid collection. No CT evidence of acute
pancreatitis, but correlate with serum lipase, which is more
sensitive.
2. Biliary stent unchanged in position with minimal
pneumobilia.
3. Fatty liver without focal lesion.
4. Soft tissue densities anterior to celiac axis grossly stable
from ___ represent lymph nodes or splenic tissue.
5. Left ovarian 3.6 cm simple cyst.
6. Stable appearance of post-operative anatomy compatible with
history of heterotaxy and malrotation.
CXR ___
FINDINGS: The lung volumes are normal. Normal size of the
cardiac
silhouette. Normal hilar and mediastinal contours. The lung
parenchyma shows normal structure and transparency. No evidence
of pneumonia, no pulmonary edema.
RUQ U/S ___
The liver is diffusely echogenic, consistent with fatty
infiltration. No
focal liver lesion is identified. No biliary dilatation is seen
and the
common duct measures 0.5 cm. No ascites is seen in the right
upper quadrant. The visualized portion of the IVC is
unremarkable. No hydronephrosis is seen on limited views of the
kidneys. The spleen is noted to be absent. The patient is
status post cholecystectomy.
IMPRESSION:
1. No biliary dilatation.
2. Echogenic liver consistent with fatty changes. Other forms
of liver
disease and more advanced liver disease including significant
hepatic
fibrosis/cirrhosis cannot be excluded on this study.
3. No ascites or fluid collection seen in the right upper
quadrant.
discharge labs:
___ 05:18AM BLOOD WBC-10.9 RBC-4.28 Hgb-12.8 Hct-39.0
MCV-91 MCH-30.0 MCHC-32.9 RDW-13.1 Plt ___
___ 05:18AM BLOOD Glucose-88 UreaN-9 Creat-0.6 Na-139 K-4.6
Cl-101 HCO3-28 AnGap-15
Brief Hospital Course:
This is a ___ yo F with h/o heterotaxy, cholecystectomy, 6 weeks
of abd pain, gastritis, esophageal ulcer and recent ERCP with
cbd stent placement c/b pancreatitis who presents with continued
abdominal pain.
# Abdominal Pain: The patient has chronic abdominal pain of
unclear etiology. She underwent ERCP with CBD stent placement
because of potential biliray stricture on ___ at ___.
This course was c/b post ercp pancreatitis pancreatitis. Patient
also with recent EGD showing chronic stable gastritis as well as
an esophageal ulcer for which she is on BID PPI. CT here was
reassuring with no fluid collection, abscess, or pancreatitis
and lipase is normal. RUQ U/S suggests normal, and with normal
LFTs, suggests stent has been working; the case was discussed
with ___ team who agreed with this assessment. Of note, patient
did have leukocytosis on arrival, but this quickly resolved
overnight without intervention. We considered several potential
diagnoses in this patient with history of instrumentation,
including serious conditions such as cholangitis and biliary
perforation versus biliary sludging and stent occlusion, but
none of these were supported by our diagnostic studies.
Ultimately, we believe that there is an element of chronic
abdominal pain NOS in addition to known gastritis, ulcer
disease, as well as constipation. She was treated supportively
with dilaudid, zofran and a bowel regimen; PPI and carafate were
continued. Patient was tolerating oral diet and medications
well and was discharged with plan for close follow up with a new
gastroenterologist here at ___ (as she wishes to transfer her
GI care here).
# Psych: Continued effexor, wellbutrin, and clonazepam
# Hypothyroidism: Continued levothyroxine
PENDING LABS
- blood cultures drawn on ___ (NGTD)
TRANSITIONAL ISSUES:
- Patient will need repeat ERCP by ___ (~8 weeks
after initial ERCP on ___ for re-evaluation and stent
removal
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg Oral
daily
3. BuPROPion 200 mg PO DAILY
4. Clonazepam 1 mg PO BID
5. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Venlafaxine XR 150 mg PO DAILY
9. Bisacodyl 10 mg PO DAILY:PRN constipation
10. Senna 1 TAB PO BID:PRN constipation
11. Sucralfate 1 gm PO QID
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. BuPROPion 200 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Senna 1 TAB PO BID:PRN constipation
7. Sucralfate 1 gm PO QID
8. Venlafaxine XR 150 mg PO DAILY
9. Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg ORAL
DAILY
10. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
11. Clonazepam 1 mg PO BID
12. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 0.5 - 1.0 tablet(s) by mouth
Q3H:PRN Disp #*30 Tablet Refills:*0
13. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth Q8H:PRN Disp #*21
Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 packet by mouth
DAILY:PRN Disp #*14 Unit Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic abdominal pain
Peptic ulcer disease
Gastritis
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___:
It was a pleasure to take care of you. You were admitted to the
___ with worsening abdominal pain in the context of a recent
ERCP, stent placement, and post-ERCP pancreatitis. We performed
imaging of your abdomen, which was reassuring for no acute
process. We also performed several laboratory tests to look for
infection, and did not find any signs for infection. We reviewed
the case with our ERCP team here, who did not feel there was
need for emergent or repeat ERCP at this time. We also treated
you with a bowel regimen (because of constipation), anti-nausea
medicines, and pain medicines. While the workup to understand
your pain will continue with our GI colleagues, your recent
diagnosis of peptic ulcer disease as well as gastritis in
addition with recent onset constipation are likely contributing.
These are being treated with medications.
Please follow up with your doctors as ___ below. We are
setting you up with a gastroenterologist here.
Please resume your home medications as well. See attached sheets
for any changes.
Followup Instructions:
___
|
10371476-DS-18 | 10,371,476 | 23,102,268 | DS | 18 | 2176-02-25 00:00:00 | 2176-02-25 22:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Seroquel
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a pleasant ___ y/o F w/hx heterotaxy, malrotation
requiring surgical correction as an infant, chronic abdominal
pain, fatty liver, pancreatitis, asplenia, CBD strictures, and
multiple ERCPs who presents today after a recent discharge for
abd ___ with persistent abdominal pain. She has had abd
problems for virtually her whole life, however starting in
___ she had increased RUQ pain and was initially seen at
___. At this time, a CBD stent was placed for unclear
reasons. This was removed during her last admission. She had
w/u of her mild transaminitis at that time as well which was
unrevealing. The hospitalization was complicated by cellulitis
surrounding the ___ IV site which was treated with Bactrim and
Keflex. Since discharge, she states that her RUQ pain has
worsened and she also has had nausea, sweats, abd distension and
decreased PO intake because of the pain, as well as one temp to
101 and shakes in her arms and legs. She has not gotten out of
bed for the last ___ because of the pain. Denies N/V/D, dark or
bloody BMs. She has plans to establish care with Dr ___
has not yet had an appointment.
In the ED, initial vitals 98.2 106 135/97 16 95% RA. THe
patient was tearful and uncomfortable, tachycardic. Abd exam
was notable for TTP in RUQ, without guarding or rebound. Labs
notable for mild transamititis, leukocytosis. UA was benign.
RUQ US was performed and did not show any evidence of CBD
obstruction. She received zofran/morphine. ERCP was consulted
and will plan to follow in house but does not recommend ERCP at
this time.
Currently, pt describes the pain as stabbing, constant ___.
No other complaints
ROS: per HPI, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria. She states that she
sometimes gets short of breath from pain. She has mild anterior
___ pain with ambulation. Last BM was ___.
Past Medical History:
- ulcers and gastritis
- congenital abnormalities "heterotaxy syndrome"
- lap band removed due to complications
- cholecystectomy
- pancreatitis
- malrotation corrected age ___
- asplenic (congenital), UTD on vaccinations
- hysterectomy for bleeding, cysts
- early delivery of pregnancy (30weeks) leading to PTSD (on
clonazepam)
- depression/anxiety
- OSA
- hypothyroidism
Social History:
___
Family History:
No family history of pancreatic or hepatic disease. Father with
hep c and throat cancer
Physical Exam:
ON ADMISSION:
VS - 97.6 137/87 92 18 96 RA
GENERAL - well-appearing woman in NAD, tearful, appears older
than stated age
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - obese, hypoactive BS, soft/diffusely tender, worse in
RUG, ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, no calf edema, mildly ttp
bilaterally anteriorly
SKIN - no rashes or lesions, R anticubital old IV site without
errythema, discharge
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength grossly
intact
PSYCH - tearful, appropriate, reponsive
Pertinent Results:
ON ADMISSION:
___ 11:35PM BLOOD WBC-12.9* RBC-4.42 Hgb-13.0 Hct-40.3
MCV-91 MCH-29.4 MCHC-32.3 RDW-13.0 Plt ___
___ 11:35PM BLOOD Neuts-44* Bands-0 ___ Monos-11
Eos-3 Baso-3* Atyps-2* ___ Myelos-0
___ 11:35PM BLOOD ___ PTT-34.4 ___
___ 11:35PM BLOOD Glucose-124* UreaN-12 Creat-0.7 Na-139
K-5.1 Cl-105 HCO3-23 AnGap-16
___ 11:35PM BLOOD ALT-63* AST-65* AlkPhos-93 TotBili-0.2
___ 11:35PM BLOOD Albumin-4.1
US ___
Limited study due to overlying bowel gas again demonstrates an
echogenic liverconsistent with fatty deposition within the liver
as seen previously. Previously visualized common bile duct stent
has now been removed with the common bile duct measuring 6-8 mm,
which is at the upper limits of normal for a patient status post
cholecystectomy.
CT ___
1. No intra-abdominal fluid collection. No CT evidence of acute
pancreatitis, but correlate with serum lipase, which is more
sensitive.
2. Biliary stent unchanged in position with minimal
pneumobilia.
3. Fatty liver without focal lesion.
4. Soft tissue densities anterior to celiac axis grossly stable
from ___
may represent lymph nodes or splenic tissue.
5. Left ovarian 3.6 cm simple cyst.
6. Stable appearance of post-operative anatomy compatible with
history of heterotaxy and malrotation.
US ___
Limited study due to overlying bowel gas again demonstrates an
echogenic liver consistent with fatty deposition within the
liver as seen previously. Previously visualized common bile
duct stent has now been removed with the common bile duct
measuring 6-8 mm, which is at the upper limits of normal for a
patient status post cholecystectomy.
MRCP ___
Preliminary ReportIMPRESSION:
Preliminary Report1. No interval biliary changes since the prior
CT to explain the patient's symptoms.
Preliminary Report2. Hepatomegaly, with moderate to severe
hepatic steatosis. Other forms of hepatic disease including
steatohepatitis cannot be excluded.
Preliminary Report3. Anatomic changes relating to malrotation.
The pancreas also appears diminutive in size, with the location
between the SMA and SMV, likely also a consequence of
malrotation.
Preliminary Report4. No fluid or fluid collection seen about the
biliary tree or along the inferior aspect of the liver to
suggest the presence of bile leak. No biliary abnormalities to
explain the patient's symptoms.
Brief Hospital Course:
Pleasant ___ yo female with hx of chonic abd pain, recent ERCP,
presented with worsening abd pain.
# Abd pain: Patients presentation of abdominal pain was similar
to prior presentations, with prior workup that did not show
clear etiology of her pain. On this admission her LFTs were
mildly elevated (at baseline). Her w/o for this (hepatitis
serologies, ttg, ___, smooth muscle, TSH) were non-revealing.
Her RUQ US did show fatty deposition of the liver, and she was
felt to have NASH. For w/o of her abdominal pain she had a RUQ
US and MRCP. The US showed fatty deposition
within the liver, CBD 6-8 mm, no intrahepatic duct dilatation.
Her MRCP showed, preliminary report, no interval biliary changes
to explain patients symptoms, hepatomegaly, anatomic changes
relating to malrotation and pancreas diminutive in size, with
the location between the SMA and SMV, likely also a consequence
of malrotation. ERCP service also recommended an MRE.
However, patient requested to be discharged and elected to
continue her evaluation as an outpatient. She was discharged
with a short course of dilaudid and instructed to follow up with
her PCP for continued evaluation as well as with
gastroenterology.
# RUE Cellulitis: Resolved, she completed her course
bactrim/keflex
# OSA: stable; CPAP in house
# Hypothyroidism: TSH wnl.
Transitional issues:
1. Patient has follow up with gastroenterology.
2. MRCP final read will need to be followed
3. Blood cultures from ___ will need to be followed
4. Urine cultures from ___ will need to be followed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. BuPROPion 200 mg PO DAILY
3. Clonazepam 1 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Sucralfate 1 gm PO QID
8. Venlafaxine XR 150 mg PO DAILY
9. Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg ORAL
QDAY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for abdominal pain. You had
an ultrasound of the abdomen that showed fatty deposition within
the liver and an MRCP that preliminarily showed an enlarged
liver and malrotation of the pancreas. The work up of your
enlarged liver (including hepatitis A, B, C, autoimmune work up
were negative) and likely due to "Nonalcoholic steatohepatitis."
Unfortunately, you did not want to stay to complete the work up
of your abdominal pain, which would have been an
MR-enterography.
We have discharged you on a very short course of dilaudid for
pain control. This is a sedating medication; do NOT take with
alcohol, while driving, or while operating heavy machinary. You
can take tylenol for pain as well, up to 2 grams per ___.
Please follow up with your primary care physician as well as
gastroenterology (see beneath).
Followup Instructions:
___
|
10371557-DS-18 | 10,371,557 | 24,074,403 | DS | 18 | 2115-10-07 00:00:00 | 2115-10-07 16:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / losartan
Attending: ___.
Chief Complaint:
Anorexia, increased creatinine
Major Surgical or Invasive Procedure:
___ - Kidney Biopsy
History of Present Illness:
Ms. ___ is a ___ with PMH of Afib on Coumadin,
fibromyalgia, HTN, HLD, and urinary incontinence who presented
to the ED at the request of her PCP after being found to have
hyponatremia and a creatinine >7.
Ms. ___ reports that around two weeks ago, she developed
significant anorexia and hasn't been able to eat much since. Two
of her best friends died last month, so her PCP felt that this
was likely a grief reaction but ordered labs to rule out a
medical cause. A CMP on ___ showed a sodium of 131 and
creatinine of 5.6, and a repeat CMP on ___ showed a sodium of
135 and creatiine of 7.6. Because of her worsening creatinine,
she was advised to come to the ED for further evaluation.
Because she did not trust the ED in ___ and had bad experiences
at ___, she traveled to ___.
Past Medical History:
Urinary frequency
Hypertension, essential
Fibromyalgia
Esophageal reflux
Osteoporosis
Impaired fasting glucose
Hypercholesterolemia
Atrial fibrillation, chronic
Social History:
___
Family History:
No family history of renal issues
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Vital Signs: 97.9 152/75 98 18 95 RA
General: Alert, oriented, appears fatigued but in no distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, no LAD
CV: irregularly irregular rate and rhythm, no murmurs, rubs, or
gallops
CHEST: faint erythematous rash on anterior chest with healing
excoriations
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM
======================
Vital Signs: 97.8 ___ 70-80s 18 ___ r.a.
General: Alert, oriented, appears fatigued but in no distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple,
CV: Irregularly irregular rate and rhythm, no murmurs, rubs, or
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact
SKIN: No hematoma at site of renal biopsy.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 08:00PM BLOOD WBC-6.1 RBC-3.95 Hgb-11.9 Hct-36.5 MCV-92
MCH-30.1 MCHC-32.6 RDW-13.7 RDWSD-46.5* Plt ___
___ 08:00PM BLOOD Neuts-66.1 Lymphs-16.2* Monos-13.2*
Eos-3.1 Baso-0.7 Im ___ AbsNeut-4.01 AbsLymp-0.98*
AbsMono-0.80 AbsEos-0.19 AbsBaso-0.04
___ 10:21PM BLOOD ___ PTT-46.3* ___
___ 08:00PM BLOOD Glucose-111* UreaN-73* Creat-7.0* Na-131*
K-6.4* Cl-95* HCO3-16* AnGap-26*
___ 07:30AM BLOOD TotProt-5.5* Albumin-2.9* Globuln-2.6
Calcium-8.2* Phos-5.2* Mg-2.0
DISCHARGE LAB RESULTS
=====================
___ 07:40AM BLOOD WBC-13.3*# RBC-3.55* Hgb-10.4* Hct-32.2*
MCV-91 MCH-29.3 MCHC-32.3 RDW-14.0 RDWSD-46.8* Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD Glucose-161* UreaN-91* Creat-6.4* Na-136
K-3.8 Cl-99 HCO3-17* AnGap-24*
PERTINENT LABS
==============
___ 07:30AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Positive IgM HAV-PND
___ 07:30AM BLOOD ANCA-NEGATIVE B
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD PEP-NO SPECIFI IgG-722 IgA-301 IgM-44
IFE-NO MONOCLO
___ 07:30AM BLOOD C3-128 C4-28
___ 07:30AM BLOOD HCV Ab-Negative
___ 07:30AM BLOOD ANTI-GBM-Test NEGATIVE
MICROBIOLOGY
============
___ - Urine Culture negative
IMAGING
=======
___ Renal Ultrasound:
The right kidney measures 11.7 cm. The left kidney measures 10.6
cm. There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally. The bladder is moderately
well distended and normal in appearance.
___ CXR:
Cardiomegaly is moderate. Pulmonary vasculature is not engorged
and there is no edema or pleural effusion. No focal pulmonary
abnormality is present
Brief Hospital Course:
HOSPITAL COURSE
===============
___ with PMH of Afib on Coumadin, HTN, who presented to the ED
at the request of her PCP after being found to have hyponatremia
and a creatinine > 7. Baseline creatinine 0.8. Unclear etiology,
creatinine had rapidly increased. Renal U/S negative and FeNa
>3% pointing away from pre or post-renal causes. Granular casts
on microscopy, which suggested ATN. Renal biopsy on ___
indicated interstitial nephritis, trigger unknown but likely due
to antibiotics in setting of prolonged bronchitis in ___.
Started on prednisone on ___, long course planned to be
supervised by nephrology. Creatinine at discharge 6.4. Patient
started on calcium (already on Vitamin D), given information on
low sodium, potassium diet. Discharged with Nephrology follow up
on ___ with Atrius Nephrology, Dr. ___. Lisinopril and
warfarin held due to ___ and renal biopsy respectively, to be
evaluated for restart by Dr. ___.
ACTIVE ISSUES
=============
# Acute Kidney Injury: Baseline creatinine 0.8. Unclear
etiology, creatinine has rapidly increased. Renal U/S negative
and FeNa >3% pointing away from pre or post-renal causes.
Granular casts on microscopy, which suggest ATN. No new
medications but did have hives to losartan and has had a rash on
her chest, has pyuria on UA, thus could consider an allergy to
lisinopril leading to AIN. No evidence of nephritic or nephrotic
syndrome. ANCA, anti GBM, ___ were negative, C3 and C4 were
normal. Patient had a renal biopsy on ___ indicating
interstitial nephritis, trigger unknown but likely due to
antibiotics in setting of prolonged bronchitis in ___.
Started on prednisone on ___, long course planned to be
supervised by nephrology. Creatinine at discharge 6.4. Patient
started on calcium (already on Vitamin D), given information on
low sodium, potassium diet. Discharged with Nephrology follow up
on ___ with ___ Nephrology, Dr. ___. Lisinopril and
warfarin held due to ___ and renal biopsy respectively, to be
evaluated for restart by Dr. ___.
# Atrial fibrillation: Currently rate-controlled on metoprolol,
anticoagulated at home with warfarin. INR of 4 on admission,
possibly due to poor PO intake. Continued metoprolol succinate
150 mg BID. Held warfarin given supratherapeutic INR and renal
biopsy, to be evaluated for restart by outpatient Neprhologist.
# HTN: Lisinopril was held given ___.
# HLD: Continued simvastatin 10 mg daily.
# Urinary incontinence: Detrol LA not on formulary; prescribed
short-acting Detrol 2 mg BID.
TRANSITIONAL ISSUES
===================
[ ] Started on prednisone 60mg on ___, decreased to 40 mg
on ___, with plans of tapering after appointment on
___.
[ ] Follow up with nephrology on on ___.
[ ] Follow up with PCP on ___ at 11:50AM
[ ] Held warfarin after ___ biopsy, to be evaluated for
restart on Nephrology follow up
[ ] Held Lisinopril in setting of kidney disease. Nephrology and
PCP ___ consider restarting this medication.
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Detrol LA (tolterodine) 4 mg oral DAILY
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Succinate XL 150 mg PO BID
4. Simvastatin 10 mg PO QPM
5. Vitamin D 1000 UNIT PO BID
6. Warfarin 2.5 mg PO DAILY16
7. Fish Oil (Omega 3) 3000 mg PO DAILY
Discharge Medications:
1. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by
mouth once a day Disp #*60 Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Detrol LA (tolterodine) 4 mg oral DAILY
4. Fish Oil (Omega 3) 3000 mg PO DAILY
5. Metoprolol Succinate XL 150 mg PO BID
6. Simvastatin 10 mg PO QPM
7. Vitamin D 1000 UNIT PO BID
8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until you are instructed to by your
kidney doctor
9. HELD- Warfarin 2.5 mg PO DAILY16 This medication was held.
Do not restart Warfarin until you are instructed to by your
kidney doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Interstitial Nephritis
Secondary Diagnosis:
- Hyponatremia
- Atrial fib
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___
Why did you come to the hospital?
=================================
- You came to the hospital because your kidney function had
worsened.
What did we do for you?
=================
- You had a biopsy of your kidney so that we could determine the
cause of your worsening kidney function. We found you had a
condition called interstitial nephritis, which may have been
triggered by the illness or antibiotics you had earlier this
year. You were started on steroids (prednisone), and will
continue to take them supervised by your nephrologist, Dr.
___.
Because steroids can cause bone loss, you were started on
calcium.
Because you had a kidney biopsy, your warfarin (blood thinner)
is being held. Do not restart this medication until your kidney
doctor restarts it.
Because of your kidney injury, your blood pressure medication
(lisinopril) is being held. Do not restart this medication until
your kidney doctor restarts it.
What do you need to do?
==================
Please have labs drawn at ___ on ___.
Follow up with nephrologist, Dr. ___ at ___ on
___.
Please call ___ at ___ to confirm the
appointments above.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
10372217-DS-12 | 10,372,217 | 26,566,510 | DS | 12 | 2141-06-06 00:00:00 | 2141-06-07 09:31:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diabetic ketoacidosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with PMHx Diabetes c/b DKA requiring ICU stays
in past, Narcolepsy, OSA, presenting as a transfer from
___ for DKA. He has been off his home medications (Januvia) for
at
least a month and presented today with several days of gradually
worsening generalized malaise, fatigue, decreased appetite,
thirst, urinary frequency as well as multiple episodes of nausea
and vomiting associated with abdominal pain this afternoon. He
was feeling increasingly fatigued and off balance when walking
around and collapsed attempting to go up the stairs to his
apartment. A neighbor helped him off the stairs and back to his
apartment where he called EMS who took him to the ED at ___
before being transferred to ___.
On arrival to ___ patient reports that he is feeling much
better
than prior to admission. His nausea is almost entirely resolved
and he is wondering when he will be able to eat. Other than mild
nausea he is feeling well without further complaints. He has
been
off of his medications for diabetes for the last two months due
to issues obtaining the medicine through his insurance. In that
time he has been attempting to self medicate by taking diabetic
supplements from ___.
Past Medical History:
Type 2 Diabetes
Narcolepsy
OSA
Social History:
___
Family History:
Extensive history of diabetes including father,
paternal/maternal
grandparents
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 97.7, HR 105, BP 134/89, RR 16, Sat 100% RA
GEN: Well appearing ___ man, no apparent distress
EYES: sclera anicteric, PERRLA, EOMI
HENNT: NC/AT, MMM, OP Clear
CV: RRR, +S1/S2, no m/g/r
RESP: CTAB
GI: Soft, nontender, nondistended
MSK: Extremities WWP, no clubbing/cyanosis/edema
SKIN: no rashes/bruising/lesions
NEURO: AAOx3, face symmetric, moving all extreimties with
purpose
PSYCH: affect appropriate
DISCHARGE PHYSICAL EXAM
=======================
Pertinent Results:
ADMISSION LABS
==============
___ 10:40PM BLOOD WBC-14.8* RBC-4.86 Hgb-16.2 Hct-49.8
MCV-103* MCH-33.3* MCHC-32.5 RDW-12.2 RDWSD-46.0 Plt ___
___ 10:40PM BLOOD Neuts-84.8* Lymphs-4.9* Monos-8.7
Eos-0.0* Baso-0.3 Im ___ AbsNeut-12.50* AbsLymp-0.73*
AbsMono-1.29* AbsEos-0.00* AbsBaso-0.05
___ 10:40PM BLOOD ___ PTT-38.2* ___
___ 10:40PM BLOOD Glucose-590* UreaN-28* Creat-1.7* Na-140
K-5.3 Cl-101 HCO3-4* AnGap-35*
___ 10:40PM BLOOD ALT-15 AST-13 AlkPhos-110 TotBili-0.4
___ 10:40PM BLOOD Albumin-4.6 Calcium-9.6 Phos-6.3* Mg-2.6
___ 10:46PM BLOOD ___ pO2-41* pCO2-25* pH-6.95*
calTCO2-6* Base XS--28
PERTINENT LABS
==============
___ 02:51AM BLOOD %HbA1c-13.8* eAG-349*
IMAGING
=======
CXR ___
1. No acute cardiopulmonary abnormality.
2. Sclerotic focus in the proximal left humerus/humeral head,
which may
reflect a bone infarct or benign chondroid lesion.
MICROBIOLOGY
============
___ 10:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS
==============
Brief Hospital Course:
___ year old male with history of Type 2 Diabetes c/b diabetic
ketoacidosis, nacrolepsy, OSA, presenting as a transfer from
___ with diabetic ketoacidosis.
# Diabetic ketoacidosis
# Anion gap metabolic acidosis
# Type 2 diabetes
Presented with evidence of DKA with pH 6.92, glucose 590, AG 35
and urine positive for ketones. This most likely occurred in the
setting of medication non-compliance and diabetes overall poorly
controlled with HgA1C 13.8%. He has had multiple prior
admissions for DKA. He was admitted initially to the ICU for IVF
and insulin gtt per DKA protocol. ___ was consulted to assist
in transition to SC insulin regimen. He was stabilized on a
regimen of Lantus 50 units in the morning, 20 units before
bedtime, Humalog 20 units at breakfast, 18 units at lunch, 20
units at dinner, and then Humalog sliding scale, as well as
metformin 500 mg PO BID. He will follow up with ___,
appointment to be scheduled, as well as his endocrinologist, Dr.
___.
# Melena
One episode of dark black, "oily", guaiac positive stool. No
hematemesis. Had one dose of 600mg ibuprofen prior to arrival,
reports occasional 1 drink of alcohol, no iron supplements or
bisacodyl. Hgn downtrended throughout admission felt secondary
to dilution. He was given IV pantoprazole, transitioned to PO.
He will establish with a new PCP at ___, who will follow up this
problem. He may benefit from an EGD and/or colonoscopy to
evaluate. CBC should be checked upon PCP ___.
# Acute Kidney Injury, resolved
Cr 1.7 on admission from last known baseline 0.9-1.1 in ___.
Most likely pre-renal injury in the setting of volume depletion
from DKA. Resolved to creatinine 0.8 on discharge.
# OSA
# Narcolepsy
Per ___ records patient has had a sleep study and possibly a
MSLT in the past. Has refused CPAP on previous admissions. Would
likely benefit from f/u with sleep medicine after discharge.
Patient reports he was most recently on nuvigil 375mg daily for
narcolepsy, which he will resume at home.
TRANSITIONS OF CARE
-------------------
# ___: He was stabilized on a regimen of Lantus 50 units
in the morning, 20 units before bedtime, Humalog 20 units at
breakfast, 18 units at lunch, 20 units at dinner, and then
Humalog sliding scale, as well as metformin 500 mg PO BID, which
he will continue at home. He will follow up with ___,
appointment to be scheduled, as well as his endocrinologist, Dr.
___. He will establish with a new PCP at ___, who will
follow up this problem. He may benefit from an EGD and/or
colonoscopy to evaluate. CBC should be checked upon PCP
___.
# Code Status: Full (confirmed)
# Emergency Contact: ___ (Friend) ___ or
___ (Friend) ___
Medications on Admission:
Not taking any medications on arrival
Discharge Medications:
1. Glargine 50 Units Breakfast
Glargine 20 Units Dinner
Humalog 20 Units Breakfast
Humalog 18 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 50 Units before BKFT; 20 Units before DINR; Disp
#*30 Syringe Refills:*0
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
Up to 10 Units QID sliding scale, 20 Units before breakfast, 18
Units before LNCH; 20 Units before DINR; Disp #*10 Syringe
Refills:*2
RX *insulin syringe-needle U-100 [BD Insulin Syringe] 29 gauge X
___ AS DIR Disp #*50 Syringe Refills:*2
2. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*40
Tablet Refills:*0
3. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth q24h Disp #*30
Tablet Refills:*0
4. Januvia (SITagliptin) 100 mg oral DAILY
5. Nuvigil (armodafinil) 375 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetic ketoacidosis
Anemia, likely from acute blood loss
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___.
Why was I here?
- You came to the hospital because you were feeling generally
unwell.
- You were found to have a condition called diabetic
ketoacidosis, also known as 'DKA', in which you have very high
blood sugars and it causes your blood to be acidic.
What was done while I was here?
- You were admitted to the ICU initially where you received
insulin.
- You will need to continue on insulin at home to help manage
your diabetes.
What should I do when I get home?
- Please take all of your medications as prescribed and go to
all of your follow up appointments as listed below.
We wish you the best!
- Your ___ Team
Followup Instructions:
___
|
10372384-DS-21 | 10,372,384 | 23,286,568 | DS | 21 | 2190-03-30 00:00:00 | 2190-03-31 09:14:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
___ 4.8L Therapeutic and diagnostic paracentesis
History of Present Illness:
PRIMARY ONCOLOGIST: ___, MD
PRIMARY DIAGNOSIS: Metastatic ER+ lobular breast carcinoma.
Sites of disease include diffuse osseous, and omental disease
with malignant ascites.
TREATMENT REGIMEN: Pembro/eribulin on ___ protocol
Chief Complaint: Nausea/vomiting
___ is a ___ yo woman with metastatic (bones,
omentum, ascites) ER+ lobular breast cancer, who presents with
acute vomiting x 3 days
Ms. ___ reports she was in her USOH until ___ afternoon
(
3 days PTA), when she vomited after drinking a glass of milk.
Over the next 3 days, she has had intermittent vomiting, usually
occurring ___ minutes after eating or drinking, although she
has also woken up in the middle of the night retching/vomiting.
She denies any sensation of nausea. She reports that in general
the emesis is either food particles from what she just ate or
bilious liquid (the color of turmeric). She denies fevers,
chills, suspicious food intake, recent travel, sick contacts. No
diarrhea, abdominal pain, URI symptoms. She has had poor
appetite
for months, but is especially afraid to eat or drink in the last
3 days with these symptoms.
She was postulated to have gastroparesis in s/o malignant
ascites
and started on reglan 10 TID 1 month ago. She says this does not
seem to help her symptoms. She has not been taking zofran as she
does not feel nauseous.
She also has malignant ascites requiring paracentesis q ___
weeks. Her last para was ___ for 4L and she was scheduled for
paracentesis on ___.
Her acute symptoms are on top of a subacute course of worsening
functional status. She reports worsening fatigue/malaise and
appetite loss over the last ___ months. Her last scheduled chemo
on ___ for C16D8 was held d/t these ongoing complaints and her
oncology team is considering switching therapy.
In the ED: T ___ F | 88 | 105/66 | 100% RA. She was noted to have
a severe episode of nausea, retching 7 times over a short period
of time. A CT A/P was obtained which was negative for
obstruction. It did demonstrate peritoneal carcinomatosis with
large volume ascites. Labs were remarkable for acute on chronic
anemia 6.7 (baseline 9), thrombocytosis to 600s.
=== REVIEW OF SYSTEMS ===
Constitutional: No fevers, chills, night sweats. Appetite is
poor
per HPI. Fatigue/malaise per HPI. Approximate 5 lb weight loss
over last month.
Neurologic: Mild headache when retching/vomiting. No blurry
vision, numbness or tingling, focal weakness
HEENT: No rhinorrhea, sore throat
Cardiovascular: No chest pain, palpitations
Respiratory: No shortness of breath, cough
Gastrointestinal: Per HPI. Last BM yesterday
Genitourinary: No dysuria
Hematologic: No bleeding observed including blood per rectum,
blood in emesis, hematuria, and epistaxis
Musculoskeletal: No myalgias, swelling
Dermatologic: No rashes
All other review of systems are negative unless stated otherwise
Past Medical History:
-Pemphigus foliacous - involves scalp, torso and other skin
areas; referred to Dermatology previously; etiology unclear but
thought not related to the neoplasm.
- Diabetes, type II
Oncologic history
In ___, she was noted to have pea sized palpable mass in
upper outer quadrant of right breast. Ultrasound negative. She
was due for repeat mammogram, but due to her mother's death from
___ disease and the death of her husband's father, this
was delayed. Mammogram obtained ___ showed 1.6 cm area of
architectural distortion. Wide excision done ___ in which a
4.9 x 3.7 x 2.2 cm specimen was removed which grossly contained
an 8 mm mass located at the lateral margin. Final pathology
showed an infiltrating lobular carcinoma that was 2.1 cm in
size.
There was also extensive LCIS and ALH. There was no
lymphovascular invasion. The tumor was ER positive/PR
positive/HER-2 non-amplified.
Due to incomplete margins, she underwent re-excision and SLNB
with Dr. ___ at ___ ___. Due to positive SLNB, she
underwent axillary lymph node dissection on ___. Final
pathologic staging was felt to be T1cN2M0 (4 of 17 notes
positive).
She was treated with AC x 4 cycles ___. Followed by
RT
which was completed ___. She then completed 4 cycles of
taxol
___ and was transitioned to adjuvant tamoxifen
___.
In ___, she was switched to letrozole and completed this
___.
In ___, she was found to have hydronephrosis. CEA and CA
___
were elevated. CT A/P ___ showed bilateral moderate
hydronephrosis, left greater than right, as well as thickening
of
the dome of the bladder. There was no other clear radiographic
evidence of recurrent disease and no intra-abdominal or
retroperitoneal masses. She had stents placed bilaterally. A
presumptive diagnosis of recurrent lobular carcinoma of the
breast was made in view of the fact that tissue could not be
obtained short of a laparotomy.
Started on fulvestrant ___ IM monthly. Tumor markers fell. In
___, markers began to rise again. MRI abdomen ___ raised
concern for abnormal studding, enhancement, and diffusion of the
mesentery as well as "salt and pepper" appearance of
thoracolumbar spine, findings highly suspicious for metastatic
disease.
Biopsy done of omental nodule ___ showed lobular carcinoma
of the breast, ER positive, PR positive, HER2/Neu negative.
Started on capecitabine ___ (initially took half dose due
to
misunderstanding and then started full dose ___. Follow up
CT in ___ showed decreased omental thickening and decreased
ascites. Tumor markers also fell
By ___, tumor markers were rising again and CT demonstrated
extensive bony disease and omental stranding and nodularity. She
was transitioned to bazodoxifene plus palbociclib(C1D1 ___
per trial ___.
Follow up imaging showed progressive increase in ascites in
___. She was transitioned to eribulin and pembrolizumab (C1D1
___
Social History:
___
Family History:
Mother - breast cancer diagnosed at age ___ died of ___
dementia at ___.
Brother - melanoma in his ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
=====================
VITALS: 98.2 F | 116/76 | 88 | 100% RA
General: Tired chronically ill appearing Caucasian woman,
resting
in bed, pleasant. Vomited during exam with clear dark yellow
liquid in basin approx 200 cc
Neuro:
PERRL, palate elevates symmetrically. Alert and oriented,
provides clear history. ___ plantar and dorsiflexion. ___
handgrip
HEENT: Oropharynx clear with slightly moist mucus membranes. No
palpable cervical adenopathy.
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Lungs clear to auscultation bilaterally
Abdomen: Soft, normoactive bowel sounds, firm carcinomatosis,
distended with ascites. No rebound, no guarding, nontender
Extr/MSK: Thin extremities, no pitting edema
Skin: No rashes
Access: R POC which is c/d/i and nontender to palpation
DISCHARGE PHYSICAL EXAM:
======================
VS: 24 HR Data (last updated ___ @ 1244)
Temp: 98.1 (Tm 98.5), BP: 113/80 (103-129/67-85), HR: 92
(83-98), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: Ra
GEN: thin, frail woman in bed, laying in dark, better spirits
this morning
HEENT: anicteric sclera, PERRLA, EOMI, neck supple with no LAD,
oropharynx clear
CV: RRR, no m/r/g
PULM: lungs CTAB
ABD: mildly distended, non-tender, no rebound or guarding, no
HSM
Ext: 1+ pitting edema in lower extremities ___, which is baseline
per pt; WWP, pulses intact, no rashes
Neuro: AAOx4, CN2-12 grossly intact
Pertinent Results:
ADMISSION LABS:
=============
___ 04:55PM BLOOD WBC-5.5 RBC-2.51* Hgb-6.7* Hct-22.8*
MCV-91 MCH-26.7 MCHC-29.4* RDW-22.2* RDWSD-72.1* Plt ___
___ 04:55PM BLOOD Neuts-18.3* ___ Monos-29.5*
Eos-0.7* Baso-0.7 Im ___ AbsNeut-0.99* AbsLymp-2.72
AbsMono-1.61* AbsEos-0.04 AbsBaso-0.04
___ 04:55PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL
Polychr-OCCASIONAL Ovalocy-OCCASIONAL
___ 04:55PM BLOOD ___ PTT-47.8* ___
___ 04:55PM BLOOD Ret Aut-3.3* Abs Ret-0.08
___ 04:55PM BLOOD Glucose-85 UreaN-8 Creat-0.5 Na-139 K-4.1
Cl-104 HCO3-21* AnGap-14
___ 04:55PM BLOOD ALT-9 AST-22 LD(LDH)-256* AlkPhos-113*
TotBili-0.3 DirBili-<0.2
___ 04:55PM BLOOD Lipase-15
___ 04:55PM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.2 Mg-2.2
___ 04:55PM BLOOD Hapto-282*
___ 05:08PM BLOOD Lactate-1.3
MICRO:
=====
___ 08:54AM ASCITES TNC-61* RBC-81* Polys-1* Lymphs-43*
___ Macroph-53* Other-3*
___ 08:54AM ASCITES TotPro-2.6 Albumin-1.7
___ 8:54 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
STUDIES/REPORTS:
==============
___ CT ABD & PELVIS WITH IV CONTRAST, NO PO CONTRAST
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. A
small right
and trace left pleural effusion, grossly unchanged. No
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Homogeneous liver parenchyma demonstrating
scattered
subcentimeter hypodensities too small to characterize but
unchanged from
prior. Surgically absent gallbladder. No intrahepatic biliary
ductal
dilatation.
The redemonstration of a large volume simple ascites and
peritoneal
enhancement consistent with known peritoneal carcinomatosis.
Loculated
ascites within the lesser sac is re-demonstrated and similar to
prior.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: 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 is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. Diverticulosis of the sigmoid colon is
noted, without evidence of wall thickening and fat stranding.
The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is
fluid extending into the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: Diffuse sclerotic appearance of the axial and
appendicular skeleton is
consistent with osseous metastatic disease, unchanged from
prior.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No evidence of bowel obstruction.
2. Diverticulosis without evidence of acute diverticulitis.
3. Peritoneal thickening with large volume ascites slightly
greater in volume,
in keeping with peritoneal carcinomatosis. Loculated ascites
within the lesser
sac is similar to prior. Unchanged diffuse osseous metastatic
disease.
4. Small right and trace left pleural effusion.
___ PARACENTESIS
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 4.8 L of fluid were removed.
___ BREAST ULTRASOUND
FINDINGS:
Tissue density: B- There are scattered areas of fibroglandular
density.
Right: Postoperative changes from prior lumpectomy underlie the
BB indicating
the site of palpable concern. The surgical site appearance is
unchanged dating
back to at least ___. There is a biopsy clip in the lower
central right
breast. Note is made of skin thickening as well as trabecular
think getting
consistent with fluid overload. Scattered benign calcifications
are seen.
There is no new suspicious dominant mass, unexplained
architectural distortion
or suspicious grouped calcification.
Left: The left breast is without suspicious dominant mass,
unexplained
architectural distortion or suspicious grouped calcifications.
Scattered
benign calcifications are seen.
RIGHT BREAST ULTRASOUND:
Images from a targeted ultrasound of the right breast in the
area of palpable
concern at ___ o'clock, 10 cm from the nipple demonstrates an
irregular,
hypoechoic mass without dominant vascularity demonstrating
minimal shadowing and convex borders measuring 1.4 x 1.2 x 1.6
cm. While likely the with postoperative surgical scar, the
appearance of convex borders suggests the possibility of local
recurrence.
IMPRESSION:
1.6 cm indeterminate mass in the right breast at ___ o'clock,
10 cm from the
nipple. Ultrasound-guided core biopsy has been requested and
will be performed as previously ordered by her care team later
same day.
RECOMMENDATION(S): Ultrasound-guided core biopsy as previously
ordered by her care team.
NOTIFICATION: Findings and recommendations for biopsy were
discussed with the patient. She is in agreement with the plan.
BI-RADS: 4B Suspicious - moderate suspicion for malignancy.
___ BREAST BIOPSY ULTRASOUND GUIDED
COMPARISON: Prior imaging earlier same day.
FINDINGS:
Again re-demonstrated in the right breast ___ o'clock 10 cm
from the nipple
is a 1.6 cm irregular hypoechoic solid mass which was the target
for biopsy.
PROCEDURE: The procedure, risks, benefits and alternatives were
discussed
with the patient and written informed consent was obtained.
Time-out certification: Performed using three patient
identifiers.
Allergies and/or Medications: Reviewed prior to the procedure.
Clinicians: ___, N.P.. The procedure was supervised by
___, M.D.(Attending).
Description: Using ultrasound guidance, aseptic technique and 1%
lidocaine for
local anesthesia, a 13-gaugecoaxial needle was placed adjacent
to the right
breast mass and using a 14-gauge Bard spring-loaded biopsy
device, 6 cores
were obtained. Next, a percutaneous HydroMark coil was deployed
under
ultrasound guidance. The needle was removed and hemostasis was
achieved.
Estimated blood loss: < 1 cc.
Specimens: Sent to pathology.
Anesthesia: ___ cc 1% lidocaine
Complications: No immediate complications.
Post procedure diagnosis: Same.
A postprocedure mammogram was deferred as the clip was seen in
the mass under ultrasound.
IMPRESSION:
Technically successful US-guided core biopsy of the breast
lesion. Pathology
is pending. The patient expects to hear the pathology results
from her referring provider ___ ___ business days. Standard post
care instructions were provided to the patient. The patient
left the breast section in good condition awaiting
transport to bring her back to her inpatient room.
___ DIAGNOSTIC MAMMOGRAM
IMPRESSION:
1.6 cm indeterminate mass in the right breast at ___ o'clock,
10 cm from the
nipple. Ultrasound-guided core biopsy has been requested and
will be performed as previously ordered by her care team later
same day.
RECOMMENDATION(S): Ultrasound-guided core biopsy as previously
ordered by her care team.
NOTIFICATION: Findings and recommendations for biopsy were
discussed with the patient. She is in agreement with the plan.
BI-RADS: 4B Suspicious - moderate suspicion for malignancy.
PATHOLOGY:
=========
___ BREAST BIOPSY - PENDING
Brief Hospital Course:
___ yo F with metastatic (bones, omentum, ascites) ER+ lobular
breast cancer, who presents with acute vomiting x 3 days found
to have large volume ascites.
HOSPITAL COURSE BY PROBLEM:
#Nausea/vomiting, improved
Suspect multifactorial. She presented with large volume
malignant ascites likely the cause of her abdominal discomfort
and possible nausea/vomiting. Her symptoms did improve initially
after large volume paracentesis on ___. She also has a
loculated ascites pocket near stomach curvature which is
accessible by drainage. Her symptoms of nausea/vomiting may also
be related to gastroparesis. She also describes hiccupping often
and a very sensitive gag reflex so it is possible this may have
contributed to her vomiting. She felt improved after initiation
of baclofen and improvement in her hiccups. She was continued on
reglan and given oral Ativan which she found very helpful. She
was also given a PPI to treat a GERD component/esophageal
irritation from vomiting.
# Acute on chronic anemia, stable
Admission Hbg 6.7, received 1U PRBCs on ___ with greater than
appropriate increase in Hbg. No visualized source of bleed.
Unclear as thrombocytosis argues against myelosuppression. No
evidence of hemolysis. No hx of anemia with chemo. Responded
more than appropriately to 1unit PRBCs ___ thus her anemia
value may have been spurious.
# Metastatic breast cancer
Diagnosed in ___ with T1cN2M0 right breast cancer (ER+/PR+,
HER2 -) s/p AC and ___ yrs of hormone therapy. Metastatic
recurrence in ___ with involvement in omentum, ascites, bone.
Bx of omentum w/ ER+/PR+/HER2- lobular carcinoma. Progressed
through fulvestrant, capecitabine, bazodoxifene/palbociclib. Now
on clinical trial with eribulin and pembrolizumab (C1D1
___, with worsening functional status in last ___ months
thinking about next line of therapy vs transitioning goals of
care. Palliative care consulted which she found helpful and will
see her as outpatient.
# Hx of PE
Continued anticoagulation.
TRANSITIONAL ISSUES:
===================
- Follow up with palliative care as an outpatient ideally on
same day as next visit as Dr. ___, as patient found this
very helpful.
- If unable to control vomiting or keep up adequate PO intake,
pt may need to consider TPN for adequate hydration/caloric
intake vs regular IVF therapy as outpatient.
- Discharged with home physical therapy.
- Patient underwent outpatient mammogram/ultrasound and breast
biopsy on ___, the results of which to be followed up by
primary oncology team.
- Peritoneal fluid culture no growth at time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. Nystatin Cream 1 Appl TP BID:PRN rash
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN
scalp
4. Metoclopramide 10 mg PO TID W/MEALS
5. Omeprazole 20 mg PO BID
6. Rivaroxaban 20 mg PO DAILY
7. Spironolactone 100 mg PO DAILY
8. Docusate Sodium 200 mg PO DAILY
9. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
11. tacrolimus 0.1 % topical BID:PRN
12. Mupirocin Nasal Ointment 2% 2 % nasal TID
Discharge Medications:
1. Baclofen 5 mg PO TID hiccups
RX *baclofen 10 mg 0.5 (One half) tablet(s) by mouth three times
per day as needed Disp #*30 Tablet Refills:*0
2. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth as needed every
6 hours for nausea Disp #*20 Tablet Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN
scalp
5. Docusate Sodium 200 mg PO DAILY
6. Metoclopramide 10 mg PO TID W/MEALS
7. Mupirocin Nasal Ointment 2% 2 % nasal TID
8. Nystatin Cream 1 Appl TP BID:PRN rash
9. Omeprazole 20 mg PO BID
10. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
12. Rivaroxaban 20 mg PO DAILY
13. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
14. Spironolactone 100 mg PO DAILY
15. Tacrolimus 0.1 % topical BID:PRN topical rash
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Nausea/vomiting
Gastroparesis
Malignant ascites s/p diagnostic and therapeutic paracentesis
Metastatic breast cancer
Protein-calorie malnutrition
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 with significant vomiting.
You had a paracentesis which removed almost 5L fluid from your
abdomen which did improve your abdominal distention. You were
started on a medication called baclofen which can help with the
hiccupping component leading to vomiting. We think your
nausea/vomiting may be secondary to a sensitive gag reflex, your
hiccupping and diaphragm irritation as well as gastroparesis
(slow stomach emptying) and the ascites fluid in your belly. We
hope that you start to feel better and we are encouraged that
you felt well enough to be discharged home.
WHAT TO DO NEXT?
- Please eat small bites of food slowly, small meals more
frequently might be helpful.
- Take the baclofen for hiccups as needed and reglan with meals.
- Take the Ativan as needed for nausea.
- Please follow up with your primary oncologist after discharge.
- Please seek care if you develop refractory nausea and vomiting
and are unable to keep anything down.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
10372580-DS-19 | 10,372,580 | 20,904,490 | DS | 19 | 2186-02-21 00:00:00 | 2186-02-25 13:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
pcn / ciprofloxacin
Attending: ___.
Chief Complaint:
fever/ C.diff colitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with history of ulcerative colitis (well
controlled on Asacol without flares since ___ who presents
with low volume watery diarrhea and fevers. The patient had been
on antibiotics (unsure what, X10 days) for a gum graft two weeks
ago. She developed low grade fevers, BRBPR (streaks and in
toilet bowl) and lower abdominal cramping/gassiness ___
and presented to her PCP ___ ___. It was initially felt she
had a viral gastroenterities, not UC flare and was encouraged to
maintain hydrated, rested. The patient had ___ bowel movements
that day (___), 15 bowel movements last ___, the low
grade fevers and BRBPR resolved by ___. The patient was
instructed to increase her Asacol dosage on ___
given persistent diarrhea for possible UC flare. She felt her
diarrhea did improve the day afterwards, previously was going
every 10 minutes (low volume diarrhea). Stool studies, CDiff
assay sent and found to be CDiff positive X2. She was prescribed
Flagyl 500mg TID X 14 days yesterday, first dose taken this
morning. She developed fevers to ___ this afternoon ~1:30pm,
with chills and fatigue. The patient took a nap and her second
dose of Flagyl without improvement in her fever and thus called
her PCP's office who told her to come to the ___ ED. The
patient initially tried contacting ___ Urgent Care to be
seen there instead but was urged to proceed directly to an ED.
No nausea/vomiting and able to tolerate POs but poor appetite.
Of note, the patient recently got the Zostavax. In general, she
feels her current diarrhea is more painful/crampy and slimy than
her UC flare diarrhea, but also less bloody. She has not had any
extra-intestinal manifestations of her UC previously.
In the ED, initial VS: T103.4, HR114, BP106/83, RR18, 97% on RA,
pain ___. Labs were notable for leukocytosis to 16.6 with left
shift, normal coags, LFTs, Chem 7, lactate. KUB was within
normal limits. She was given tylenol ___ for her fever and
metronidazole 500mg X1 for the known CDiff. She was rehydrated
with two liters NS IVF and admitted given "high risk substrate."
On transfer, VS: T100.0, HR91, RR12, BP92/55, O2 sat 100% on RA,
pain ___.
Past Medical History:
* Dense breasts
* Osteopenia - BMD ___ shows spine 0.9, total hip -2.0, fem
neck -1.9--osteopenia, spine sl improved otherwise unchanged
from ___.
* Lattice degeneration of the retina
* Menopause - In late ___ and completed ___ took HRT < ___ year
___, minimal symptoms overal
* Ulcerative colitis - Presented with blood diarrhea and found
to have colitis beyond 40 cm on flex sig ___ Treated with
sulfasalazine (d/c'd for nausea, headaches) and prednisone -->
Asacol. Flare in ___ treated with Rowasa/Cortenemas and in
remission since ___ on Asacol 2.4 grams/daily. Colonoscopies in
___ all normal without dysplasia. Colonoscopy in
___ showed one hyperplastic polyp, no dysplasia. Repeat
colonoscopy ___.
Social History:
___
Family History:
Father ___ ASHD; Mother ___, Stroke;
Sister ___ Cancer in other family members
Physical Exam:
On Admission:
VS - Temp 98.8F, BP 90/Doppler, HR 78, R 18, O2-sat 96% RA
GENERAL - Well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry mucus
membranes, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding
but TTP in bilateral lower quadrants
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and
sensation grossly intact
On Discharge:
VS - T98.6 BP96/63, HR68, R18, O2-sat 98%RA
GENERAL - Well-appearing woman in NAD, sitting up in chair
reading comfortably, conversation appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, moist mucus
membranes, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no wheezing, rales, rhonchi, good air
movement, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - Soft, non-tender, non-distended, BS +ve, Hepatomegaly
or splenomegaly, no rebound/guarding,
EXTREMITIES - well perfused, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and
sensation grossly intact
Pertinent Results:
On Admission:
___ 06:30PM BLOOD WBC-16.6* RBC-4.67 Hgb-12.9 Hct-38.8
MCV-83 MCH-27.5 MCHC-33.1 RDW-13.1 Plt ___
___ 06:30PM BLOOD Neuts-92.9* Lymphs-5.3* Monos-1.4*
Eos-0.2 Baso-0.1
___ 06:30PM BLOOD ___ PTT-24.5* ___
___ 06:30PM BLOOD Glucose-116* UreaN-12 Creat-0.8 Na-136
K-5.2* Cl-104 HCO3-22 AnGap-15
___ 06:30PM BLOOD ALT-16 AST-30 AlkPhos-60 TotBili-0.4
___ 06:30PM BLOOD Albumin-4.1
___ 06:20AM BLOOD Calcium-7.0* Phos-2.7 Mg-1.9
___ 06:30PM BLOOD Lactate-1.1 K-3.6
Cdiff positive X2 reportedly from ___ lab
Urine and blood cultures pending from ___ and ___
On Discharge:
___ 06:00 AM
Hg/Hct: 10.5/32.6
WBC: 8.4
Lytes: ___
Ca: 7.9
Phos: 2.1
TSH (outside records): 3.44
VitD: 27L (___)
MICRO:
___ 1:54 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Reported to and read back by J MINEDI ___ @9:10 AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Preliminary):
___ 6:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 6:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 1:54 am URINE Source: ___.
URINE CULTURE (Pending):
IMAGES:
CXRAY OF ABD ON ___:
FINDINGS: Upright and supine views of the abdomen. No prior.
There is a
nonspecific bowel gas pattern identified. Nondilated loops of
air-filled
___ are seen in the right hemiabdomen. There are no abnormal
air-fluid
levels nor free air below the hemidiaphragm. Mild mid lumbar
levoscoliosis is
identified. Multiple phleboliths are identified in the pelvis.
IMPRESSION: Nonspecific nonobstructive bowel gas pattern
identified.
Brief Hospital Course:
___ year old woman with history of ulcerative colitis previously
well controlled on Asacol who presents with C. diff colitis
after taking antibiotics after a dental procedure.
#. Moderate to severe C. diff colitis- The patient presented
from here PCP office with ___ known diagnosis of C. diff and was
started on Flagyl. She presented to the ED after only 2 doses
with fevers>103, WBC>15,000 and >20 episodes a day of watery
diarrhea. Given the severity of her presentation she was
started on Vancomycin 125mg PO QID to compete a 14 day cource.
Within 24 hours of hospitalization, the patient became afebrile,
WBC normalized, and her diarrhea improved. She was discharged
on ___ in improved condition with a normal WBC and reportedly
one loss BM over the last 12 hours
#. hypocalcemia- The patient takes vit D and calcium
supplementation as an outpatient, but presented with
hypocalcemia to 7.0 (with a normal albumen). Her last
documented vitamin D level in ___ was 27 (low). The
hypocalcemia is likely related to the severity of her C. diff
colitis, but other cause such as low Vit D or hypoparathyroidism
could not be excluded. The patient was instructed to follow up
with her PCP for further management of hypocalcemia.
#. Ulcerative colitis - The patient's last flare was over a
decade ago, but given recent diarrhea there was concern for a
flair. Given her rapid improvement with vancomycin, it was felt
that a flare was less likely. However, we continued to treated
her with high dose Asacol at 1200mg PO TID and she should follow
up with her PCP and gastroenterologist for further management.
Medications on Admission:
* Metronidazole 500mg three times daily X 14 days
* Mesalamine 400mg three tablets TID (was on three tabs BID)
* Calcium Carbonate-Vitamin D3 600mg-200units twice daily
* Vitamin C 500mg daily
* Multivitamin daily
Discharge Medications:
1. Mesalamine ___ 1200 mg PO TID
2. Vancomycin Oral Liquid ___ mg PO Q6H
RX *Vancocin 125 mg 1 Capsule(s) by mouth four times daily Disp
#*48 Capsule Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit Oral BID
RX *Calcium 600 + D(3) 600 mg calcium (1,500 mg)-400 unit 1
(One) Tablet(s) by mouth Daily Disp #*30 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
clostridium difficile colitis
Secondary Diagnosis:
ulcerative colitis
hypocalcemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for
severe diarrhea. We found that you had clostridium difficile
colitis, or in other words, a bacteria that was causing your
diarrhea. You will need to take an antibiotic, Vancomycin,
until ___ (to complete 14 days of antibiotics) even if you
are feeling better.
Please follow up with your primary care doctor for ___
management of your ulcerative colitis and for low calcium.
Medication Changes:
START taking Vancomycin 125mg by mouth four times daily for 12
days. Your last day of antibiotics will be on ___.
Please continue to take the higher dose of Asacol 1200mg by
mouth three times daily until instructed otherwise by your
primary care physician or ___.
We have started you on daily Vitamin D and Calcium tablets due
to your low calcium and prior findings of a low vitamin D level.
Please continue to take these vitamins until instructed
otherwise by your primary care physician.
Continue all other medication as prescribed
Followup Instructions:
___
|
10372681-DS-16 | 10,372,681 | 26,947,515 | DS | 16 | 2162-08-08 00:00:00 | 2162-08-09 15:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Complex right wrist injury
Major Surgical or Invasive Procedure:
___: R median nerve repair, R FPL, IF FDP and FDS repair, LF
FDS repair ___, ___.
History of Present Illness:
___ h/o pancreatic ca, seizures currently undergoing
chemotherapy
presented to OSH after fall this morning at 8 am with a coffe
mug
in his hand. Has a 4-5 cm lac over his right carpal tunnel.
Complaining of numbness, weakness and pain in his hand.
Past Medical History:
Carpal tunnel syndrome
Hypertension
Hyperlipemia
Peroneal tendonitis
Screening for colon cancer
Cervical radiculopathy
Type 2 diabetes mellitus, without long-term current use of
insulin
Colon adenoma
Partial seizure disorder
Primary osteoarthritis of first carpometacarpal joint of left
hand
Alcohol use disorder
Fusion of spine of cervical region
Presbyopia
Pancreatic adenocarcinoma
Social History:
___
Family History:
NC
Physical Exam:
GEN: AOx3 WN, WD in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
EXT:
Surgical dressing c/d/i
Firing wrist flex/ext
Radial 2+, WWP at all digits
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have a complex right wrist laceration and was admitted to the
hand surgery service. The patient was taken to the operating
room on ___ for complex repair of multiple right wrist
fractures, 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. ___ hospital course was otherwise
remarkable for some difficulty to void and an elevated bladder
scan which was later found to be a confounding read secondary to
his known ascites. Patient remained in the hospital for an
additional overnight stay due to some postoperative nausea and
vomiting which resolved.
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
nonweightbearing in the right upper extremity. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Ranitidine 150 mg PO QHS
3. OxyCODONE SR (OxyCONTIN) 15 mg PO Q12H
4. OxyCODONE Liquid ___ mg PO Q4H:PRN Pain - Moderate
5. Prochlorperazine 5 mg PO Q8H
6. Lisinopril 20 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO QID
8. Lantus U-100 Insulin (insulin glargine) 100 unit/mL
subcutaneous 5 units SC qHS
9. glimepiride 2 mg oral QAM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
Partial fill ok. Wean. No driving/heavy machinery.
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed
Disp #*25 Tablet Refills:*0
3. Citalopram 40 mg PO DAILY
4. glimepiride 2 mg oral QAM
5. Lantus U-100 Insulin (insulin glargine) 100 unit/mL
subcutaneous 5 units SC qHS
6. Lisinopril 20 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO QID
8. Prochlorperazine 5 mg PO Q8H
9. Ranitidine 150 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Complex Left wrist injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand 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:
-Nonweightbearing right upper extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone on top of your home dose as needed for
increased pain. Aim to wean off this medication in 1 week or
sooner. This is an example on how to wean down:
Take 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
FOLLOW UP:
Please follow up with your Hand Surgeon, Dr. ___, in 1 week.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
NWB LUE, light ADLs only, splint in place until clinic followup
Treatments Frequency:
Keep RUE splint clean and dry
Cover for showers
Continue previous ___ services as usual (per patient receives IV
hydration)
Followup Instructions:
___
|
10373251-DS-6 | 10,373,251 | 24,754,263 | DS | 6 | 2177-07-11 00:00:00 | 2177-07-11 17:54:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
perforated marginal ulcer
Major Surgical or Invasive Procedure:
Debridement and ___ patch of perforated marginal ulcer
History of Present Illness:
Mrs. ___ is a ___ year old woman s/p lap RnY gastric
bypass in ___ and ex-lap with SB resection for intussussecption
in ___, and hx marginal ulcer, with ___ hours of sudden onset
severe epigastric abdominal pain. The pain is only slightly
better with IV dilaudid. It is worse than she has felt with her
ulcer before. She denies any nausea or vomiting. Prior to
today
she was feeling well, and was compliant with PPI daily and
sucralafate prn but had not had pain in several months. She
does
report smoking, ___ pack per day. At one point she had quit but
started again to cope with quitting alcohol. She has been sober
for one month. She denies NSAID use recently but does report
occasional use for headaches, none in past few months.
Past Medical History:
PMH: hx morbid obesity, hypercholesterolemia, urinary
incontinence, migraine headaches
PSH: LEEP (___), laparascopic Roux-en-Y gastric bypass (___),
exploratory laparotomy with small bowel resection, lysis of
adhesions (___)
___: Zoloft 100', Adderall XR 30', Klonapin 0.5'' prn, Fe
supplement-dosage uncertain
Social History:
___
Family History:
Ulcers
Physical Exam:
Vitals: 98.6 60 98/60 18 100 RA
Gen: NAD, AAOx3
CV: RRR
Pulm: CTAB
Abd: soft, appropriately TTP, incision CDI, steri strips in
place, JPs with serous drainage x2, G-tube with scant bilious
output
Ext: no c/c/e
Pertinent Results:
___ 07:03AM WBC-16.4*# RBC-4.35# HGB-13.0# HCT-40.7#
MCV-94# MCH-30.0# MCHC-32.1 RDW-16.2*
___ 07:03AM GLUCOSE-106* UREA N-19 CREAT-0.5 SODIUM-142
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-27 ANION GAP-9
___ 05:01AM BLOOD WBC-7.0 RBC-3.62* Hgb-10.7* Hct-34.0*
MCV-94 MCH-29.6 MCHC-31.5 RDW-15.5 Plt ___
___ 05:15AM BLOOD Glucose-110* UreaN-19 Creat-0.5 Na-140
K-4.1 Cl-105 HCO3-26 AnGap-13
Brief Hospital Course:
Mrs. ___ presented to ___ ED as a transfer from an OSH on
___ with sudden onset severe epigastric abdominal
pain. She is status post laparoscopic roux-en-y gastric bypass
in ___, small bowel resection for intussuseception in ___ and
has a history of a marginal ulcer. A CT scan performed at the
OSH showed free air suggestive of a perforated marginal ulcer.
The patient was admitted to the ICU for close monitoring and
taken to the OR the same day for Debridement and ___ patch of
the perforated marginal ulcer and gastrostomy tube placement.
The procedure was uncomplicated, two ___ drains were placed at
the end of the procedure, a central lumen catheter was placed by
anesthesia. Pt was extubated, taken to the PACU until stable,
then transferred to the ICU for close observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA, an
epidural was placed on POD 2 due to poor pain control. The
epidural was split, then discontinued on POD 3 and she was
maintained on a PCA. She was transitioned to oral Roxicet when
tolerating a stage 3 diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. The patient was
maintained on TPN starting on POD 1. On POD 8, the NGT was
removed, an upper GI study was negative for a leak. The diet was
advanced to a Bariatric Stage 3 diet, which was well tolerated.
Patient's intake and output were closely monitored. JP output
remained serosanguinous throughout admission; the right JP drain
was removed prior to discharge; the left JP drain and G-tube
were left in place on discharge.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a stage 3
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. Adderall *NF* (amphetamine-dextroamphetamine) 30 mg Oral
Daily
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Sertraline 100 mg PO DAILY
5. Sucralfate 500 gm PO QID
6. Calcet Creamy Bites *NF* (calcium citrate-vitamin D3) 500 mg
calcium -400 unit Oral BID
7. Cyanocobalamin 500 mcg PO DAILY
8. Docusate Sodium (Liquid) 60 mg PO BID
9. Multivitamins W/minerals 1 TAB PO BID
Discharge Medications:
1. Docusate Sodium (Liquid) 60 mg PO BID
RX *docusate sodium [Colace] 60 mg/15 mL 25 mL by mouth twice a
day Disp #*750 Milliliter Refills:*0
2. Sertraline 100 mg PO DAILY
3. Sucralfate 500 gm PO QID
4. Adderall *NF* (amphetamine-dextroamphetamine) 30 mg ORAL
DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO BID
8. Calcet Creamy Bites *NF* (calcium citrate-vitamin D3) 500 mg
calcium -400 unit Oral BID
9. Omeprazole 40 mg PO DAILY
10. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ mL
by mouth every four (4) hours Disp #*250 Milliliter Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated Marginal Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance diet, do not drink out of a straw or chew
gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should take a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
|
10373434-DS-16 | 10,373,434 | 24,382,130 | DS | 16 | 2170-10-28 00:00:00 | 2170-11-04 08:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Difficulty walking, shortness of breath, back/hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with hx of HTN, CHF, ?CAD, ?CKD
and and asthma/COPD who presents with weakness, difficulty
walking and worsening shortness of breath.
In ED, pt stated he has become progressively short of breath
over the past few weeks, worsening with exertion. Also noted
worsening PO intake, lethargy and weakness.
In the ED, initial vitals were: afebrile 88 159/70 16 95% RA
- Exam notable for: Diffuse inspiratory and expiratory wheeze
- Labs notable for: Na 131, K 2.6, Cl 85, HCO3 32, BUN 41, Cr
2.6, Trop .06, CK MB 4, proBNP 1036, WBC 16.4, Hb 12.9
- Imaging was notable for: CXR showing relatively hyperinflated
lungs, suggesting chronic obstructive pulmonary disease.
Scattered areas of linear opacity which may be due to
atelectasis, but underlying infectious process is not excluded
in the appropriate clinical setting.
- Patient was given: albuterol neb, ipratropium neb, prednisone
60 mg, Azithromycin 500 mg x1, Aluminum-Magnesium
Hydrox.-Simethicone 30 ml, KCl 40 mg PO x1, KCl 40 mg IV x1
-ED team was concerned RE ST elevations in V2/V3 with elevated
troponin and cardiology was consulted. Bedside TTE performed and
difficult to interpret but noteable for ?hypokinesis of the
anterior/anterior septal walls, low normal EF, LVH and no
valvular disease. Cardiology recommended repletion of lytes,
gentle IVF, formal TTE. EKG changes and wall motion abnormality
thought to be old and mild trop with negative MB in setting of
renal failure likely demand.
Upon arrival to the floor, patient notes that "I wasn't
functioning at home and I couldn't make it to the bathroom
because I can't walk." Pt says that he is here because he has
"made an arrangement with his doctor and would like to go to the
___ program to assist with strength." He says that he has had
issues with weakness and difficulty walking for ___ months but
over the last couple of weeks it has gotten a lot worse. He fell
once a couple of days ago but is unable to describe the event.
When asked about his SOB, he notes that he has had difficulty
breathing for many months. It used to be relieved with
nebulizers but no longer is. Not worse with exertion. He denies
orthopnea. Does not take any daily inhalers.
Also reports decreased appetite and less PO intake.
No CP, palpitations, fever, chills, ___ swelling, change in
weight. Does note urinary symptoms and says sometimes his stream
is "unusual" and sometimes he has "pain with urination."
Initially reports that he has "diarrhea" but then says that he
has difficulty going and gets "backed up."
Patient has a difficult time answering questions directly and
continues to mention that he is here because he would like to be
set up with a "BI program." He believes that he is unsafe at
home.
Recently seen by PCP for back pain. Opiates were discontinued at
this appt. Note indicates that patient is not on maintenance
therapy for COPD. Medication history also indicates recent fill
of prednisone.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Pt is unable to answer reliably
From "outside records tab" CHA note ___
Colonic polyps
Internal hemorrhoids
Dyspepsia
Anal fissure
Arthritis
Back pain
Cataracts
CHF ("EF 30%" followed by Dr. ___ at ___
Diverticulosis
dry eyes
Reflux
Hypertension
Hematruia
Insomnia
Moderate to severe COPD
Hypertension
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:
===============
VITAL SIGNS: 97.5 162 / 89 89 20 95 Ra
GENERAL: Elderly appearing male, no acute distress
HEENT: PERRL, No JVD
CARDIAC: RRR, s1 and s2 heard, no m/r/g
LUNGS: Diffuse wheezing heard throughout all lung fields
ABDOMEN: Soft, nontender, NABS, no rebound/guarding
EXTREMITIES: No ___ edema
NEUROLOGIC: AxO x3, CN ___ intact, ___ and ___ strength ___
DISCHARGE EXAM:
================
Vitals: Tc 98.3 BP 137/66 HR 85 RR 18 O2sat 93% RA
General: NAD, lying in bed, appears more energetic and
interactive
HEENT: PERRL, MMM, no sclera icterus
Neck: Supple, no JVD appreciated
Cardiac: RRR, S1/S2 normal, no M/R/G
Lungs: Good air movement throughout with diffuse fine crackles
Abdomen: Soft, NT, ND, no rebound tenderness or guarding
Extremities: WWP, no pedal edema
Neurologic: CNs ___ grossly intact, ___ BUE/BLE, SILT
Skin: No rashes or other lesions
Pertinent Results:
ADMISSION LABS:
================
___ 10:20PM BLOOD WBC-16.4* RBC-4.04* Hgb-12.9* Hct-36.7*
MCV-91 MCH-31.9 MCHC-35.1 RDW-12.5 RDWSD-41.1 Plt ___
___ 10:20PM BLOOD Neuts-70.3 Lymphs-18.8* Monos-6.9 Eos-2.7
Baso-0.4 Im ___ AbsNeut-11.51* AbsLymp-3.08 AbsMono-1.13*
AbsEos-0.44 AbsBaso-0.06
___ 10:20PM BLOOD ___ PTT-24.8* ___
___ 10:20PM BLOOD Glucose-91 UreaN-41* Creat-2.6* Na-131*
K-2.6* Cl-85* HCO3-32 AnGap-17
___ 10:20PM BLOOD CK(CPK)-123
___ 10:20PM BLOOD CK-MB-4 proBNP-1036*
___ 10:20PM BLOOD cTropnT-0.06*
OTHER PERTINENT LABS:
=====================
___ 07:13AM BLOOD ALT-23 AST-27 AlkPhos-69 TotBili-0.5
___ 05:16PM BLOOD LD(LDH)-184
___ 10:20PM BLOOD CK-MB-4 proBNP-1036*
___ 10:20PM BLOOD cTropnT-0.06*
___ 07:13AM BLOOD CK-MB-4 cTropnT-0.04*
___ 05:16PM BLOOD CK-MB-3 cTropnT-0.04*
___ 06:25AM BLOOD proBNP-559
___ 07:13AM BLOOD Albumin-4.1 Calcium-14.7* Phos-3.6
Mg-3.4*
___ 05:16PM BLOOD TotProt-6.0* Calcium-14.6* Phos-2.0*
Mg-2.9* UricAcd-12.4*
___ 12:26AM BLOOD Calcium-13.7* Phos-2.4* Mg-2.6
___ 05:53AM BLOOD Albumin-3.5 Calcium-12.3* Phos-3.3 Mg-2.4
___ 05:16PM BLOOD PTH-20
___ 07:13AM BLOOD TSH-0.55
___ 05:16PM BLOOD VitB12-786
___ 07:13AM BLOOD Cortsol-5.7
___ 05:16PM BLOOD 25VitD-35
___ 05:16PM BLOOD PEP-NO SPECIFI
___ 05:33AM BLOOD FreeKap-31.6* FreeLam-29.3* Fr K/L-1.1
___ 05:33AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 01:00PM BLOOD Ethanol-NEG
___ 12:18AM BLOOD ___ pO2-33* pCO2-52* pH-7.46*
calTCO2-38* Base XS-10 Intubat-NOT INTUBA
___ 07:57PM BLOOD ___ pO2-50* pCO2-41 pH-7.44
calTCO2-29 Base XS-3
___ 12:18AM BLOOD Lactate-0.9
___ 07:57PM BLOOD Lactate-1.8
___ 07:57PM BLOOD freeCa-1.42*
DISCHARGE LABS:
===============
___ 06:41AM BLOOD WBC-12.0* RBC-3.15* Hgb-10.4* Hct-30.8*
MCV-98 MCH-33.0* MCHC-33.8 RDW-13.6 RDWSD-48.2* Plt ___
___ 06:41AM BLOOD Glucose-105* UreaN-42* Creat-2.1* Na-133
K-4.8 Cl-97 HCO3-27 AnGap-14
___ 06:41AM BLOOD Albumin-3.4* Calcium-8.2* Phos-2.6*
Mg-3.7*
URINE STUDIES:
==============
___ 02:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 02:45AM URINE RBC-1 WBC-14* Bacteri-FEW Yeast-NONE
Epi-0
___ 03:30PM URINE Hours-RANDOM Creat-101 Na-<20
___ 03:31PM URINE Hours-RANDOM TotProt-11
___ 03:31PM URINE U-PEP-NO PROTEIN
___ 03:30PM URINE Osmolal-327
___ 11:02AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MICROBIOLOGY:
=============
___ 12:50AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 2:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 5:16 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:16 pm SEROLOGY/BLOOD
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
Reference Range: Non-Reactive.
___ 5:53 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:45 am URINE Site: CATHETER
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 1:00 pm BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:04 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING/STUDIES:
=================
Chest XRay (___):
Relatively hyperinflated lungs, suggesting chronic obstructive
pulmonary
disease. Scattered areas of linear opacity which may be due to
atelectasis, but underlying infectious process is not excluded
in the appropriate clinical setting.
ECG Study Date of ___ 3:48:18 AM
Sinus rhythm. Intraventricular conduction delay. There are mild
ST segment
depressions in the inferior and lateral leads which could be
related to myocardial ischemia. Clinical correlation is
suggested. There are mild ST segment elevations in the right
precordial leads that are most consistent with secondary
repolarization changes combined with early repolarization.
Clinical correlation is suggested. No previous tracing available
for comparison.
Intervals Axes
Rate PR QRS QT QTc P QRS T
87 ___ 66 13 49
CT Chest w/o Contrast (___):
No suspicious pulmonary nodule or mass to suggest a primary
bronchus
carcinoma. Mild to moderate centrilobular emphysematous changes,
diffuse bronchial wall thickening and subpleural interstitial
thickening in the anterior aspects of the upper lobe suggesting
smoking related lung disease. Interstitial thickening with
associated bronchiectasis in the posterior basal aspect of the
right lower lobe (suggesting focal fibrosis) with associated
subpleural thickening/atelectasis and trace pleural effusion:
Chronic aspiration should be excluded. Pulmonary artery measures
at the upper limits of normal and pulmonary hypertension should
be excluded. Mild coronary artery calcification
ECHO (___):
The left ventricle is not well seen. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-45 %). Right ventricular chamber size and
free wall motion are normal. The mitral valve leaflets are
mildly thickened. There is no pericardial effusion. If
clinically indicated, a transesophageal echocardiographic
examination is recommended for better assessment of cardiac
structures.
Renal U/S (___):
5 mm nonobstructing stone in the lower pole of the right kidney.
Otherwise normal sonographic appearance of both kidneys.
Chest XRay (___): Small pleural effusions.
CT Head w/o Contrast (___):
FINDINGS: There is no evidence of infarction, hemorrhage,
edema, or mass. The ventricles and sulci are normal in size and
configuration. Small chronic lacunar infarct in the left
thalamus. There are mild chronic small vessel ischemic changes.
There is no evidence of acute fracture. There is chronic nasal
bone 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: There are no acute changes.
MRI L-Spine (___):
1. No evidence of marrow signal abnormality suggest osseous
metastatic disease. No abnormal lesions are seen within the
spinal canal or paravertebral soft tissues on noncontrast exam.
2. Multilevel degenerative changes, as detailed above. This is
worse at
L2-L3, where there is moderate spinal canal stenosis, moderate
right neural foraminal and severe left neural foraminal stenosis
with contact upon the exiting left L2 nerve root. At L4-L5,
there is severe right-sided and moderate left-sided neural
foraminal stenosis with contact upon the exiting right L4 nerve
root.
3. Additional findings as described above.
Renal U/S (___):
1. No evidence of hydronephrosis.
2. Nonobstructive 3 mm calculus in the lower pole of the right
kidney is
unchanged as compared to renal ultrasound ___.
Brief Hospital Course:
Mr. ___ is a ___ with h/o HTN, CHF (EF 30%), CKD, and COPD who
presented with FTT and back/hip pain, found to have severe
hypercalcemia, and acute on chronic kidney injury.
Initial calcium on admission was 14.7. Although initially c/f
malignancy, hypercalcemia was eventually attributed to overuse
of calcium carbonate leading to milk alkali syndrome. An an
extensive workup was otherwise unrevealing.
Acute kidney injury felt to be multifactorial. In particular, pt
was found to have urinary retention c/f BPH, with post void
residuals of 300-400cc. Hypercalcemia from milk alkali syndrome
likely also contributed. No hydronephrosis on renal ultrasound.
He was started on tamsulosin and requires outpatient Nephrology
follow-up. Workup for organic causes of pt's FTT including
vitamin and nutritional deficiencies was also unrevealing.
In regards to his weakness and lower back pain, the patient had
an MRI that demonstrated degenerative changes in moderate
stenosis. He had not been walking as much at home due to pain.
Pt received tramadol, gabapentin, and acetaminophen which
provided sufficient pain relief, permitting ambulation with
___. Pt declined acute rehabilitation, but was assessed to be
safe for discharge to home. Given his past discussions with his
PCP regarding use of narcotics for pain control, discussed
increasing his gabapentin as an outpatient with the goal of
discontinuing tramadol.
ACTIVE ISSUES:
=================
# Back/hip pain: Patient presented with 4 months of worsening
left lateral back/hip pain. He felt this was worsening secondary
to his Percocet being discontinued as an outpatient. On exam
with lower extremity weakness and increased tone. MRI obtained
that demonstrated multilevel degenerative changes worse at L2-L3
with moderate spinal canal stenosis and moderate right neural
foraminal and severe left neural foraminal stenosis with contact
on the L2 nerve root. At L4-L5 there was also severe right-sided
and moderate left-sided neural foraminal stenosis contacting the
exiting right L4 nerve root. For pain he was given
acetaminophen, gabapentin 200mg BID, and tramadol 50mg po q6h
with a plan to uptitrate gabapentin as an outpatient. He worked
with physical therapy, who had initially recommended rehab. The
patient refused, but after working with him more throughout his
hospitalization he was cleared for home with home physical
therapy.
# Hypercalcemia
# Milk Alkali Syndrome: Intially with severe hypercalcemia to
14.7, low-normal PTH 20, and new back/hip pain initially with
c/f hypercalcemia of malignancy. Undewent a CT chest to look for
evidence of malignancy given his smoking history, which
demonstrated emphysema without any worrisome lesions. He was
given pamidronate 30mg IV x 1, calcitonin 200mg BID, and was
given IV fluids and Lasix prn. Further work-up demonstrated
normal 25-vitamin D, 1,25-vitamin D, SPEP/UPEP, kappa/lambda
ratio 1.1, and PTHrP. Hypercalcemia subsequently improved and
given renal failure and alkalosis on admission, was felt to be
secondary to milk-alkali syndrome from unintentional calcium
carbonate overdose. Patient reported taking Tums about 5x/day,
although history unclear. His calcium improved, and he
temporarily became mildly hypocalcemic, which improved prior to
discharge.
# Acute on chronic kidney injury: Creatinine elevated from
baseline of 1.5 to 2.1-2.6. Multiple myeloma workup
unremarkable. Failed to improve w/ either IVF or trial of IV
lasix for possible cardiorenal syndrome. Likely multifactorial
___ ___ decreased renal perfusion i/s/o hypotension,
vasoconstriction from hypercalcemia, and urinary obstruction
given PVR 340 w/ symptoms of urinary retention. Renal ultrasound
demonstrated no hydronephrosis. Urine sediment unremarkable. He
was started on tamsulosin during his hospitalization for
retention, and will follow-up with nephrology as an outpatient.
Creatinine 2.1 on day of discharge.
# Toxic metabolic encephalopathy: On admission with confusion,
and on ___ had an episode when he was unresponsive. CT
unremarkable. Felt to be secondary to hypercalcemia initially.
Mental status improved with improvement in his calcium. Other
work-up included normal RPR, B12, TSH, and serum/urine tox
screens. He was given multivitamin and thiamine during admission
to help support nutrition.
# Fever/leukocytosis: Had low grade temperature to ___ with
leukocytosis between 10K - 18K during hospitalization.
Infectious work-up performed and urine and blood cultures
remained negative. No evidence of thrombosis on exam, and
clinically did not appear infected. Monitored throughout
hospitalization.
# Abnormal EKG: On admission with ST segment elevations stable
on repeat EKG and trops downtrending. TTE (___) notable for
mildly depressed overall left ventricular systolic function
(40-45%). Focal wall motion abnormality could not be excluded on
TTE due to suboptimal technical quality. No chest pain or
concern for ischemia during admission.
# Systolic Congestive heart failure: Repeat Echo demonstrated
reduced EF to 40-45%. While receiving continuous IV fluids
developed lower lung crackles, so was given intermittent boluses
of IV Lasix. Sats remained stable, and he was discharged on home
po Lasix.
CHRONIC ISSUES:
================
# SOB/COPD: No e/o acute COPD exacerbation during his
hospitalization. Continued on his home nebulizers with duonebs
prn.
# Reflux/heartburn: Continued home famotidine at 5 mg BID per pt
request. Held his Tums given hypercalcemia as above. Started
pantoprazole for better control of his GERD. He was resistant to
stopping famotidine or changing the dose, however no role for
both H2 blocker and PPI.
***TRANSITIONAL ISSUES***
==========================
# For pain control: Pt is discharged on tramadol 50 mg PO Q6H
PRN, gabapentin 200 mg PO BID, and acetaminophen 650 mg PO Q6H
for pain. PMP was checked. Consider increasing gabapentin and
weaning off tramadol as an outpatient.
# For urinary retention: Started tamsulosin 0.4 mg PO QHS for
likely BPH
# For GERD, stopped TUMS and started pantoprazole 40 mg PO Q24H
for heartburn. Discussed stopping his famotidine as well given
little benefit on top of pantoprazole, however patient wished to
maintain his home dose of famotidine 5mg po BID with no changes.
# For Acute on chronic kidney injury: Aspirin, furosemide, and
calcium carbonate were held. Consider restarting lower dose
aspirin as an outpatient, as patient stated he was taking full
strength daily.
# Monitor weights daily and restart furosemide if evidence of
fluid overload
# Patient should have repeat electrolytes, kidney function,
calcium, phosphorus, and magnesium checked on ___ and faxed to
his PCP ___ at ___
# Pt will require outpatient f/u with Nephrology for management
of ___. Consider urology follow-up if BPH symptoms do not
improve.
# Pt will require outpatient f/u with his PCP for management of
his pain and monitoring of electrolytes and intermittent
leukocytosis. An outpatient appointment at the Pain Management
Center has been arranged.
# CODE: Full
# CONTACT: ___ (daughter/HCP)
## Plan of care discussed directly with patient's outpatient
primary care office prior to his discharge given complexity
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 60 mg PO BID
2. Prazosin 5 mg PO TID
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
5. Aspirin 325 mg PO DAILY
6. Famotidine 5 mg PO BID
7. Calcium Carbonate 500 mg PO QID:PRN dyspepsia
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp
#*240 Tablet Refills:*0
2. Gabapentin 200 mg PO BID
RX *gabapentin 100 mg 2 capsule(s) by mouth twice daily Disp
#*120 Capsule Refills:*0
3. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
5. TraMADol 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*28
Tablet Refills:*0
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
9. Famotidine 5 mg PO BID
10. Prazosin 5 mg PO TID
11. HELD- Aspirin 325 mg PO DAILY This medication was held. Do
not restart Aspirin until instructed by your nephrologist or PCP
12. HELD- Furosemide 60 mg PO BID This medication was held. Do
not restart Furosemide until instructed by your doctors
13.Outpatient Lab Work
Please check CHEM10 and fax result to Dr. ___ at
___
ICD10: ___.52, N17.9
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY: Hypercalcemia, milk alkali syndrome, acute on chronic
renal failure
SECONDARY: Chronic pain syndrome, gastroesophageal reflux
disease, chronic obstructive pulmonary disease, hypokalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Requires cane.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___
(___) for weakness, back pain, and difficulty with urination.
We obtained blood tests and imaging of your back and chest,
which showed compression of the nerve roots in your lower back.
However, this is mostly unchanged from before. We treated your
pain with tramadol, gabapentin, and acetaminophen.
You were also found to have very high calcium, low potassium,
and worsening of your kidney function. We believe that your high
calcium was caused by Tums, which you had been taking for your
reflux. Your low potassium was most likely caused by lasix.
Please continue to take famotidine and pantoprazole instead of
Tums for your reflux. You may have an enlarged prostate gland
causing difficulty with urination and possibly contributing to
poorer kidney function. Please attend your clinic appointments
with the Nephrology (Kidney) Department. You should also stop
taking lasix for now as it may cause further worsening of your
kidney function.
Please continue to walk as much as possible to prevent
deconditioning.
Thank you for allowing us to be involved in your care!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10373434-DS-17 | 10,373,434 | 22,324,032 | DS | 17 | 2171-08-10 00:00:00 | 2171-09-19 09:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with HTN, HFrEF, CKD and COPD who presents with chest pain
and shortness of breath. He reports shortness of the past month,
associated with occasional cough. He was treated with 2 weeks of
prednisone after presenting at OSH ED (completed course on
___, and reports no benefit from prednisone.
He notes over the past 2 weeks he has had increasing
intermittent
substernal chest pain. Occurs at rest. Pain only lasts for a few
seconds and is a pressure-like sensation. The pain is
nonradiating, not associated with nausea, vomiting, diaphoresis.
He also notes lightheadedness upon standing. He denies any
history of previous similar episodes.
Code STEMI was called on patient for ST elevations in V1-V3.
Cardiology evaluated patient and did not activate cath lab as ST
elevations improved and trop only 0.02 with stable hemodynamics
and spontaneous resolution of chest pain. He refused aspirin.
In the ED initial vitals were: 98.7, ___, 99% RA.
Reportedly hypoxic to 92% on RA, required 4L to get up to 97%.
- EKG:
1: 107 bpm, NSR, NA/NI, Q wave in III, 2mm ST elevation in
V1-V2,
1mm in V3, inverted T waves in V4-V6
2: 106 bpm, NSR, NA/NI, Q wave in III, 2mm ST elevation in
V1-V2,
1mm in V3, inverted T waves in V4-V6
3: 102 bpm, NSR, NA/NI, Q wave in III, 1mm ST elevation in
V1-V2,
1mm in V3, inverted T waves in V4-V6
- Labs/studies notable for: WBC 14.3, trop 0.02, CK 38, MB 3
- Patient was given: heparin gtt, refused aspirin
- Exam: unremarkable
On the floor, patient reports being most bothered by his
shortness of breath. Chest pain has resolved completely. Denies
lightheadedness, palpitations, abd pain, N/V, leg swelling,
orthopnea, PND.
Past Medical History:
Pt is unable to answer reliably
From "outside records tab" CHA note ___
Colonic polyps
Internal hemorrhoids
Dyspepsia
Anal fissure
Arthritis
Back pain
Cataracts
CHF ("EF 30%" followed by Dr. ___ at ___
Diverticulosis
dry eyes
Reflux
Hypertension
Hematruia
Insomnia
Moderate to severe COPD
Hypertension
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 98.7, BP 147/68, HR 90, RR 15, Spo2 96% 2L NC
GENERAL: WDWN male, lying at ___ in bed, in NAD.
HEENT: PERRL, OP clear, fair dentition
NECK: Supple with no JVP noted
CARDIAC: RRR, S1+S2, I/VI systolic murmur heard throughout
LUNGS: exp>insp wheezes throughout. No ronchi or crackles.
ABDOMEN: obese, soft, non-tender. Umbilical hernia, easily
reducible. NABS.
EXTREMITIES: WWP, no edema.
SKIN: No lesions, rashes.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
=========================
VS: 99.0 ___ 91-95% on RA
Weight: 79.6 from 79.4 from 79.4 from 79.3 kg from 80.6 kg
GENERAL: ___ male, lying at ___ in bed, in NAD.
HEENT: PERRL, OP clear, fair dentition
NECK: Supple with no JVP noted
CARDIAC: RRR, S1+S2, I/VI systolic murmur heard throughout
LUNGS: exp>insp wheezes throughout. No ronchi or crackles.
ABDOMEN: obese, soft, non-tender. Umbilical hernia, easily
reducible. NABS.
EXTREMITIES: WWP, no edema.
SKIN: No lesions, rashes.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
LABS
=======
___ 12:00AM PTT-75.2*
___ 05:00PM PTT-82.4*
___ 12:54PM %HbA1c-6.6* eAG-143*
___ 06:55AM GLUCOSE-93 UREA N-24* CREAT-1.2 SODIUM-143
POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-37* ANION GAP-10
___ 06:55AM CK-MB-3 cTropnT-0.02*
___ 06:55AM CALCIUM-8.5 PHOSPHATE-4.0 MAGNESIUM-2.2
CHOLEST-171
___ 06:55AM TRIGLYCER-120 HDL CHOL-65 CHOL/HDL-2.6
LDL(CALC)-82
___ 06:55AM PLT COUNT-184
___ 06:55AM PTT-36.8*
___ 12:48AM LACTATE-1.5
___ 12:45AM GLUCOSE-111* UREA N-25* CREAT-1.3* SODIUM-139
POTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-38* ANION GAP-9*
___ 12:45AM estGFR-Using this
___ 12:45AM CK(CPK)-38*
___ 12:45AM cTropnT-0.02*
___ 12:45AM CK-MB-3 proBNP-534
___ 12:45AM WBC-14.3* RBC-4.09*# HGB-12.6* HCT-38.4*
MCV-94 MCH-30.8 MCHC-32.8 RDW-16.2* RDWSD-54.6*
___ 12:45AM NEUTS-78* BANDS-1 LYMPHS-13* MONOS-6 EOS-1
BASOS-0 ___ METAS-1* MYELOS-0 AbsNeut-11.30* AbsLymp-1.86
AbsMono-0.86* AbsEos-0.14 AbsBaso-0.00*
___ 12:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 12:45AM PLT SMR-NORMAL PLT COUNT-190
___ 12:45AM ___ PTT-25.3 ___
NOTABLE OTHER INVESTAGATIONS:
___: ECHO
The left atrial volume index is moderately increased. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with inferior/inferolateral hypokinesis. The
remaining segments contract normally (LVEF = 40%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Technically-difficult study. Mild regional left
ventricular systolic dysfunction, most c/w CAD.
Brief Hospital Course:
This is a ___ with history of HTN, HFrEF with EF of 40%
(confirmed this admission), CKD, and COPD who presented with
acute chest pain and shortness of breath and was referred to the
___ from an OSH for cath. His presenting EKG showed transient
ST elevation in the anterior leads which improved spontaneously.
Due to spontaneous resolution, the cath lab was not activated.
His trops were elevated but flatx2 and his CKMB was negativex2.
The patient did not have recurrence of his chest pain but his
shortness of breath persisted. His admission his WBC was
elevated and his CXR showed evidence of pneumonia and he was
started on levofloxacin. Due to prior SE of levofloxacin, the
patient decline the medication and he was started on
azithromycine (___).
During the hospital stay, the patient underwent an Echo which
showed hypokinesis in the mild regional left ventricular
systolic dysfunction, most c/w CAD. However, since he ultimately
declined aspirin on the long term, a PCA/PCI was deferred since
placing a stent without DAPT caries high risk of thrombosis.
The patient was evaluated by ___ while in-house and recommended
rehabilitation. However, the patient declined and home ___ and
home safety eval were offered.
While in-house, the patient complained of vertigo during stay
while his tele did not show evidence of arrhythmias. Also the
short lived nature of the spells make cardiac arrhythmia
unlikely.
TRANSITIONAL ISSUES:
[ ] f/u recurrence of symptoms of dizziness, presyncope, and
lightheadedness.
[ ] Monitor chest pain and reinforce lifestyle changes including
stopping smoking.
[ ] Please repeat a CXR in 1 month for radiological resolution
of pna
[ ] CBC in 1 week to follow up WBC count.
[ ] Cont azithro for 1 more day after discharge.
Code status: full code.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Furosemide 20 mg PO DAILY
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
4. Prazosin 5 mg PO TID
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Azithromycin 250 mg PO ONCE Duration: 1 Dose
take this on ___
RX *azithromycin 250 mg 1 tablet(s) by mouth once Disp #*1
Tablet Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Furosemide 60 mg PO BID
RX *furosemide 20 mg 3 tablet(s) by mouth twice a day Disp #*180
Tablet Refills:*0
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 0.5 mg mg ih every
six (6) hours Disp #*20 Vial Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
primary diagnosis: community aquiered pneumonia and unstable
angina.
secondary diagnosis: COPD, heart failure with reduced ejection
fraction chronic kidney disease stage II.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had chest pain and shortness of
breath.
What happened while I was in the hospital?
-We found that you have pneumonia
-We treated you with antibiotics for your pneumonia
-We performed an ultrasound on the heart which showed that you
have evidence indicating that one part of your heart might not
be getting enough blood likely from a narrowing in the blood
vessel. However, the narrowing in the blood vessel was not
confirmed. Since you refused to take aspirin in the long term,
we did not pursue further testing and treatment of coronary
artery disease such as a stent.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- You will take a pill of azithromycin tomorrow to complete your
course treatment of pneumonia.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Followup Instructions:
___
|
10373824-DS-14 | 10,373,824 | 21,508,144 | DS | 14 | 2142-03-09 00:00:00 | 2142-03-13 09:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lipitor / Actonel / Lisinopril / Simvastatin
/ Zetia
Attending: ___.
Chief Complaint:
dyspnea/tachypnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMHx significant for asthma, PMR, DM2, HTN & h/o STEMI
___ c/b ischemic bowel requiring ileostomy who presents with
respiratory distress. Patient reports that 5 days ago she
started to have rhinorrhea and a cough. The following day she
reports having shaking & chills in the evening (was afebrile).
The next day, the patient's sister came to visit her and the
patient felt too ill to get out of bed. Her sister called the
pt's PCP who recommended that she start azithromycin. Patient
actually started taking azithro the following day (2 days prior
to admission) and felt better enough to go her PCP's office
where she had a chest xray that did not show any acute
intrathoracic process. The patient was also noted to have thrush
and started on a 14-day course of clotrimazole troches. The
following day (the day prior to admission), the patient felt
worse; on the day of admission, the patient's sister tried to
call her with no answer. Pt's sister went over to patient's
house where she found home health aide ringing the doorbell
outside; apparently patient was too dyspneic/tachyneic to answer
the door. At that point, they called ___ and the patient was
brought to the ___ ED. In transit, she received an
albuterol/ipratropium neb and IV magnesium.
In the ED, inital vitals were 100.8 116 148/55 32 92% NRB.
Non-rebreather was removed and patient was satting 94% RA with
RR 35. She was placed on 4L nasal cannula for comfort with SpO2
99%; RR decreased to low ___. On exam, the patient appeared
tachypneic and was using some accessory muscles; only able to
speak short sentences. Labs were significant for WBC 20.5 with
81% neutrophils and 5% bands. Lactate 3.6. U/A without evidence
of infection. CXR showed bibasilar opacities, new from
___, which may represent atelectasis, aspiration, or
infection. The patient was started on levofloxacin 750mg IV as
well as ceftriaxone 1g. She also received Solu-Medrol 125mg IV
and another albuterol/ipratropium neb. Dyspnea improved and the
patient was admitted to the ___ for further management. VS on
transfer were 133/39, 115, RR 30, 99%4L NC.
On arrival to the ICU, the patient appears in have mildly
increased work of breathing, but is not using accessory muscles
and is able to speak in full sentences. She reports that the
nebs helped most with her breathing. Has a wet, productive
cough, although has not brought up any sputum. She denies any
fevers or chills (aside from once, 4 days prior to admission).
Currently states that her breathing is improved but she still
has mild shortness of breath.
Review of systems:
(+) Per HPI, wheezing, malaise, low-back pain in the setting of
recent sacral insufficiency fracture
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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 myalgias. Denies rashes or skin
changes.
Past Medical History:
1. Diabetes mellitus type 2
2. Hypertension
3. Asthma: Followed by Dr. ___ at ___
4. Polymyalgia rheumatica
5. Osteoporosis
6. Right eye blindness - not associated with diabetes
retinopathy
7. Coronary artery disease:
- NSTEMI ___
- S/p cardiac catheterization ___ ___: pt unclear about
indication, stated "abnormal EKG". Reportedly non obstructive
CAD, EF 80 %.
.
Surg Hx: Hysteroscopy/D&C ___, s/p excision of benign left
breast lesion, repair of left radial fracture ___, cardiac cath
___ and ___
.
Social History:
___
Family History:
Father had colon CA
Physical Exam:
ON ADMISSION:
Vitals: T: 98.7, BP: 130/48, P: 107, R: 20, O2: 93% 2L NC
General: Alert, oriented, tachypneic
HEENT: Sclera anicteric, very dry mucus membranes, +thrush in
oropharynx, left pupil round & reactive to light, right pupil
damaged - neither round nor reactive (blind in right eye)
Neck: supple, JVP at clavicle, no LAD
Lungs: Inspiratory/expiratory wheezes throughout bilaterally
with poor air movement, no crackles or rhonchi
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, ileostomy present with
greenish/brown stool in bag, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
___ 12:01PM BLOOD WBC-20.5*# RBC-4.83 Hgb-14.2 Hct-45.6
MCV-95 MCH-29.5 MCHC-31.3 RDW-14.2 Plt ___
___ 12:01PM BLOOD Neuts-81* Bands-5 Lymphs-10* Monos-4
Eos-0 Baso-0 ___ Myelos-0
___ 12:01PM BLOOD ___ PTT-23.8* ___
___ 12:01PM BLOOD Glucose-184* UreaN-17 Creat-1.0 Na-136
K-4.9 Cl-98 HCO3-23 AnGap-20
___ 12:01PM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
___ 12:08PM BLOOD Lactate-3.6*
.
URINE STUDIES
___ 01:00PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-150 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:00PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ CXR (Portable)
COMPARISON: ___.
FINDINGS: A frontal upright view of the chest was obtained
portably. Lungs are mildly hyperinflated, unchanged. Since two
days ago, there are new bibasilar opacities, which may represent
atelectasis, aspiration or infection. Bi-apical
pleuroparenchymal scarring, right worse than left, is unchanged.
No pleural effusion or pneumothorax. Cardiac and mediastinal
silhouettes are stable. Moderate dextroscoliosis is unchanged.
An old healed left rib fracture is seen.
IMPRESSION: Bibasilar opacities, new from ___, may
represent atelectasis, aspiration, or infection.
.
EKG: sinus tach w/sinus arrhythmia @ 124bpm, LVH,
interventricular conduction delay, STD V4-6 (old), mostly
unchanged from prior, although with faster rate
___ 01:51AM BLOOD WBC-21.5* RBC-4.21 Hgb-12.3 Hct-39.4
MCV-94 MCH-29.2 MCHC-31.2 RDW-14.2 Plt ___
___ 07:30AM BLOOD WBC-20.5* RBC-4.10* Hgb-11.8* Hct-38.8
MCV-95 MCH-28.7 MCHC-30.3* RDW-14.0 Plt ___
___ 06:30AM BLOOD WBC-12.5* RBC-4.15* Hgb-12.2 Hct-38.5
MCV-93 MCH-29.4 MCHC-31.7 RDW-14.5 Plt ___
___ 06:30AM BLOOD Glucose-180* UreaN-21* Na-138 K-4.0
Cl-104 HCO3-25 AnGap-13
___ 06:30AM BLOOD Phos-2.0*
___ 02:11AM BLOOD Lactate-1.2
___ 5:30 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
___ 6:30 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).
Brief Hospital Course:
REASON FOR ICU ADMISSION:
___ with PMHx significant for asthma, PMR, DM2, HTN & h/o STEMI
___ c/b ischemic bowel requiring ileostomy who presents with
respiratory distress and was found to have asthma exacerbation
in the context of new LLL pneumonia.
.
HOSPITAL COURES
# Respiratory distress: pt presented with RR in the ___ and
increased WOB but no clear hypoxia (satting 94% on RA in ED) but
was placed on NC for comfort and RR decreased to ___. New
possible infiltrate in LLL seen on CXR that was not present 2
days ago which could reflect atelectasis vs infection. Etiology
of respiratory distress was felt to be multifactorial; asthma
exacerbation and possible pneumonia and/or concurrent URI.
Accordingly these problems will be discussed separately below.
# ASTHMA: pt with history of asthma although has only required
hospital admission twice in the alst ___ years for asthma. At
home should be on spiriva and advair, and recently she stopped
taking these because she felt one of them was causing a rash.
She had described preceeding symptoms of rhinorrhea and cough
and congestion, and URI may have precipitated asthma
exacerbation. Pt received 125mg IV solumedrol in the ED and was
subsequently given a 5 day steroid burst which tapered during
that same time period.
#Commmunity Acquired Pneumonia - pt did have new CXR findings of
LL lobe infiltrate on CXR not present on CXR 2 days before. She
did report several days of cough and malaise. Pneumonia could
have possibly triggered her underlying asthma as well. Pt was
started on levofloxacin and ceftriaxone but remained stable and
felt improved the day after admission so CTX was DCd. she will
complete a course of Levofloxacin.
# Elevated lactate - presented with mildly elevated lactate
which resolved on next laboratory draw. Likely elevated in
setting of difficulty breathing and dehydration. Pt did not have
hypotension or fever to suggest a systemic infectious response
athough there was concern for underlying pneumonia as above.
# Thrush: Patient presented to her PCP's office two days prior
to admission and was noted to have thrush. This is most likely
due to incorrect usage of her inhalers. She was started on
clotrimazole troches which were continued although on admission
there was not much evidence of thrush at all.
# MRSA carrier: found in ICU. Was given Mupirocin ointment x 5
days.
# DM2: Patient takes glyburide at home which was held during
this hospitalization. Used insulin sliding scale with goal FSG
<180 as pt was getting burst course of steroids for asthma
exacerbation as above.
# Diarrhea: Stool was negative for C. Diff. This improved
during hospitalization.
# CAD: Continued aspirin, metoprolol.
# Hypertension: Continued amlodipine, metoprolol.
# Recent sacral insufficieny fracture: Secondary to
osteoporosis. continued calcium, vitamin D.
.
# Communication: ___ (sister) ___. ___
___ (nephew/HCP) ___
# Code: DNR/Okay to intubate
Medications on Admission:
ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet
- 2 Tablets by mouth q6h as needed for back pain
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs Inh
every four (4) hours
AMLODIPINE - 5 mg Tablet - 1 Tablet by mouth once a day
CALCITONIN (SALMON) - 200 unit/dose Spray, Non-Aerosol - 1 spray
intranasally once a day alternate nostrils daily
CLOTRIMAZOLE - 10 mg Troche - qid x 14d (___)
CODEINE SULFATE - 30 mg Tablet - 1 Tablet by mouth twice a day
as needed for pain no more than two pills per day - pt is taking
this infrequently
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk with Device - 1 puff inhaled twice a day - always rinse
mouth after each use (**Not taking as directed**)
GLYBURIDE - 5 mg Tablet - 1 Tablet by mouth once a day
METOPROLOL TARTRATE - 100 mg Tablet - 1 Tablet by mouth twice a
day
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet by mouth qd (take
w/100 mg in am)
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule by
mouth twice a day
PREDNISONE - 5 mg Tablet - 1 Tablet by mouth once a day as
directed
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 capsule(s) inhaled once a day (**Not
taking as directed**)
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply twice a day
ACETAMINOPHEN - 500 mg Tablet - 2 Tablets by mouth three times a
day
ASPIRIN - 162 mg by mouth once a day
CALCIUM CARBONATE 500 mg (1,250 mg) Tablet - 1 Tab by mouth
twice a day
CYANOCOBALAMIN (VITAMIN B-12) 500 mcg Tablet - 2 Tablets by
mouth once a day
ERGOCALCIFEROL (VITAMIN D2) 400 unit Capsule - 2 Capsules by
mouth once a day
Discharge Medications:
1. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day) for 8 days.
Disp:*32 Troche(s)* Refills:*0*
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*0*
4. metoprolol tartrate 25 mg Tablet Sig: One Hundred ___
(125) mg PO QAM (once a day (in the morning)).
5. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO QPM
(once a day (in the evening)).
6. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO BID (2 times a day).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every ___ hours as needed for shortness
of breath or wheezing.
13. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) spray Nasal DAILY (Daily): one spray intranasally
daily, alternating nostrils daily.
14. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
17. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain or fever.
18. mupirocin 2 % Ointment Sig: One (1) application Topical
twice a day for 5 days.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD exacerbation
Pneumonia
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted with a COPD flare and pneumonia. You will
need to complete a course of antibiotics as prescribed. Please
take your Advair inhaler as prescribed and do not stop this
medication. You had loose stool and infection was not found.
You have follow-up appointments scheduled with your PCP and ___
new pulmonary doctor.
.
NEW MEDICATION: Levofloxacin, Prednisone taper as written,
mupirocin ointment
RESTARTED MEDICATION: Advair
Followup Instructions:
___
|
10373824-DS-15 | 10,373,824 | 24,795,095 | DS | 15 | 2145-04-13 00:00:00 | 2145-04-13 12:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lipitor / Actonel / Lisinopril / Simvastatin
/ Zetia
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old female c hx of T2DM, ischemic
colitis s/p bowel resection with end ostomy, CAD s/p stents who
complains of abdominal and flank pain. Over the past few days
patient states she has had pain both over her abdomen as well as
her lower R back/buttock. States it is peristent, and the only
time it will be relieved is if laying down and going to sleep.
It is aggravated by sitting up. Patient has also had nausea and
coughing up phlegm. She denies any dysuria, hematuria, foul
smelling urine. Additionally, she states her ostomy has had
normal output, no blood or mucous. Also denies fevers or
chills.
In the ED, initial vitals were 97.2 83 125/45 16 98% RA. Labs
were significant for WBC 19, BUN/Cr 34/1.4, lactate 2.5, UA with
few bacteria, 12 RBCs, neg leuks, neg nitrites. Exam: Ostomy
normal appearing, mildly tendern. Mild tenderness of R ilium.
Stool guaic negative. CT A/P showed abnormal left urothelial
hyperenhancement concerning for ascending UTI, mild fullness of
left collecting system and delayed excretion of contrast
possibly due to 3 mm left stone, and no evidence of bowel
obstruction as well as small pleural effusion. She was given 2 L
IVF, IV zofran, cipro/flagyl, and sent to the floor.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
1. Diabetes mellitus type 2
2. Hypertension
3. Asthma: Followed by Dr. ___ at ___
4. Polymyalgia rheumatica
5. Osteoporosis
6. Right eye blindness - not associated with diabetes
retinopathy
7. Coronary artery disease:
- NSTEMI ___
- S/p cardiac catheterization ___ ___: pt unclear about
indication, stated "abnormal EKG". Reportedly non obstructive
CAD, EF 80 %.
Surg Hx: Hysteroscopy/D&C ___, s/p excision of benign left
breast lesion, repair of left radial fracture ___, cardiac cath
___ and ___
The Preadmission Medication list is accurate and complete
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Amlodipine 5 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoprolol Tartrate 100 mg PO BID
6. Metoprolol Tartrate 25 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
10. Tiotropium Bromide 1 CAP IH DAILY
11. Acetaminophen 650 mg PO Q8H:PRN pain
12. ammonium lactate 12 % topical daily:prn
13. Aspirin 162 mg PO DAILY
14. Calcium Carbonate 500 mg PO BID
.
Social History:
___
Family History:
Father had colon CA
Physical Exam:
Vitals: 98.2 120/44 82 18 95% RA
General: Alert, oriented, no acute distress, hard of hearing
HEENT: Sclera anicteric, MMM, oropharynx clear, Fixed known
pupil changes in the R eye, L eye reactive to light and
accomodation, eyes sunken in
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, ostomy with green
output, no organomegaly, no rebound or guarding
BACK: No CVA tenderness bilaterally
MSK: Mild tenderness on palpation of L buttock.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
___ 07:10AM BLOOD WBC-9.8 RBC-3.58* Hgb-10.7* Hct-31.9*
MCV-89 MCH-30.0 MCHC-33.6 RDW-13.6 Plt ___
___ 07:59AM BLOOD WBC-12.7* RBC-3.75* Hgb-11.3* Hct-33.1*
MCV-88 MCH-30.0 MCHC-34.0 RDW-13.3 Plt ___
___ 05:00PM BLOOD WBC-19.0*# RBC-4.23 Hgb-12.9 Hct-38.1
MCV-90 MCH-30.6 MCHC-34.0 RDW-13.6 Plt ___
___ 05:00PM BLOOD Neuts-86.2* Lymphs-7.0* Monos-6.0 Eos-0.5
Baso-0.2
___ 07:10AM BLOOD Glucose-137* UreaN-16 Creat-0.9 Na-140
K-4.0 Cl-108 HCO3-25 AnGap-11
___ 07:59AM BLOOD Glucose-136* UreaN-27* Creat-1.6* Na-139
K-4.0 Cl-105 HCO3-24 AnGap-14
___ 05:00PM BLOOD Glucose-176* UreaN-34* Creat-1.4* Na-135
K-4.8 Cl-100 HCO3-22 AnGap-18
___ 05:00PM BLOOD ALT-19 AST-28 AlkPhos-71 TotBili-1.4
___ 05:00PM BLOOD Lipase-20
___ 07:10AM BLOOD Phos-3.1 Mg-1.7
___ 07:59AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9
___ 05:00PM BLOOD Albumin-4.2 Calcium-10.6* Phos-3.6 Mg-1.8
___ 07:45AM BLOOD Lactate-1.5
___ 05:08PM BLOOD Lactate-2.5*
.
IMPRESSION:
1. Abnormal left urothelial hyperenhancement is concerning for
ascending
urinary tract infection without definite signs of nephritis.
2. Mild fullness of the left collecting system and delayed
excretion of
contrast may be secondary to a 3 mm left UVJ stone. Given a
pressurized
infected system, close follow up is recommended for development
of sepsis.
3. No evidence of bowel obstruction.
4. Small left pleural effusion.
.
Microbiology:
___ URINE URINE CULTURE-FINAL EMERGENCY WARD NO
GROWTH
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
Brief Hospital Course:
___ with PMHx significant for asthma, PMR, DM2, HTN & h/o STEMI
___ c/b ischemic bowel requiring ileostomy who presents with
abdominal and flank pain found to have likely upper UTI and
nephrolithiasis.
.
#Abdominal/Flank pain
#UTI
#nephrolithiasis
#leukocytosis
Given CT findings, she likely had small kidney stone causing
inflammation of the left upper urinary tract vs. ascending
urinary tract infection. Her UA was relatively bland except for
some blood. Her pain and other symptoms had resolved by the
morning after admission. Given radiographic evidence of
infection as well as pt having diabetes making her "complicated
UTI", elected to treat patient for 7 day course of antibiotic
therapy. Urine culture did return negative. She was treated with
cipro adjusted for her renal function. Given radiographic
findings and microscopic hematuria, would consider repeat u/a,
?CT and consideration of potential urology evaluation to eval
for other causes other than stone/infection.
___: Likely prerenal in the setting of poor po
intake/infection. Elevated lactate and ___ resolved with
aggressive IVF.
CHRONIC ISSUES
#DM- held home meds, ISS while in house. Resumed metformin 48
hours after CT scan. ___ evening dose.
#CAD- continued ___. restarted metoprolol on DC
#HTN- continued amlodipine, restarted metoprolol on DC
#Asthma/COPD- continued advair, spiriva, albuterol
#PMR- not on meds
# FEN: regular/cardiac/diabetic diet
# PPX: Subcutaneous heparin, senna/colace, pain meds
# ACCESS: peripherals
# CODE STATUS: Full (confirmed)
# CONTACT: ___ nephew ___
.
Transitional care
1.repeat u/a for microscopic hematuria. Consideration of need
for repeat imaging and/or urology consultation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Amlodipine 5 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. MetFORMIN (Glucophage) 500 mg PO BID restart ___ evening
48hrs after dye
5. Metoprolol Tartrate 100 mg PO BID
6. Metoprolol Tartrate 25 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
10. Tiotropium Bromide 1 CAP IH DAILY
11. Acetaminophen 650 mg PO Q8H:PRN pain
12. ammonium lactate 12 % topical daily:prn
13. Aspirin 162 mg PO DAILY
14. Calcium Carbonate 500 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Amlodipine 5 mg PO DAILY
4. Aspirin 162 mg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Montelukast 10 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
10. Tiotropium Bromide 1 CAP IH DAILY
11. ammonium lactate 12 % topical daily:prn
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Metoprolol Tartrate 100 mg PO BID
14. Metoprolol Tartrate 25 mg PO QAM
15. Ciprofloxacin HCl 250 mg PO Q12H
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day
Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
nephrolithiasis
complicated UTI
acute renal failure
chronic CAD, HTN, DM2
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 evaluation of abdominal pain with nausea
and vomiting. You had a CT scan that revealed suspicion for a
kidney stone and a urinary infection. Your symptoms resolved
during admission. You were treated with antibiotics and would
continue to take your antibiotics to complete a 7 day course.
Please discuss with Dr. ___ you ___ need a repeat
urinalysis and repeat CT imaging and/or a urology evaluation.
Followup Instructions:
___
|
10373824-DS-16 | 10,373,824 | 23,483,665 | DS | 16 | 2145-07-08 00:00:00 | 2145-07-10 16:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lipitor / Actonel / Lisinopril / Simvastatin
/ Zetia
Attending: ___
Chief Complaint:
cc: ___, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with COPD, CAD, type 2 diabetes, osteoporosis
presents with ___ day history of ___, malaise, increased
glucose.
Patient reports that she has a frequent ___, productive of
white phlegm since last ___, three days prior to
presentation. Also around that time c/o sore throat, congestion,
and generally "not feeling herself." Denies N/V, able to keep
good PO. Her home finger stick blood glucose has been elevated
in the low to mid ___ range over the past 24 hours. She denies
abdominal pain, N/V, dysuria, increased frequency, polyuria or
polydipsia. At the urgence of her her, pt sought evaluation by
her PCP as OP. In PCP office, noted to be febrile to 101.4,
tachycaridc 100, BP stable 116/58, and non-hypoxic. Pt appeared
hypovolemic, and decreased breath sounds appreciated throughout.
Given age and co-morbidities referred to ED for further
evaluation.
In the ED, initial vitals were: 99.4 90 113/48 22 100% RA
- Labs were significant for :
Leukocytosis (16.5), normocytic anemia (10.6/32.7). BMP WNL,
lactate WNL. Coags WNL
- Imaging revealed
CXR:Subtle opacities in the upper lungs is concerning for an
early pneumonia. Mild pulmonary vascular congestion also noted.
- As patient had been hospitalized in the last 90 days for
kidney stone, pt was treated for HCAP. The patient was given
___ 19:54 PO Benzonatate 100
___ 19:54 IV CefePIME 2 g
___ 20:21 IV Levofloxacin 750 mg
___ 21:48 IV Vancomycin 1000 mg
Vitals prior to transfer were: 99.6 97 119/68 18 96% RA
Upon arrival to the floor: 99.3 117/44 110 18 94%RA
On arrival, pt states that she had only been taking Robitussin
"diabetes" for ___, not effective. Denied feeling febrile,
although notes fever on vitals at PCP. Denies chills or rigors.
Endorses good PO intake, denies lightheadedness, dizziness.
Ednorses mild generalized weakness and not feeling herself.
States that persistent ___ is most distressing symptom, not
remarkably SOB. Denies N/V, constipation, diarrhea. Takes 2
Tyleol Extra Strength at home for R shoulder fracture. Please
see below for other ROS. Denies cp, tightness, palpitations,
wheezing.
Past Medical History:
1. Diabetes mellitus type 2
2. Hypertension
3. Asthma: Followed by Dr. ___ at ___
4. Polymyalgia rheumatica
5. Osteoporosis
6. Right eye blindness - not associated with diabetes
retinopathy
7. Coronary artery disease:
- NSTEMI ___
- S/p cardiac catheterization ___ ___: pt unclear about
indication, stated "abnormal EKG". Reportedly non obstructive
CAD, EF 80 %.
Surg Hx: Hysteroscopy/D&C ___, s/p excision of benign left
breast lesion, repair of left radial fracture ___, cardiac cath
___ and ___
The Preadmission Medication list is accurate and complete
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Amlodipine 5 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoprolol Tartrate 100 mg PO BID
6. Metoprolol Tartrate 25 mg PO DAILY
7. Montelukast 10 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
10. Tiotropium Bromide 1 CAP IH DAILY
11. Acetaminophen 650 mg PO Q8H:PRN pain
12. ammonium lactate 12 % topical daily:prn
13. Aspirin 162 mg PO DAILY
14. Calcium Carbonate 500 mg PO BID
.
Social History:
___
Family History:
Father had colon CA
Physical Exam:
Admission Physical Exam:
Vitals: 99.3 117/44 110 18 94%RA
General: Alert, oriented x 3, no acute distress, very hard of
hearing
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
Fixed known
pupil changes in the R eye with overlying blue cataract, L eye
reactive to light
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Rhoncherous throughout L > R
Abdomen: Soft, non-tender, non-distended, ostomy with dark green
output, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities, grossly normal sensation, gait deferred.
Discharge Physical Exam:
Vitals: T:98.4 Tm:99.3 BP:118/54 P:86 R:18 O2:98% RA
General: Alert, sitting up in bed. oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Good air movement throughout, few expiratory wheezes, no
rales or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
___ 04:15PM BLOOD WBC-16.5*# RBC-3.58* Hgb-10.6* Hct-32.7*
MCV-91 MCH-29.6 MCHC-32.4 RDW-13.2 RDWSD-44.4 Plt ___
___ 04:15PM BLOOD Neuts-68.5 Lymphs-13.7* Monos-16.4*
Eos-0.2* Baso-0.4 Im ___ AbsNeut-11.33* AbsLymp-2.27
AbsMono-2.71* AbsEos-0.04 AbsBaso-0.06
___ 04:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:50PM BLOOD ___ PTT-25.2 ___
___ 04:15PM BLOOD Plt Smr-NORMAL Plt ___
___ 04:15PM BLOOD Glucose-192* UreaN-18 Creat-1.0 Na-134
K-4.8 Cl-100 HCO3-25 AnGap-14
___ 04:21PM BLOOD Lactate-1.8
Discharge Labs:
___ 07:00AM BLOOD WBC-13.5* RBC-3.75* Hgb-10.9* Hct-34.6
MCV-92 MCH-29.1 MCHC-31.5* RDW-13.5 RDWSD-45.9 Plt ___
___ 07:00AM BLOOD Neuts-67.5 Lymphs-15.9* Monos-11.5
Eos-3.6 Baso-0.7 Im ___ AbsNeut-9.12* AbsLymp-2.15
AbsMono-1.56* AbsEos-0.49 AbsBaso-0.09*
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-163* UreaN-15 Creat-0.8 Na-139
K-4.1 Cl-104 HCO3-23 AnGap-16
___ 07:00AM BLOOD Calcium-9.2 Phos-2.5* Mg-1.6
Imaging
CXR ___
FINDINGS:
PA and lateral views of the chest provided. Subtle opacity in
the upper
lungs may represent an early pneumonia. The hila appear
somewhat prominent
which may indicate mild vascular congestion. No overt edema or
large effusion
is seen. Dense atherosclerotic calcification along the aorta is
noted. The
heart is top-normal in size. Severe degenerative disease at the
right
shoulder is again seen. There is a dextroscoliosis of the
T-spine.
IMPRESSION:
Subtle opacities in the upper lungs is concerning for an early
pneumonia.
Mild pulmonary vascular congestion also noted.
Brief Hospital Course:
___ woman with COPD, multiple comorbidities, admitted
for fever, productive ___ and radiographic evidence consistent
with pneumonia.
# HCAP: Patient febrile with tachycardia and leukocytosis on
admission, meeting SIRS criteria. Hospitalization in late ___ for kidney stones, so concern for HCAP. Patient received
vanc/cef/levo in ED. However, on exam patient was non-toxic
appearing, not hypoxic, so MRSA or Pseudomonal infection
considered unlikely. Bilateral infiltrates on CXR may be
suggestive of Legionella, so urine legionella sent and returned
negative. CXR without remarkable evidence of volume overload. No
wheezing on exam, so little concern for COPD exacerbation.
Patient narrowed to Levofloxacin for likely community acquired
pneumonia and remained afebrile throughout admission. Received
500cc bolus with resolution of tachycardia. Patient's chief
concern was ___, which was treated with Benzonatate and
Guaifenesin with codeine. Patient discharged in good condition
with instructions to follow up with PCP.
# Hypertension: Patient hemodynamically stable and clinically
well appearing throughout admission. Held amlodipine for concern
for sepsis. Home Metoprolol was continued. Patient's systolic
blood pressures in 110's over course of hospitalization, so
amlodipine not resumed upon discharge. ___ be re-started as
outpatient at PCP's discretion.
# COPD: Followed by Dr. ___ at ___. Continued albuterol,
spiriva, montelukast, advair diskus. No concern for COPD
exacerbation.
# Coronary artery disease: NSTEMI ___ S/p cardiac
catheterization ___ ___. Reportedly non obstructive CAD,
EF >55% % (echo ___. Continued aspirin, BB, statin. No chest
pain during admisison.
#IDDM: Patient reported elevated blood sugars prior to admission
to hospital. Stopped home Metformin and patient's blood sugars
well controlled on insulin sliding scale. Metformin resumed upon
discharge.
Transitional Issues:
- Patient to complete course of Levofloxacin for pneumonia
(750mg q48 x 5 days. Last day of antibiotics ___.
- Patient's amlodipine stopped ___ systolic blood pressures in
110's. Consider re-starting as outpatient if blood pressures
become elevated.
- Patient should follow up with PCP ___ ___ weeks of
discharge to ensure resolution of symptoms as per above.
- New meds: benzonatate, codeine-guaifenesin, levofloxacin
- CODE STATUS: DNR/DNI, confirmed
- CONTACT: Sister, ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. Montelukast 10 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
10. Tiotropium Bromide 1 CAP IH DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Metoprolol Tartrate 100 mg PO BID
13. Metoprolol Tartrate 25 mg PO QAM
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO BID
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Metoprolol Tartrate 100 mg PO BID
7. Metoprolol Tartrate 25 mg PO QAM
8. Montelukast 10 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
11. Tiotropium Bromide 1 CAP IH DAILY
12. Benzonatate 200 mg PO TID
RX *benzonatate 200 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
13. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN ___
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth every
six (6) hours Refills:*0
14. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth once Disp #*1
Tablet Refills:*0
15. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Pneumonia
Secondary Diagnosis: None
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 to the hospital for fever and
___ and found to have Pneumonia. You were started on
Levofloxacin (an antibiotic) and you should continue this
medication at home (take one pill on ___. You were
also prescibed medications to suppress your ___ you should
continue taking these medications as needed for ___ at home.
During admission, your blood pressures were low, so we held your
amlodipine. Your primary care doctor ___ determine if you need
to re-start this medication.
You should follow up with your primary care doctor as scheduled
below. If you develop fevers, worsening ___ or shortness of
breath, you should call your doctor immediately or go to the
Emergency Deparment.
We wish you all the best in your recovery.
Sincerely,
Your Medical Team
Followup Instructions:
___
|
10373824-DS-19 | 10,373,824 | 28,293,498 | DS | 19 | 2146-11-19 00:00:00 | 2146-11-23 09:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lipitor / Actonel / Lisinopril / Simvastatin
/ Zetia / levofloxacin / cefuroxime
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ year old female with h/o COPD, CHF with EF 15%, ostomy p/w 1
week of dyspnea. Her symptoms were first noted while ambulating
with her walker at ___. Sx improve with rest, worsening with
activity. No additional pillows at night but endorses orthopnea.
No known increase in weights, doesn't check on a daily basis.
+chronic cough and congestion. Denies fevers/chills. +rhinorrhea
and sneezing with known sick contacts (daughter).
Of note at her last clinic visit on ___ with PCP, she had labs
that showed a mild decline in Hct with normal MCV and BNP
elevated to the range of 10,000. She was treated with increased
dose of furosemide to 40 mg daily. ___ CXR showed mild left
pleural effusion.
She was admitted in ___ for similar symptoms and was diuresed
with an IV equivalent of her home dose of Lasix. Her symptoms
were thought to be due to medication non-compliance and she was
discharged without antibiotics or steroids.
Denies ___ edema, no increased output or bloodiness in ostomy.
In the ED initial vitals were: 98.7 F, BP 130/50s, HR ___, RR
24, 99% RA
Exam notable for: decreased air movement throughout lungs with
decreased lung sounds on the left lower lung fields
Labs/studies notable for: Hgb 9.1 (stable from 1 week ago), WBC
11.7, plts 256, trop <0.01, BNP 15864, lactate 2.6, Cr 1.2
(stable from 1 week ago), INR 1.0
CXR significant for: hyperinflation of lungs, ?infiltrates in
the b/l lower lobes with stable pleural effusion on the left.
Patient was given: n/a
On the floor the patient reports feeling at her baseline. She
states that she was getting more short of breath with activity.
She denies fever, chest pain, lightheadedness, increased ostomy
output, blood in her stools, urinary symptoms. She endorses
taking all her medications at home. She thinks she might be
getting a cold, she has had increased runny nose, and she has a
crhonic cough. No wheezing.
Past Medical History:
- CAD s/p small inferior STEMI in ___, PCTA to complex ___ RCA
lesion c/b large femoral hematoma and afib, ischemic bowel
requiring colectomy s/p ostomy
- hip fracture
- HTN
- HLD
- paroxysmal afib
- CHF with EF 15% thought to be due to Takutsubo cardiomyopathy
Social History:
___
Family History:
Father had colon CA. Mother possibly with history of CHF, MI,
or other heart problems. Her sister had an MI in ___.
Physical Exam:
ON ADMISSION:
VS: afebrile, BP 90/60s, HR ___, RR 20, 97% RA
GENERAL: Elderly, thin female appearing stated age. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm in the upright position.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: Poor lung sounds, but 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. Bruise
on left forearm.
PULSES: Distal pulses palpable and symmetric
ON DISCHARGE:
VS: afebrile, BP 90/60s, HR ___, RR 20, 97% RA
GENERAL: Elderly, thin female appearing stated age. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm in the upright position.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: Poor lung sounds, but 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. Bruise
on left forearm.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
___ 04:41PM BLOOD Lactate-2.6*
___ 07:35AM BLOOD calTIBC-497* VitB12-179* Folate-17
___ Ferritn-37 TRF-382*
___ 07:35AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.6 Iron-31
___ 04:30PM BLOOD ___
___ 04:30PM BLOOD cTropnT-<0.01
___ 07:35AM BLOOD ALT-6 AST-13 LD(LDH)-173 AlkPhos-78
TotBili-0.9
___ 04:30PM BLOOD Glucose-150* UreaN-36* Creat-1.2* Na-139
K-4.2 Cl-97 HCO3-26 AnGap-20
___ 07:35AM BLOOD Glucose-157* UreaN-29* Creat-1.1 Na-140
K-3.8 Cl-97 HCO3-30 AnGap-17
___ 07:35AM BLOOD Ret Aut-1.8 Abs Ret-0.06
___ 04:30PM BLOOD ___ PTT-24.9* ___
___ 04:30PM BLOOD Neuts-65.3 Lymphs-17.6* Monos-13.4*
Eos-2.9 Baso-0.5 Im ___ AbsNeut-7.67* AbsLymp-2.06
AbsMono-1.57* AbsEos-0.34 AbsBaso-0.06
___ 04:30PM BLOOD WBC-11.7* RBC-3.23* Hgb-9.1* Hct-29.6*
MCV-92 MCH-28.2 MCHC-30.7* RDW-13.5 RDWSD-46.0 Plt ___
___ 07:35AM BLOOD WBC-10.1* RBC-3.26* Hgb-9.0* Hct-29.3*
MCV-90 MCH-27.6 MCHC-30.7* RDW-13.6 RDWSD-45.0 Plt ___
URINE CULTURE:
___ 8:17 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
CHEST X RAY ___:
PA and lateral views of the chest provided.
Lungs are hyperinflated and lucent compatible with provided
history of COPD.
There is persistent opacity at the left lung base which likely
reflects
persistent small left effusion and basal atelectasis. No
convincing evidence
for pneumonia. The heart is moderately enlarged. No signs of
edema. Chronic
degenerative disease at the right glenohumeral joint noted.
Otherwise bony
structures appear unremarkable.
IMPRESSION:
COPD, small left effusion and basal atelectasis, moderate
cardiomegaly.
Brief Hospital Course:
___ year old female with h/o CHF EF 15%, COPD/asthma, pAF, and
CAD presenting with dyspnea on exertion likely related to viral
URI and underlying COPD/CHF.
# dyspnea: based on symptoms of sneezing and rhinorrhea, likely
a viral URI. Not consistent with COPD exacerbation or PNA.
Although BNP was elevated, it is likely chronically elevated
because of EF <15%, and only an elevation >20,000 would be
consistent with a true CHF exacerbation. Patient was euvolemic
on exam. She was treated with a nebulizer and felt better,
suggesting that this might be more of a respiratory process. She
was arranged to have cardiology follow up for discussion of an
ECHO and pulmonology follow up for her asthma/COPD. Home Advair
was increased.
# anemia: workup initiated for chronic anemia. found to have
evidence of B12 deficiency on anemia labs. Injection offered but
patient deferred. This should be discussed in the ___
setting. Also, started on iron supplement for likely iron
deficiency.
***Transitional issues***:
- patient deferred dose of B12. Should discuss in outpatient
setting.
- Advair increased to 250 mcg formulation. This can be titrated
as needed. Patient should follow up with Dr. ___
(___) and consider having repeat PFTs to evaluate
severity of lung disease.
- patient should be monitoring daily weights. Weight on date of
discharge: 42 kg
- Cr on ___: 1.1
- may benefit from pulmonary rehab
DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. Tiotropium Bromide 1 CAP IH DAILY
4. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
5. Omeprazole 40 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Losartan Potassium 12.5 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Metoprolol Tartrate 125 mg PO QAM
10. Aspirin 162 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 500 mg PO BID
12. Metoprolol Tartrate 100 mg PO QPM
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
14. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
15. Acetaminophen 1000 mg PO QPM
16. Ibuprofen 200 mg PO QAM
Discharge Medications:
1. 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
2. Acetaminophen 1000 mg PO QPM
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
4. Aspirin 162 mg PO DAILY
5. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
puff ih twice a day Disp #*1 Disk Refills:*0
7. Furosemide 40 mg PO DAILY
8. Ibuprofen 200 mg PO QAM
9. Losartan Potassium 12.5 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 500 mg PO BID
11. Metoprolol Tartrate 125 mg PO QAM
12. Metoprolol Tartrate 100 mg PO QPM
13. Montelukast 10 mg PO DAILY
14. Omeprazole 40 mg PO DAILY
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
16. Rosuvastatin Calcium 5 mg PO 3X/WEEK (___)
17. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Shortness of breath
Vitamin B12 deficiency
Secondary diagnoses:
COPD/asthma
acute systolic CHF with EF 15%
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 seen in the hospital for shortness of breath. You
received an evaluation of your symptoms, and we suspect that
there are multiple factors contributing. Your asthma medications
were increased to improve your breathing. You should follow up
with Dr. ___ re-connect with Dr. ___
pulmonologist, to discuss your breathing problems.
Please follow up with your doctors as listed below.
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10373824-DS-20 | 10,373,824 | 28,818,620 | DS | 20 | 2147-03-02 00:00:00 | 2147-03-02 17:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lipitor / Actonel / Lisinopril / Simvastatin
/ Zetia / levofloxacin / cefuroxime
Attending: ___.
Chief Complaint:
DYSPNEA, COUGH
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ yo F w/ h/o COPD, atrial fibrillation, and diabetes, and CHF
(EF 15%) presents with dyspnea concerning for CHF exacerbation.
Patient states breathing worse x 1 week. Last night breathing
was very difficult with lying down, also difficult with walking
around. No additional complaints, no fever, no CP, no abdominal
pain or N/V/D.
Per review of recent PCP records patient was recently admitted
to ___ on ___ with acute on chronic systolic
congestive heart failure.
At that time she presented with worsening dyspnea but no
hypoxia. Chest x-ray was consistent with pulmonary edema. TTE
showed severely reduced LV systolic function with ejection
fraction 10% and severe global hypokinesis of the LV. Discharged
with dry weight of 94 pounds. She was discharged at that time on
Lasix 40 mg daily. Metoprolol was decreased to 100 mg b.i.d.
She was discharged on ___ and transferred to ___
___ from which she was discharged on ___.
Per review of recent PCP notes patient was referred for
palliative care.
In the ED initial vitals were:
Temp. 97.1, HR 79, BP 115/53, RR 18, 100% RA
EKG: LBBB rate 81 bpm.
Labs/studies notable for:
WBC 8.8, Hg 9.4, platelets 259. Na 140 K 4.5. BUN 30, Cr 1.2.
BNP 23702. Trop X 1 negative.
CXR showed:
Left lower lobe consolidation worrisome for pneumonia. Diffuse
increase in interstitial markings bilaterally suggest mild to
moderate interstitial edema. Possible small left pleural
effusion. Difficult to exclude trace right pleural effusion.
Patient was given: Ceftriaxone and azithromycin.
Vitals on transfer:
Temp. 97.8 HR 78 BP 121/49 RR 18 SpO2 94% RA
On the floor patient recounted the above history, including
endorsing orthopnea. She states that she has trouble sleeping
flat and that changing pillow amounts only helps a little.
Additionally she stated that she started coughing two days ago
accompanied by white productive sputum. Denied any fevers or
chills. She noted occasional trougble with swallowing however
was unable to describe any more details. She stated her diet is
well controlled at ___ (gives her all her
meals and helps with ADLs), and that she is on a low sugar/low
salt diet. However, she said that occasionally she sneaks in
chips or potato chips.
Denies chest pain, dizziness, headache, changes in vision (blind
in right eye, chronic), denies abdominal pain, diarrehea, or
constipation (has an ostomy bag, says output is normal). Denies
REVIEW OF SYSTEMS:
(+): Per HPI,
(-): Denies headache, changes in vision, dizziness, recent
fevers or chills, chest pain, cough/fever, sores in mouth,
nausea, vomiting, constipation, diarrhea, abdominal pain, new
rashes.
Per sister, patient was supposed to start Spironolactone 25 mg
PO DAILY on ___ (was called into pharmacy by PCP ___ ___, never
picked up). Also, PCP felt she may need night time O2 as she has
SOB in morning.
Past Medical History:
# CARDIAC HISTORY:
- CAD s/p small inferior STEMI in ___, PCTA to complex ___ RCA
lesion c/b large femoral hematoma
- paroxysmal afib
- HTN
- HLD
- CHF with EF 15% thought to be due to Takutsubo cardiomyopathy
# NON CARDIAC HISTORY-
- hip fracture s/p right hip replacement
- ischemic bowel requiring colectomy s/p ostomy
- COPD
- NIDDM
Social History:
___
Family History:
Father had colon CA. Mother possibly with history of CHF, MI,
or other heart problems. Her sister had an MI in ___.
Physical Exam:
ADMISSION EXAM
VS: T98.0 BP113/62 HR86 RR18 O2 SAT 94% RA (dry weight of 94
lbs)
GENERAL: Thin elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. Right eye
blindness. Otherwise EOMI, left eye pupil reactive to light. No
pallor or cyanosis of the oral mucosa, some phlegm in throat. No
xanthelasma.
NECK: Supple. JVP of 13 cm at 45 degrees
CARDIAC: PMI located in ___ intercostal space, Regular rate and
rhythm. soft s1 and s2, no murmurs appreciated.
LUNGS: No chest wall deformities or tenderness. Crackles at
bases, decreased breath sounds bilaterally, no wheezes or rales.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly. Has ostomy with normal appearing bowel contents.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. Thin extremities.
Neuro: CN II-XII grossly intact (no vision on right eye).
Strength ___ on upper and lower extremities. Gait deferred.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses soft, palpable and symmetric.
DISCHARGE EXAM
VS: Tm 98.0 T97.3 91-117/47-61 ___ 96-97%RA
I/O: 1060/2200
Wt: 41.1 kg
GENERAL: Thin elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. Right eye
blindness. Otherwise EOMI, left eye pupil reactive to light. No
pallor or cyanosis of the oral mucosa, some phlegm in throat. No
xanthelasma.
NECK: Supple. JVP of 5cm at 90 degrees
CARDIAC: Soft, regular rate, no murmurs appreciated.
LUNGS: No chest wall deformities or tenderness. Crackles at
bases, decreased breath sounds bilaterally, no wheezes or rales.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly. Has ostomy with normal appearing bowel contents.
Normal Bowel sounds.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema. Thin extremities.
Neuro: CN II-XII grossly intact (no vision on right eye).
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses soft, palpable and symmetric.
Pertinent Results:
ADMISSION LABS
___ 03:00PM BLOOD WBC-8.8 RBC-3.43* Hgb-9.4* Hct-30.6*
MCV-89 MCH-27.4 MCHC-30.7* RDW-16.3* RDWSD-53.7* Plt ___
___ 03:00PM BLOOD Neuts-63.6 ___ Monos-11.7 Eos-2.7
Baso-0.5 Im ___ AbsNeut-5.59 AbsLymp-1.86 AbsMono-1.03*
AbsEos-0.24 AbsBaso-0.04
___ 03:00PM BLOOD Glucose-107* UreaN-30* Creat-1.2* Na-140
K-4.5 Cl-99 HCO3-26 AnGap-20
___ 03:00PM BLOOD CK-MB-2 ___
___ 03:00PM BLOOD cTropnT-<0.01
___ 09:38PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:35AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:00PM BLOOD Calcium-9.5 Phos-3.8 Mg-1.8
MICRO
-------
__________________________________________________________
___ 12:48 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
__________________________________________________________
___ 6:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS
-------------------
___ 06:40AM BLOOD WBC-8.3 RBC-3.60* Hgb-9.9* Hct-31.4*
MCV-87 MCH-27.5 MCHC-31.5* RDW-15.9* RDWSD-51.5* Plt ___
___ 07:45AM BLOOD Glucose-149* UreaN-42* Creat-1.3* Na-134
K-5.0 Cl-97 HCO3-26 AnGap-16
___ 07:45AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.0
IMAGING
=============
___ (PA & LAT)
Left lower lobe consolidation worrisome for pneumonia. Diffuse
increase in
interstitial markings bilaterally suggest mild to moderate
interstitial edema.
Possible small left pleural effusion. Difficult to exclude
trace right
pleural effusion.
Brief Hospital Course:
___ yo F w/ h/o COPD, atrial fibrillation, and diabetes, and CHF
(EF 15%) presents with dyspnea found to have weight gain
concerning for systolic CHF exacerbation.
# ACUTE DECOMPENSATED SYSTOLIC HEART FAILURE (EF 15%)
Patient presented with worsening dyspnea for one week and cough
for two. Labs on admission were remarkable for elevated BNP
(23K), pulmonary edema on CXR and small left sided pleural
effusion on CXR in addition to 3 lbs. Weight gain on admission.
Inciting event may have been viral URI versus an acute decline
in setting of advanced heart failure with reduced EF. Patient
was diuresed with IV lasix 40 mg daily. She was transitioned
initially to torsemide 20 mg daily but patient developed ___. As
such Torsemide was held with plan to have weights followed up by
PCP and to consider starting torsemide 10 mg daily on day of
follow up. Metoprolol 100 mg BID was decreased to Metoprolol XL
50 BID. Losartan was increased to 25 mg daily. Spironolactone
was started, however patient developed hyperkalemia and thus was
stopped. Discharge weight was 41.1. Kg. Patient's ideal dry
weight is likely around 41.5 kg. Patient should have close
weight monitoring as an outpatient and if weight continues to
down trend Torsemide dose may need to be adjusted.
# ___ on CKD (baseline Cr 1.1): Patient developed ___ in setting
of transition to PO torsemide 20 mg daily. Creatinine peaked at
1.5 and patient was noted to be hyperkalemic. As such diuretic
held and spironolactone stopped. Improved, discharge Cr was 1.3.
Patient needs chemistry check on follow up on ___
to ensure renal function is stable. Spironolactone should not be
trialed again given hyperkalemia.
#Abdominal Pain: Likely indigestion/gas iso roast beef; improved
with maalox, simethicone, and tylenol.
# Paroxysmal Atrial fibrillation:
Patient remained in sinus rhythm while in the hospital. She was
continued on aspirin 81 mg daily and metoprolol continued as
above.
# HLD
Crestor home dose ___ continued
# COUGH
Patient presented with cough x 2 days; there was initial concern
of possible pneumonia and patient was given 1 dose of
ceftriaxone and azithromycin. However, on further evaluation her
cough was felt to be secondary to CHF exacerbation and improved
with diuresis. Antibiotics were stopped and patient remained
afebrile.
# CAD s/p small inferior STEMI in ___, PCTA to complex ___ RCA
lesion c/b large femoral hematoma. Troponins X 2 negative.
- continued aspirin 81 mg
- continued crestor M, W, F
# COPD: Patient had no signs of COPD exacerbation.
-albuterol 2 puffs BID
-continue advair BID
-continue montelukast 10 mg daily
# Diabetes
-held metformin
-ISS
#Concern of Sleep Apnea:
Per PCP, was going to get overnight oximetry as patient wakes up
short of breath. Overnight oximetry in house was normal.
TRANSITIONAL ISSUES
==================
- Weight on discharge: 41.1 kg (dry weight likely 41.5 kg)
- Lasix discontinued
- metoprolol succinate was decreased to 50 mg BID
- losartan increased to 25 mg daily
- Trialed spironolactone 12.5 mg however developed Hyperkalemia.
Should not be restarted as outpatient.
- Patients outpatient diuretic dose Torsemide 10 mg daily
started, first dose should be ___ after PCP evaluation and
___ check.
- Overnight oximetry in the hospital was normal
- continue ongoing goals of care discussion as outpatient with
referral to palliative care
- Patient should have close weight monitoring as an outpatient
and if weight continues to downtrend torsemide dose may need to
be adjusted
- Patient also needs chemistry check on follow up on ___
___ to ensure renal function is stable since had recent
___. Discharge Cr was 1.3
- patient discharged with home ___
______________________________________________
# ADVANCE CARE PLANNING
- HCP: ___ (nephew) ___
___ (sister) ___
- CODE: DNR/DNI (CONFIRMED), OK w/ non-invasive ventilation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Cyanocobalamin 1000 mcg IM/SC Q MONTHLY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Furosemide 20 mg PO DAILY
5. Losartan Potassium 12.5 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Metoprolol Succinate XL 100 mg PO BID
8. Montelukast 10 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
11. Rosuvastatin Calcium 5 mg PO M, W, F
12. Aspirin 81 mg PO DAILY
13. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral daily
Discharge Medications:
1. Torsemide 10 mg PO DAILY
RX *torsemide [Demadex] 10 mg 1 tablet(s) by mouth Daily on
___ Disp #*60 Tablet Refills:*0
2. Losartan Potassium 25 mg PO DAILY
RX *losartan [Cozaar] 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Metoprolol Succinate XL 50 mg PO BID
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth every 12
hours Disp #*60 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
5. Aspirin 81 mg PO DAILY
6. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral daily
7. Cyanocobalamin 1000 mcg IM/SC Q MONTHLY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Montelukast 10 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
13. Rosuvastatin Calcium 5 mg PO M, W, F
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Exacerbation of Heart Failure with Reduced Ejection Fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
You were admitted to the hospital for shortness of breath and
cough.
In the hospital you were treated for heart failure exacerbation
with medications to remove excess fluid from your body. Your
symptoms improved quickly.
Once you leave the hospital
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Your weight on discharge was 90.4 lbs or 41.1 kg.
- Follow up with your primary care physician ___,
MD
- Follow up with your cardiologist, Dr. ___, MD
___ was a pleasure taking care of you,
--Your ___ Care Team
Followup Instructions:
___
|
10374329-DS-15 | 10,374,329 | 21,854,083 | DS | 15 | 2136-02-23 00:00:00 | 2136-02-24 10:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
facial pain
Major Surgical or Invasive Procedure:
drain placement into abscess and drain removal
History of Present Illness:
Mr. ___ is a ___ male with hx of HTN,
hyperlipidemia who presents with right jaw pain and swelling
starting ___ evening.
Reports that he has had some oral discomfort for at least a
couple of months, but this worsened insidiously on ___, and
started to significantly bother him in the evening. Progressive
right sided jaw pain and swelling. no alleviating or
exacerbating factors. No fevers, difficulty breathing. Patient
had significant
difficulty opening his mouth fully and has avoided solid food
intake since then, but no difficulty tolerating liquids. Given
persistent and worsening symptoms, he was seen by ___ ENT
physician who performed flex laryngoscopy which revealed:
[Nasopharynx is free of lesions or masses. The airway is
unobstructed. Vocal folds move equally. Some fullness of the
lateral pharyngeal wall. Base of tongue is not obstructing.
There
is no elevation of the base of tongue. There is no aspiration of
secretions]. ENT physician sent him to ___ given concern for
right
deep neck infection vs. abscess. He was sent to ___ who
got a CT neck, which reportedly showed 25x7mm linear fluid
collection in the right floor of mouth and adjacent inflammatory
edema. He was given ceftriaxone and clindamycin, and transferred
to ___ ___ given possible concern of worsening edema leading to
airway obstruction. WBC 22.1, and mildly elevated LFTs (ALT 86,
alk phos 134) in the ___. lactate normal at 1.3
OMFS saw the patient in the ___ here, reviewed the CT scan. no
airway compromise but cannot rule out abscess vs. sialadenitis.
Recommended IV unasyn, encouraging PO intake, sialagogues, warm
compresses/massage. Per OMFS, the fluid collection too small to
drain/sample at this time. Patient reports overall improvement
of
pain from ___ to ___, and denied any other complaints. No SOB,
cough, chest pain, lightheadedness, fever, URI symptoms, sick
contacts
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
HL
Social History:
___
Family History:
not relevant to this hospitalization
Physical Exam:
EXAM(8)
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in mild discomfort
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Firm swelling over the right lateral submandibular area. limited
mouth opening, no clear lesions visualized.
CV: tachycardic bur regular, no murmur, no S3, no S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored. no stridor
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
On discharge,
Patient appeared well, had mild facial swelling on right side of
face
He had small incision at site of drain removal; still draining
small amounts on to bandage placed on top.
Small area of induration adjacent to drain removal site, not
warm, not tender.
Pertinent Results:
___ 06:51PM LACTATE-1.7
___ 01:10PM GLUCOSE-102* UREA N-13 CREAT-0.8 SODIUM-143
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-22 ANION GAP-21*
___ 01:10PM estGFR-Using this
___ 01:10PM ALT(SGPT)-57* AST(SGOT)-24 ALK PHOS-133* TOT
BILI-0.8
___ 01:10PM ALBUMIN-3.9 CALCIUM-8.5
___ 01:10PM ALBUMIN-3.9 CALCIUM-8.5
___ 01:10PM PLT COUNT-313
CT face
IMPRESSION:
1. Dilated right submandibular duct without a calculus with
surrounding
inflammatory changes and prominent lymph nodes. The appearance
and soft
tissue changes in the right floor of the mouth and surrounding
submandibular
gland appear inflammatory in nature. However, follow-up
examination after
resolution of inflammation is recommended to exclude any an
underlying lesion.
2. 2.5 cm right parotid lesion for which excision biopsy can be
performed or
ultrasound biopsy can be performed.
CXR ___
Endotracheal tube is in satisfactory position. Heart size is
top-normal,
accentuated by slightly low lung volumes. There is unfolding of
the thoracic
aorta with vascular calcification. Hilar contours are
preserved. There is no
edema. Patchy opacities are noted in the left lung base,
nonspecific. The
remainder of the lungs are clear. There is no large effusion or
pneumothorax.
IMPRESSION:
Satisfactory positioning of an endotracheal tube. Patchy
opacities in the
left lower lung field which may represent atelectasis although
infection
cannot be excluded in the appropriate context.
CXR ___
Patient has been extubated, but lung volumes are maintained.
Previous
consolidation at the lung bases has improved. Heart is normal
size and
mediastinal and pulmonary vasculature are no longer engorged.
MICRO
___ Blood cultures NO GROWTH - final
C diff toxin - NEGATIVE
___ 6:28 pm SWAB RIGHT SUBLINGUAL SPACE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH.
Penicillin test result performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CEFTRIAXONE----------- 1 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.12 S
VANCOMYCIN------------ 0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED
Discharge Labs
___ 04:17AM BLOOD WBC-6.9 RBC-3.96* Hgb-11.8* Hct-35.7*
MCV-90 MCH-29.8 MCHC-33.1 RDW-14.4 RDWSD-47.1* Plt ___
___ 04:17AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-138
K-4.7 Cl-98 HCO3-28 AnGap-12
___ 04:17AM BLOOD ALT-35 AST-16 AlkPhos-112 TotBili-0.2
Brief Hospital Course:
his is a ___ with history of HTN, HL, tobacco use, who presented
with right jaw pain and swelling, and sepsis, c/w right
sublingual and submandibular abscess now s/p I&D. Course has
been complicated by airway edema requiring intubation, hypoxemic
respiratory failure, and mild anemia . Persistent purulent
drainage from ___, necessitating continued close observation
and IV antibiotics (per OMFS).
# Sepsis secondary to
# Right sublingual and submandibular abscess
# S/p I&D in OR, ___ drain placement
Culture grew Strep anginosus.
Fever curve and WBC improved. However, he had significant
drainage from drain after placement, and was observed in the
hospital for this from ___. Drain removed on ___ by
OMFS. Pain improved after drainage and he did not require any
pain medication on discharge. ___ followed and recommended
peridex oral rinse, unasyn during admission and augmentin at
discharge for one additional week. He did better with softer
foods, and preferred chewing on the left side of his mouth given
pain. He has ___ scheduled with ___ at ___ next week.
Counselled on importance of attending that appointment.
# Acute hypoxemic respiratory failure
# Aspiration pneumonia
# Acute dCHF
# Atelectasis
New problem after intubation, now essentially resolved after
time, IS, antibiotics, and a few doses of IV diuretic. His CXR
showed bilateral consolidation concerning for pneumonia, likely
some aspiration. This should be well covered with Unasyn. ___
CXR showed improvement - PCP can consider repeat to document
full resolution He also had soft crackles and some evidence of
lower extremity edema, improved with diuretics. Could also be
atelectasis due to pain and supine positioning in OR/ICU. Would
recommend outpt TTE.
# Parotid gland mass
Incidental finding on imaging. Per OMFS, requires followup
outpatient. DISCUSSED AT LENGTH WITH PATIENT AND HIS DAUGHTER.
Advised that they ___ for this with their PCP who can refer to
ENT for biopsy.
# Diarrhea: C diff negative, likely antibiotic associated.
Recommended imodium prn
# Anemia
Hct dropped during course of admission. Now improved/stabilized.
Not iron deficient; likely myelosuppression due to acute
illness.
# Thrombocytosis: Mild, but platelet count escalating toward
end of hospitalization. Likely due to infection, but somewhat
unusual that seen as he was improving. PCP can ___ and recheck
CBC.
# Mild transaminitis- resolved.
# HTN: BPs fairly stable Continued amlodipine
# HL: Stable. Continue atorvastatin
# Work - I wrote a letter for him for work and faxed it to HR at
___. Copy of this letter is on ___ OMR. He met briefly
with social worker to discuss short term disability paperwork
and she advised him to ___ with PCP for this.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 60 mg PO QPM
3. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
3. LOPERamide 2 mg PO QID:PRN diarrha
You may buy this over the counter.
4. amLODIPine 10 mg PO DAILY
5. Atorvastatin 60 mg PO QPM
6. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abscess in mouth (submandibular and sublingual)
Parotid gland mass
Antibiotic associated diarrhea
Hypertension
Elevated cholesterol
Discharge Condition:
Mental Status: Alert and oriented
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You admitted and evaluated for facial pain and found to have an
infection that was drained and treated with antibiotics. You
will need to continue antibiotics for 7 days after discharge and
to use a mouth wash for seven days. PLEASE go to your follow up
with the ___ (oral surgery) team at ___ next
week. You were also noted to have concern for a mass near your
parotid (salivary) gland and will need to have repeat CT scan
and likely biopsy of this area after treatement for infection.
Please discuss need for a repeat CT scan with your PCP, who can
also refer you back to the ENT doctors to discuss a biopsy of
your parotid gland.
I HAVE FAXED PRESCRIPTIONS FOR YOUR AUGMENTIN AND ORAL RINSE TO
THE ___ ON ___ IN ___. Also, please change the
bandages that are covering the site of your abscess drainage as
needed. We have given you the supplies to do so.
Followup Instructions:
___
|
10374489-DS-14 | 10,374,489 | 28,843,407 | DS | 14 | 2122-11-28 00:00:00 | 2122-11-29 10:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Percocet / Hydrocodone
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old woman with MS, presenting with
back pain and difficulty walking after a fall 3 days ago. The
patient has a R "foot drop" at baseline, and on ___ prior to
presentation she tripped and fell. She caught herself easily and
stood back up, and was not bothered much at the time. No HS or
LOC. However, on ___ AM she woke up with severe back pain,
which
was similiar to pain she had experienced on past occasions, and
she says he feels like she had "thrown out" her back. The pain
is
intense and achy, and ranged up to an ___. It did radiate
somewhat down to her anterior upper thighs bilaterally. No
shooting or electrical sensations, and no numbness or weakness.
The back pain was worst with walking, and this led to
progressive
increased difficulty with walking, which she felt was at least
partially ___ pain. She also has significant baseline imbalance
(see prior ___ notes).
She was prescribed tramadol and diazepam, and she took the
tramadol but then became progressively nauseous and vomited on
___ for about 24 hours. She does have a history of vomiting
with percocet and morphine in the past. She did not have any
systemic signs of infection such as fever, chills, or diarrhea.
She had a difficult time keeping anything down. She also tried
the diazepam but did not find it very helpful, although she
notes
she may have vomited it up.
She also noted during this time a mild exacerbation of her
baseline urinary symptoms. At baseline she has urinary hesitancy
and incontinence, which has been worse since her pregnancy in
___. She routinely goes to the bathroom every 2 hours,
otherwise
she will have to run to the bathroom and sometimes doesnt make
it. Now, after the fall, she noted that it was just a little
harder for her to initiate urination and to fully empty her
bladder, and required a little more effort. However, she is also
dehydrated, and noted this could be ___ dehydration.
Of note she feels her weakness (R leg and R arm) is at baseline,
and not worse than prior. Dysmetria and vision are also at
baseline.
Treatment History:
1. ___ ___ TO ___ stopped due to activity
2. Tysabri ___ stopped for pregnancy and restarted
___ (last ___ 2: ___ virus antibody
positive ___
3. Copaxone ___ stopped for pregnancy
4. Another medication used recently for twhich the patietn does
not remember the name
5. Now back on ___
MS HISTORY IS AS FOLLOWS: per Dr. ___ note
"Briefly, in ___ she experienced transient
visual obscuration involving her left eye. She then lost most
of her vision in her left eye beginning ___ .
As the vision was improving she developed loss of vision and
pain
on eye movement involving the right eye over the past week.
Second relapse was ___ with LLE weakness and imbalance
associated with severe increase in anxiety disorder.
Third relapse ___ with symptoms of gait ataxia and urinary
incontinence,resolved gradually after 3 days of IVMP.
Fourth relapse ___: Subacute onset of increased right leg
weakness and incoordination and worsened gait instability
falling
to the left beginning 6 weeks after stopping tysabri. Received
IV
MP 1 gram for 3 days ___ with partial recovery"
After this the patient switched neurologists, and now sees Dr.
___ in ___.
ROS: + as above, otherwise negative
Past Medical History:
PMH:
-MS: onset since ___, with 5 relapses
-Anxiety disorder: Precipitated her first MS relapse since ___ and was associated with stresses of a new job. Followed by
cognitive neurology in the past at ___.
- Lumbar back strain ___
PSH:
-ear tubes placed when she was young (uncertain of age) for
recurrent infections
Social History:
___
Family History:
No history of MS, autoimmune diseases, or seizures. No history
of other neurologic diseases. No familial history of stroke or
clotting diseases.
Physical Exam:
PHYSICAL EXAMINATION:
VS: 98 76 108/70 16 99% RA
General: NAD
Resp: non labored
Abd: nd
Ext: WWP
MS: Awake, alert, oriented x 3, able to recall ___ words at 5
minutes, MOYB intact, language intact, follows complex commands.
No neglect.
CN: EOMI, PERRL, no facial asymetry, hearing intact, visual
fields full, vision at baseline, palate elevates fully and
symmetrically, trapezius and SCN full strength
- Motor -
Muscule bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR FExt FFlex IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 5- 4+ 5- 5- 5- 4 4 5 4+ 0* 5
* R foot with contracture, not able to move foot upwards
(R leg weakness noted on ___ exam, R arm weakness not noted but
per patient is not new)
- Sensation -
Intact to light touch, temperature, pinprick, vibration, and
proprioception throughout.
- DTRs -
Bic Tri ___ Quad Gastroc
L 3 3 3 3 3
R 3 3 3 3 3
Plantar response extensor bilaterally.
- Cerebellar -
Dysmetria R>L arm bilaterally. Decreased RAM R > L. (noted on
prior exam)
- Gait -
Unsteady gait, R foot is flexed so mostly relies on L leg,
almost
falls several times over to one side or the other
Pertinent Results:
ADMISSION LABS
___ 09:20PM CREAT-0.8
___ 10:46PM URINE HOURS-RANDOM
___ 10:46PM URINE UCG-NEGATIVE
___ 10:46PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 10:46PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-NEG
___ 10:46PM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-1
___ 10:46PM URINE AMORPH-RARE
___ 10:46PM URINE MUCOUS-RARE
___ 10:35PM GLUCOSE-131* UREA N-14 CREAT-0.7 SODIUM-143
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15
___ 10:35PM estGFR-Using this
___ 10:35PM ALT(SGPT)-14 AST(SGOT)-17 ALK PHOS-63 TOT
BILI-0.4
___ 10:35PM ALBUMIN-4.3
___ 10:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:35PM WBC-5.3 RBC-4.35 HGB-13.9 HCT-41.1 MCV-95
MCH-32.0 MCHC-33.9 RDW-12.3
___ 10:35PM NEUTS-49.8* ___ MONOS-7.4 EOS-4.1*
BASOS-0.8
___ 10:35PM PLT COUNT-212
___ 10:46 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
CXR
IMPRESSION: No acute cardiopulmonary process.
MRI Whole Spine Overall, no significant change in the cord
lesions of multiple
sclerosis. No enhancement or no new lesions are seen.
Low-lying conus which is unchanged.
MRI Brain
Again, white matter lesions consistent with multiple sclerosis
are seen with T1 hypointense lesions in both parietal regions.
No enhancing
lesions or definite new lesions since the previous MRI of
___. Note is
made of cerebellar atrophy as well as mild brain atrophy.
Brief Hospital Course:
___ w h/o MS, now with back pain, difficulty walking, and some
increase from baseline urinary sx after a fall. Exam shows no
new weakness or sensory loss, with unsteadiness with walking
which is questionably marginally worse than baseline. The
unsteadiness may be pain related since walking seems to trigger
her back pain. MRI brain and spine showed no active MS lesions.
She has a history of being very unsteady on prior ___ evals.
Urinary sx are close to baseline but with some difficulty fully
emptying bladder, but this may be confounded by recent
dehydration ___ vomiting at home prior to admission. No UTI on
UA.
The patients pain was treated with opiods initially, which led
to nausea. In the future, tramadol, oxycodone, morphine,
dilaudid, and other opiods should be AVOIDED. She did respond to
PO tylenol, NSAIDS (keterolac), and PO diazepam although she
continued to c/o some pain. ___ evaluated the patient and
recommended rehab.
She should follow up with her Neurologist as scheduled, and
continue her Avonex and Acthar injections (for Acthar pt did not
know home dose, if she is still at rehab on ___ she would
need an injection at that time).
The patient should be continued to be followed by social work at
rehab to evaluate home situation prior to discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Avonex (interferon beta-1a) 30 mcg injection ___
2. Amantadine 100 mg PO BID
3. Citalopram 20 mg PO DAILY
4. Acthar H.P. (corticotropin) unknown units injection monthly,
on two consecutive days
Discharge Medications:
1. Amantadine 100 mg PO BID
2. Avonex (interferon beta-1a) 30 mcg injection ___
3. Citalopram 20 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H:PRN pain
do not exceed 3 grams daily
5. Diazepam 5 mg PO Q6H:PRN Muscle spasm
RX *diazepam 5 mg 1 tablet by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
6. Acthar H.P. (corticotropin) 0 units INJECTION MONTHLY, ON TWO
CONSECUTIVE DAYS
She has some at home and is next due on ___, and has a
home supply
7. Naproxen 500 mg PO Q8H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
1. difficulty walking
2. multiple sclerosis, chronic
3. back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for difficulty walking in the
setting of back pain after a recent fall. You had an MRI brain
and spine which did not show any active MS lesions. You were
seen by physical therapy, who felt you would benefit from a
short stay at rehab to help with your walking.
It is important that you take all medications as prescribed, and
keep all follow up appointments.
Followup Instructions:
___
|
10374489-DS-15 | 10,374,489 | 29,782,216 | DS | 15 | 2127-09-13 00:00:00 | 2127-09-13 22:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Hydrocodone
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per admitting MD ___:
"CC: headache
HPI(4): Ms. ___ is a ___ female with the past
medical
history of multiple sclerosis and trigeminal neuralgia with
recent placement of baclofen pump at ___ on ___ for her MS
presenting with post-procedural headache worse with standing
since procedure.
Patient reports that she has baclofen pump placed ___ in ___ at ___ by Dr. ___. She has had a headache since
the procedure which she notes is positional in nature, ___ with
standing and ___ when lying flat. It is focusedin the front of
her head and her posterior and lateral neck, feel hard to hold
her head up. She was taking dilaudid and Compazine at home with
some effect however due to poor PO intake, her doctor directed
her to the ED for evaluation.
She denies fevers. Has had some nausea, no vomiting. Increased
urinary frequency and urgency but no dysuria or hematuria.
In terms of her pump, there is currently no baclofen going
through the pump. She has not noted increased spasticity since
procedure.
___ ER MD, "Over the course the day, I spoke with
CPS/anesthesia,
interventional radiology, and neuroradiology, in addition to
neurosurgery, all of whom are either unable or not comfortable
with performing a blood patch in this patient. I spoke with an
anesthesiology at the ___ who is recommending against blood
patch at this time given how close it is to her surgery. The
patient is still currently very symptomatic with standing. The
patient has been unable and unwilling to get up to go to the
bathroom while in the ED and is requiring a pure-wick. Her
symptoms have been treated with therapy without consistent
improvement. Given patient's inability to reliably stand up and
take care of herself along with persistent headache with
standing
that prevents her from engaging in these activities, the patient
requires admission for symptomatic management."
Vitals in the ER: 97.7 120 123/87 19 98% RA
There, the patient received: Prochlorperazine IV x1, fiorecet x2
(last at 1115am - 2 tabs), 1L NS bolus and then at 175cc/hr for
1L. She also got her home Keflex and home fluoxetine.
On arrival to the floor, the patient confirms the above history.
She notes her headache is currently a 2 but goes to a 7 with
standing. No photophobia. No recent fevers or chills. No vision
changes. Pain is a pressure in her face and back of her neck
which is much worse with getting up.
In terms of her MS, major symptoms are mobility issues and
ataxic
gait. She walks with a walker at home.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative."
Past Medical History:
PMH:
-MS: onset since ___, with 5 relapses
-Anxiety disorder: Precipitated her first MS relapse since ___ and was associated with stresses of a new job. Followed by
cognitive neurology in the past at ___.
- Lumbar back strain ___
PSH:
-ear tubes placed when she was young (uncertain of age) for
recurrent infections
Social History:
___
Family History:
No history of MS, autoimmune diseases, or seizures. No history
of other neurologic diseases. No familial history of stroke or
clotting diseases.
Physical Exam:
Admission exam:
VITALS: 98.2 PO 101/67 94 18 96 RA
GENERAL: Alert and in no apparent distress, soft spoken
EYES: Anicteric, pupils equally round
ENT: Oropharynx and nose without visible erythema or lesions. MM
moist
CV: Heart regular rate; normal perfusion, no appreciable JVD
RESP: Symmetric breathing pattern with no crackles or rhonchi.
Breathing is non-labored
GI: Abdomen soft, non-distended, nontender except in LLQ at site
of baclofen pump without surrounding erythema. Only mildly
tender
at surgical site
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, normal muscle bulk and tone
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, CN II-XII intact
PSYCH: normal thought content, logical thought process,
appropriate affect
Discharge exam:
___ 0737 Temp: 98.2 PO BP: 108/66 HR: 72 RR: 18 O2 sat: 97%
O2 delivery: Ra
GENERAL: Alert and in no apparent distress, soft spoken. Appears
more comfortable.
EYES: Anicteric, pupils equally round
ENT: Oropharynx and nose without visible erythema or lesions. MM
moist
CV: Heart regular rate; normal perfusion, no appreciable JVD
RESP: Symmetric breathing pattern with no crackles or rhonchi.
Breathing is non-labored
GI: Abdomen soft, non-distended, nontender except in LLQ at site
of baclofen pump without surrounding erythema. Minimal TTP at
at surgical site
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, normal muscle bulk and tone
Weakness of R hand grip of RUE
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, CN II-XII intact
PSYCH: normal thought content, logical thought process,
appropriate affect
Pertinent Results:
Admission :abs:
___ 10:21PM BLOOD WBC-7.3 RBC-3.75* Hgb-11.9 Hct-36.2
MCV-97 MCH-31.7 MCHC-32.9 RDW-12.3 RDWSD-42.9 Plt ___
___ 10:21PM BLOOD Neuts-82.6* Lymphs-8.7* Monos-8.0
Eos-0.1* Baso-0.3 Im ___ AbsNeut-6.06 AbsLymp-0.64*
AbsMono-0.59 AbsEos-0.01* AbsBaso-0.02
___ 10:21PM BLOOD Plt ___
___ 12:58AM BLOOD ___ PTT-26.1 ___
___ 10:21PM BLOOD Glucose-124* UreaN-10 Creat-0.6 Na-141
K-3.9 Cl-106 HCO3-22 AnGap-13
UA:
___ 05:07AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:07AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-80* Bilirub-SM* Urobiln-8* pH-6.5 Leuks-NEG
___ 05:07AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-3
Imaging studies:
CT Head W/O Contrast
No acute intracranial abnormalities.
Microbiology:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
Discharge Labs:
___ 06:10AM BLOOD WBC-6.0 RBC-3.80* Hgb-11.9 Hct-36.5
MCV-96 MCH-31.3 MCHC-32.6 RDW-12.4 RDWSD-43.0 Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD Glucose-81 UreaN-12 Creat-0.7 Na-143
K-4.0 Cl-105 HCO3-24 AnGap-14
___ 06:10AM BLOOD ALT-37 AST-15 LD(LDH)-178 AlkPhos-94
TotBili-0.2
___ 06:10AM BLOOD Albumin-3.7 Calcium-9.4 Phos-4.6* Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ female with the past medical
history of multiple sclerosis and trigeminal neuralgia with
recent placement of baclofen pump at ___ on ___ for her MS
presenting with post-procedural headache worse with
standing since procedure. Pt was evaluated for a blood patch
procedure, which was deferred in favor of medical management.
#Headache - Ms. ___ symptoms of bifrontal positional
headache since baclofen pump placement on ___ most concerning
for intracranial hypotension ___ her procedure. Neuro exam
reassuring. CTH wnl and pt was afebrile making infection
including meningitis less likely. Symptoms less consistent with
migraine at this point given lack of photophobia. Per discussion
in the ED with patient's surgeon as well as with ___ anesthesia
(only place that would do blood patch in this situation) as well
as CPS and ___ here, decision was made to hold on blood patch at
his time given risks and manage headache conservatively.
Case was discussed with NP ___ from Dr. ___
___ who agreed with this plan.
Neurology was consulted for medical management as well.
Pt improved with ~ 24 hours of Toradol standing Tylenol and IVFs
and was transitioned to APAP, ibuprofen and occ Fioricet with
good effect.
In conjunction with neurology recs, pt was rec'd to avoid
strenuous activity or straining, and lay flat when possible to
promote healing.
Her case was also reviewed by physical therapy who agreed with
patients plan to resume outpatient physical therapy 3x/week and
will discharge home to supervision
of husband. Patient has no acute ___ needs identified at this
time.
At the time of discharge, careful return symptoms were outlined
with the understanding that her likely CSF leak should heal
spontaneously, but if her overall pain does not continue to
improve would pursue fluoro-guided epidural blood patch (___ vs
___).
#Relapsing and remitting Multiple Sclerosis with progression -
Currently on rituxan infusions q6 months.
#Spasticity s/p baclofen pump - Placed at ___ on ___. ___
team was updated with care plan and at the time of discharge.
She completed her 7d post-op procedure Keflex while in house
#Mild proteinuria - Noted to have proteinuria on UA in the ED
today.
#Depression: Continuee home fluoxetine
# Asx Bacteruria: UA non infectious and pt denying sypmtoms,
however noted to have ___ ENTEROCOCCUS SP/mixed flor in
urine. Abx were held and pt was monitored clinically.
Transitional issue:
[ ] Repeat UA for evaluation of persistent proteinuria as
outpatient
[ ]If ongoing or worsening HA despite the above measures and
before NYU f/u, rec'd pt present to ___ in case blood patch
required
[ ] ___ here in ___ on prn basis
>30 minutes were spent in discharge planning and coordination of
care on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 40 mg PO DAILY
2. LORazepam 0.5 mg PO BID:PRN anxiety
3. riTUXimab 10 mg IV Q6 MONTHS
4. Vitamin D 4000 UNIT PO DAILY
5. Magnesium Oxide 400 mg PO BID
6. Vitamin B Complex 1 CAP PO DAILY
7. Cephalexin 500 mg PO Q12H
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN Headache
Duration: 10 Doses
Do not exceed 6 tablets/day.
___ cause drowsiness.
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1
capsule(s) by mouth Every six hours Disp #*8 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q8H Duration: 2 Weeks
RX *acetaminophen 500 mg 2 tablet(s) by mouth Every eights hours
Disp #*84 Tablet Refills:*0
3. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
RX *ibuprofen 800 mg 1 tablet(s) by mouth Every 8 hoursneeded
Disp #*42 Tablet Refills:*0
4. Omeprazole 20 mg PO DAILY Prevention of stomach irritation
Duration: 30 Days
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. FLUoxetine 40 mg PO DAILY
6. LORazepam 0.5 mg PO BID:PRN anxiety
7. Magnesium Oxide 400 mg PO BID
8. riTUXimab 10 mg IV Q6 MONTHS
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 4000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Post procedural headache
Discharge Condition:
Stable
Discharge Instructions:
You came to the hospital for evaluation of headaches which came
on after your baclofen pump placement.
You were seen by multiple specialists including the
neurosurgeons and neurologists and your headache was managed
with medicines and you improved.
It is important that you follow up with your neurosurgeons in
NYU at the agreed upon date (___). In speaking with ___ from
their office they wanted to stick with that follow up date to
allow additional time for healing.
If your headache is not controlled by the medications provided
on discharge please call your doctor or return to the emergency
department.
It was a pleasure taking care of you!
Followup Instructions:
___
|
10374536-DS-5 | 10,374,536 | 21,517,199 | DS | 5 | 2188-05-27 00:00:00 | 2188-05-29 15:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
levofloxacin
Attending: ___.
Chief Complaint:
Lightheadedness with standing, malaise
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ M with history of asthma, h/o HTN, tobacco
abuse, and recent hospitalization for new diagnosis of
nonischemic cardiomyopathy causing systolic heart failure (LVEF
15%) who was transferred from clinic to the ED due to
symptomatic hypotension.
Since his recent discharge ___, he was feeling well for 1 day,
then had
progressive lightheadedness, dizziness, fatigue, exertional
intolerance, with increasing dyspnea. Minimal chest discomfort,
no syncope. Had difficulty eating / keeping food down (though he
did "force" eggs down this morning). Review of systems performed
as below. Increased cough, but no sputum production. No
abdominal pain, fevers, diarrhea, constipation, or sick
contacts.
He reports to me that "something doesn't feel right" and "I feel
sick," and looked unwell (see below).
REVIEW OF SYSTEMS:
Constitutional: no fevers, chills, night sweats, weight loss; +
anorexia
HEENT: no post-nasal drip, sinus pressure
Cardiac: as per HPI
Pulmonary: no wheezing, + cough, no sputum, hemoptysis
GI: no nausea, vomiting, abdominal pain, constipation, diarrhea,
blood in stools, hemetemesis
Extremities: no swelling, pain, edema
Skin: no rashes, ulcers
Neurologic: no neuropathy, headaches, hearing or visual
difficulty or loss, speech difficulties, numbness or weakness in
extremities
MSK: no joint or back pain
GU: no frequency, urgency
Psych: no depression, anxiety
Past Medical History:
- asthma (ER twice ___ years ago, no
hospitalizations/ICU/intubations)
- seasonal allergies
- low back pain, degenerative disc disease
- provoked DVT in setting of injury (chainsaw to leg) in ___
- history of arthroscopic knee surgery
- HTN, not currently on treatment
Social History:
___
Family History:
FAMILY HISTORY: father died of lung cancer. Mother died at ___
years old of unclear reason. one brother died of liver failure
at ___ in setting of drug abuse, other brother died at ___ of
liver failure (had hx of heroin addiction). No family history of
MI, CHF, stroke, clotting issues.
Physical Exam:
PHYSICAL EXAMINATION PRIOR TO ADMISSION IN CLINIC (TRANSFERRED
TO ER FROM CLINIC):
VS: BP 70-80/40; improved to SBP 90 when lying flat; HR = 72
General: Appears ill, grey; improved lying flat; diaphoretic
Neck: Thyroid non-palpable. Jugular venous pressure is < 6 cm
H2O. Carotids and 2+ and weak
Chest: Decreased BS at R base ? dull to percussion, otherwise
good air entry
Heart: Regular, occaisonal extrasystole. No S3 appreciated, no
other murmurs or rubs
Abdomen: soft, non-tender, and normal bowel sounds. Diaphoretic;
No hepatomegaly noted. No bruits or pulsatile mass.
Extremities/Vascular: thready radial pulse; diaphoretic; no
edema
Neurologic: appears tierd and closes eyes frequently
PHYSICAL EXAMINATION ON DISCHARGE:
VS: T=97.8 BP=90-125/53-71 HR=54-68 RR=18 O2 sat= 94% on RA
GENERAL: WDWN, lying in bed and moving around the room in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. 0.5 x 0.7cm
ulcerated lesion next to left year.
NECK: Supple with JVP at/below clavicle at 45 degrees.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ radial and DP pulses bilaterally
Pertinent Results:
LABS ON ADMISSION:
___ 05:00PM BLOOD WBC-9.8 RBC-4.55* Hgb-16.0 Hct-47.6
MCV-105* MCH-35.1* MCHC-33.6 RDW-13.6 Plt ___
___ 05:00PM BLOOD Neuts-61.2 ___ Monos-5.1 Eos-4.4*
Baso-0.9
___ 05:00PM BLOOD ___ PTT-29.0 ___
___ 05:00PM BLOOD Glucose-102* UreaN-33* Creat-1.6* Na-141
K-4.4 Cl-101 HCO3-26 AnGap-18
___ 05:00PM BLOOD proBNP-704*
___ 05:00PM BLOOD cTropnT-<0.01
___ 07:45AM BLOOD Calcium-9.7 Mg-2.1
LABS ON DISCHARGE:
___ 08:05AM BLOOD WBC-9.0 RBC-4.28* Hgb-15.1 Hct-44.3
MCV-104* MCH-35.3* MCHC-34.1 RDW-13.4 Plt ___
___ 08:05AM BLOOD ___ PTT-33.4 ___
___ 08:05AM BLOOD UreaN-19 Creat-1.3* Na-139 K-4.0 Cl-102
HCO3-26 AnGap-15
___ 08:05AM BLOOD Calcium-9.6 Phos-3.5 Mg-2.0
STUDIES:
--- ECG ___ 4:52:04 ___
Sinus rhythm at the lower limits of normal rate. Leftward axis.
Intraventricular conduction delay. Consider inferior wall
myocardial
infarction. Predominantly inferior and anterolateral ST-T wave
abnormalities.
Compared to the previous tracing of ___ the rate is now
slower.
ST-T wave abnormalities are more prominent.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 ___ 61 -20 122
---CHEST X RAY (PA AND LAT) ___
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or
vascular
congestion. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities identified.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
Mr. ___ is a ___ M with history of asthma, h/o HTN, tobacco
abuse, and recent hospitalization for new diagnosis of
nonischemic cardiomyopathy causing systolic heart failure (LVEF
15%) who represented due to symptomatic orthostatic hypotension.
# Symptomatic Orthostatic Hypotension: Likely due to new
medication regimen from recent hospitalization, including
carvedilol, losartan, and torsemide. He was initially admitted
to the NP service and then transferred to the ___ service. Upon
arrival to the floor, he is no longer symptomatic with going
from lying to standing.
Diuretics were held during hospitalization and he was to
continue holding them until follow up with Dr. ___. His diet
and fluid restriction were liberalized. Carvedilol was
converted to metoprolol and he was discharged on 25mg metop
succinate BID. He was restarted on losartan at reduced dose of
25mg daily. He tolerated this regimen without lightheadedness
or dizziness prior to discharge.
# Systolic Heart Failure, compensated: Diagnosed at recent
hospitalization. EF of 15%. See above for discussion of plan
for BB, ___, diuretics. To follow up with Dr ___ on ___.
Given his low EF (15%) and frequent ectopy seen on telemetry, he
was discharged with a Lifevest.
# Asthma: On levalbuterol inhalor at home, nonformulary, so
given PRN albuterol nebs.
# Low back pain: Continue home cyclobenzaprine and
acetaminophen.
A void NSAIDs due to ___.
# Smoking cessation: Again he was strongly encouraged to
stop smoking, he states he has decreased smoking since his last
admission but not stopped. He declined somking cessation agents
at this time.
=================================
TRANSITIONAL ISSUES
=================================
[ ] Diuretics held on discharge, will follow up with Dr. ___ on
___ to evaluate volume status, titrate diuretics.
[ ] Smoking cessation- ongoing issue
[ ] Metoprolol succinate 25mg BID and Losartan 25mg daily to be
uptitrated as blood pressure allows
[ ] Lifevest: Discharged with lifevest. He expressed doubt
that he would wear it all the time. Wearing the lifevest was
strongly encouraged and he was able to verbalize what it was for
and why it is indicated for his case as well as the possible
consequence of not wearing it if a lethal arrhythmia were to
occur.
[ ] Transitional issues still outstanding from last discharge:
---[ ] CAD: Nonobstructive CAD seen on cardiac cath, no
interventions were done. Started on ASA 81.
---[ ] Dermatology for Left Ear Ulcer: Has had non-healing
shallow
left ear ulcer for ___ years. Derm follow up strongly recommended.
---[ ] Macrocytosis: Not anemic on presentation (Hgb/Hct
14.3/41.9). After procedure/blood draws during stay had Hgb/HCt
of 13.7/31.2. MCV 105, denies EtOH use in last ___ years. B12 was
WNL.
---[ ] Pulmonary disease: Has diagnosis of asthma, given smoking
history there could be a COPD component. Would recomment PFT's
as an outpatient. His albuterol rescue inhaler was changed to
levalbuterol.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO TID:PRN back pain, spasm
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. TraZODone 100 mg PO HS:PRN insomnia
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. Aspirin 81 mg PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Carvedilol 25 mg PO BID
9. Losartan Potassium 50 mg PO DAILY
10. Xopenex HFA (levalbuterol tartrate) 45 mcg/actuation
inhalation 16hr:PRN shortness of breath
11. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Cyclobenzaprine 10 mg PO TID:PRN back pain, spasm
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Multivitamins 1 TAB PO DAILY
8. TraZODone 100 mg PO HS:PRN insomnia
9. Metoprolol Succinate XL 25 mg PO BID
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Xopenex HFA (levalbuterol tartrate) 45 mcg/actuation
INHALATION 16HR:PRN shortness of breath
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostatic hypotension
Compensated systolic congestive heart failure
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 lightheadedness and low blood
pressure. This was the result of the large amount of fluid
recently removed during your admission for new congestive heart
failure. We have stopped your diuretic (torsemide) and switched
your beta-blocker from carvedilol to metoprolol. We also
decreased the dose of the losartan. With these changes, your
blood pressure improved and your symptoms resolved. When you see
your cardiologist next week, he will decide if you should
restart the torsemide.
It was a pleasure taking part in your care and we wish you a
speedy recovery!
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
10374990-DS-14 | 10,374,990 | 24,432,993 | DS | 14 | 2188-02-16 00:00:00 | 2188-02-16 14:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / bee stings
Attending: ___.
Chief Complaint:
Abdominal pain and distention
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of multiple prior abdominal
surgeries including exlap/splenectomy for Hodgkin's disease in
the ___ and multiple episodes of recurrent SBO since then.
Two
of these required exlap and lysis of adhesions, also in the
___ but subsequent episodes, most recently in ___, have
resolved with non-operative management.
Patient now presents with acute onset of abdominal pain that
started last night - epigastric, crampy. She recognized it as
similar to her past episodes of SBO. Has had bilious emesis x9.
Had a very small BM yesterday; last substantial BM was two weeks
ago. Cannot recall when she last passed flatus. Had nausea,
relieved with Zofran received in ED. Denies fever, chills, chest
pain, SOB. Just returned from 2-week trip to ___ and
had been feeling fine up until yesterday.
Past Medical History:
aortic stenosis
moderate mitral stenosis
radiation heart disease
Hodgkin's disease, Stage 2A - s/p mantle radiation/adriamycin
(___)
Restrictive lung disease ___ mediastinal radiation
breast Ca (___) s/p bilat mastectomies/reconstruction
TIA ___ radiated vertebral artery)
cervical spine muscle atrophy (r/t radiation)
P.E. s/p central line removal
GERD
dysphagia - espophageal dilatation (r/t radiation)
hypothyroidism
recurrent bowel obstructions (x6)
adrenal insufficiency
shingles (___)
aspergillosis (___)
stagin laparotomy/splenectomy (___)
left thoracotomy (___)
Ex-lap/lysis of adhesions x 3
Social History:
___
Family History:
Mother deceased age ___, breast CA. Two sisters with breast ___.
Physical Exam:
PHYSICAL EXAM UPON ADMISSION:
VS - 98.9, 82, 100/69, 16, 100% RA
GEN: NAD, non-toxic
HEENT: No scleral icterus; dry mucous membranes
CV: RRR
PULM: no respiratory distress
ABD: soft, tender at epigastrium & RLQ, non-distended. Prior
surgical incisions well-healed.
EXT: warm, no edema
DISCHARGE PHYSICAL EXAM:
VS: 98.4 108/55 68 16 100%RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, non-distended, non-tender
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 09:35AM PLT COUNT-335
___ 09:35AM NEUTS-71.6* ___ MONOS-4.9* EOS-1.0
BASOS-0.7 IM ___ AbsNeut-9.60*# AbsLymp-2.86 AbsMono-0.65
AbsEos-0.13 AbsBaso-0.09*
___ 09:35AM WBC-13.4*# RBC-4.84 HGB-14.7 HCT-43.5 MCV-90
MCH-30.4 MCHC-33.8 RDW-13.8 RDWSD-45.0
___ 09:35AM ALBUMIN-4.9
___ 09:35AM LIPASE-43
___ 09:35AM ALT(SGPT)-31 AST(SGOT)-60* ALK PHOS-121* TOT
BILI-0.6
___ 09:35AM estGFR-Using this
___ 09:35AM GLUCOSE-133* UREA N-27* CREAT-1.1 SODIUM-139
POTASSIUM-5.6* CHLORIDE-96 TOTAL CO2-28 ANION GAP-21*
___ 09:54AM LACTATE-2.8*
___ 03:00PM URINE RBC-3* WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-NEG
___ 03:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:00PM URINE UHOLD-HOLD
___ 03:00PM URINE HOURS-RANDOM
Brief Hospital Course:
___ year old female patient with multiple past medical history,
who had multiple abdominal surgeries presented to the ED
complaining of abdominal pain, distention and obstipation. CT
abdomen and pelvis was consistent with Small bowel obstruction
with multiple distinct transition points separated in space
suggesting adhesions, inflammatory bowel disease or possibly
metastatic deposits. No CT evidence for bowel wall ischemia.
Then, she was admitted to the hospital for further non-operative
management of small bowel obstruction. Initially, she stayed
NPO, IV fluid and IV pain medication. then diet has been
advanced slowly to clears and subsequently to regular diet and
patient tolerated that well. She started to pass gas on day 2
and on day 3 she has had bowel movement and pain was almost
subside completely. Foley catheter insertion was planned for
better input output measurement but the patient refused it. she
remained hemodynamically stable during hospitalization with
vital signs and blood tests being monitored periodically. MRE
has been planned to be done before the patient go home, but
giving the busy schedule at MRI, patient decided to leave and
stated that she will do it before the next visit to the clinic
with Dr. ___.
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.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO BID
3. Duloxetine 30 mg PO BID
4. Furosemide 10 mg PO DAILY
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Pregabalin 100 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___
small bowel obstruction, you were treated conservatively, you
have been recovered well and ready to go home.
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.
Followup Instructions:
___
|
10375110-DS-16 | 10,375,110 | 29,082,143 | DS | 16 | 2172-02-19 00:00:00 | 2172-02-19 13:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaundice, edema
Major Surgical or Invasive Procedure:
EGD ___
Anorectal exam under anesthesia, drainage of bilateral IRAs,
placement of setons ___
History of Present Illness:
Mr. ___ is a ___ year old male with EtOH use disorder and newly
diagnosed cirrhosis complicated by portal HTN (varices,
splenomegaly, and small ascites) who initially presented to
___ with ___ weeks of edema from his bilateral feet to
his umbilicus, yellowing of his skin, dark urine x1 day, and
scant urine output for 3 days. He denies any fevers/chills, or
abdominal pain. He notes some increased epistaxis ___ the past
few weeks and nausea/vomiting. Denies any hematemesis, bloody
stool/black tarry stool. Denies chest pain, some dyspnea on
exertion. Denies any other substance use. Reports his last drink
was yesterday, although notably has a serum alcohol level ___ the
___. At ___, he was noted to have a Na of 111 at
1200h and he was started on 3% saline at 30 cc/hr for 500 cc. He
was also given a dose of Unasyn and transferred to ___.
.
___ the ___, VS were normal. Labs notable for leukocytosis,
coagulopathy, transaminitis, Cr 1.4, and hyponatremia to 117.
RUQUS notable for sequelae of portal HTN with no PVT. He was
seen by hepatology, who recommended albumin challenge,
diagnostic para, and admission to the MICU for monitoring.
Patient received 50g 25% albumin, 40 mg IV pantoprazole, and 10
mg IV vitamin K. Given positive stool guiac, given 2g CTX and
started on octreotide gtt. A bedside ultrasound did not show a
tappable pocket.
.
On arrival to the MICU, patient confirmed that he has
experienced one and half weeks of lower extremity swelling that
resolves partially with elevation. He notes three days of
reduced urine output. Jaundice noted today. He has been drinking
significant water daily due to thirst. Reports he had one drink
yesterday, generally ___ drinks daily. Denies recreational or IV
drug use. Reports he took a single Tylenol 2 weeks ago, denies
recent Tylenol use or overdose. Reports he lives at home with
his parents and has good family support structures. No change ___
bowel movements or blood ___ stool recently. Denies recent
fevers, chest pain, nausea, vomiting, new rash or lesion,
headaches, weakness/numbness/tingling.
.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
EtOH use disorder
Social History:
___
Family History:
No FH liver disease. Grandfather died of colon Ca, stomach CA on
mother's side.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Reviewed ___ metavision
GEN: Lying ___ bed, NAD
EYES: Scleral icterus, EOMI, PERRLA
HENNT: NCAT, MMM
CV: RRR, non significant murmurs/rubs/gallops
RESP: CTAB, no wheezes, rales, rhonchi
GI: Soft, NTND
Ext: 2+ ___ pitting edema ___ lower extremities
SKIN: Jaundice throughout
NEURO: AO x 3, mild asterixis, no focal deficits
PSYCH: Affect appropriate
DISCHARGE EXAM:
General: NAD
HEENT: Scleral icterus
Lung: Clear to auscultation bilaterally without wheezes,
rhonchi,
or rales
Card: Normal rate and rhythm. Normal S1/S2. Grade ___ systolic
murmur heard loudest at left sternal border.
Abd: Obese. Soft, nontender, nondistended.
Ext: Warm. Trace pitting edema.
Neuro: AAOx3. No asterixis. Motor and sensory function grossly
intact and symmetric throughout.
Skin: Gauze ___ place over upper gluteal cleft. ___ ___ place.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:45PM BLOOD WBC-20.8* RBC-2.25* Hgb-9.1* Hct-24.8*
MCV-110* MCH-40.4* MCHC-36.7 RDW-16.7* RDWSD-66.4* Plt ___
___ 04:45PM BLOOD Neuts-79.6* Lymphs-6.6* Monos-11.7
Eos-1.0 Baso-0.3 Im ___ AbsNeut-16.55* AbsLymp-1.37
AbsMono-2.44* AbsEos-0.20 AbsBaso-0.06
___ 04:45PM BLOOD ___ PTT-64.8* ___
___ 04:45PM BLOOD Glucose-116* UreaN-24* Creat-1.4* Na-117*
K-3.6 Cl-81* HCO3-22 AnGap-13
___ 04:45PM BLOOD ALT-65* AST-183* AlkPhos-134*
TotBili-19.6* DirBili-14.8* IndBili-4.8
___ 04:45PM BLOOD Albumin-2.3* Calcium-7.5* Phos-4.4 Mg-1.8
___ 04:45PM BLOOD %HbA1c-4.7 eAG-88
___ 04:45PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS* HAV
Ab-POS* IgM HAV-NEG
___ 11:30AM BLOOD C3-71* C4-7*
___ 04:45PM BLOOD HIV Ab-NEG
___ 04:45PM BLOOD ASA-NEG Ethanol-76* Acetmnp-NEG
Tricycl-NEG
___ 04:45PM BLOOD HCV Ab-NEG
___ 11:59PM BLOOD ___ Temp-36.8 pO2-52* pCO2-34*
pH-7.43 calTCO2-23 Base XS-0
___ 11:59PM BLOOD Glucose-156* Lactate-3.4* Creat-1.4*
Na-117* K-3.1* Cl-84*
___ 08:23PM BLOOD freeCa-1.06*
DISCHARGE LABS:
___ 06:42AM BLOOD WBC-6.4 RBC-2.63* Hgb-9.7* Hct-29.5*
MCV-112* MCH-36.9* MCHC-32.9 RDW-17.3* RDWSD-72.2* Plt ___
___ 06:42AM BLOOD ___ PTT-46.8* ___
___ 06:42AM BLOOD Glucose-135* UreaN-13 Creat-1.0 Na-140
K-4.1 Cl-103 HCO3-21* AnGap-16
___ 06:42AM BLOOD ALT-22 AST-38 AlkPhos-165* TotBili-6.2*
PERTINENT IMAGING:
==================
LIVER OR GALLBLADDER US (SINGLE ORGAN)Study Date of ___
IMPRESSION:
1. Hepatic vasculature is patent, although flow is reversed ___
the main,
right and left portal veins.
2. Sequela of portal hypertension including splenomegaly, small
volume
ascites, splenic varices and a patent umbilical vein are
present.
3. Echogenic liver consistent with steatosis. Other forms of
liver disease
and more advanced liver disease including steatohepatitis or
significant
hepatic fibrosis/cirrhosis cannot be excluded on this study. No
focal liver
lesions are identified. See recommendations below.
RECOMMENDATION(S): Radiological evidence of fatty liver does
not exclude
cirrhosis or significant liver fibrosis which could be further
evaluated by
___. This can be requested via the ___
(FibroScan) or the
Radiology Department with either MR ___ or US
___, ___
conjunction with a GI/Hepatology consultation" *
* ___ et al. The diagnosis and management of nonalcoholic
fatty liver
disease: Practice guidance from the ___ Association for the
Study of
Liver Diseases. Hepatology ___ 67(1):328-357
CHEST (PA & LAT)Study Date of ___
IMPRESSION:
No pulmonary edema.
EGD ___
Normal esophagus
No evidence of esophageal varices
No evidence of gastric varices
Portal hypertensive gastropathy
LIVER OR GALLBLADDER US (SINGLE ORGAN)Study Date of ___
IMPRESSION:
1. Cirrhotic liver morphology with no focal lesions identified.
2. Patent portal veins with reversed direction of flow.
3. Small perihepatic ascites.
4. Splenomegaly.
SIGMOIDOSCOPY ___
Stool ___ the colon
No bleeding source identified ___ this study
US EXTREMITY LIMITED SOFT TISSUE LEFTStudy Date of ___
IMPRESSION:
Subcutaneous and left gluteal muscle edema and heterogeneous
echotexture with no focal collection. This appearance is non
specific, however if symptoms persist, MRI would better
characterized this abnormality.
MR PELVIS W&W/O CONTRASTStudy Date of ___
IMPRESSION:
Extensive soft tissue edema, extending from the left buttock to
the perineum
surrounding the base of penis, urethra, and rectum, with
possible
communication and areas of low signal/susceptibility artifact
suspicious for
gas (which is best appreciated by CT). These findings are
concerning for
necrotizing infection including Fournier's gangrene.
RECOMMENDATION(S): Communication to the rectum may be better
assessed by
dedicated body MRI, perianal fistula protocol, on a nonurgent
basis.
US ABD LIMIT, SINGLE ORGANStudy Date of ___
IMPRESSION:
No ascites identified ___ the abdomen.
Radiology ReportMRI (ABDOMEN & PELVIS) W&W/O CONTRASTStudy
Date of ___ 8:05 ___
COMPARISON: Ultrasound from ___
FINDINGS:
Lower thorax: No pleural effusion. Bilateral gynecomastia.
Liver: Liver demonstrates slightly nodular contour suggestive of
cirrhosis.
No hepatic steatosis. No focal concerning lesion.
Biliary: No intra or extra biliary duct dilatation. The
gallbladder is
distended however no gallstones and no wall edema.
Pancreas: The pancreas demonstrates normal signal and bulk. No
main duct
dilatation. 4 mm cystic lesion at the tail of the pancreas
(series 12, image
24) likely represent a side branch IPMN.
Spleen: Mild splenomegaly measuring 14 cm.
Adrenal Glands: Unremarkable.
Kidneys: Unremarkable. No hydronephrosis.
Gastrointestinal Tract: No bowel obstruction.
Pelvis: The urinary bladder is unremarkable. No ascites.
Lymph Nodes: Prominent porta hepatic lymph nodes are noted. No
pelvic
lymphadenopathy.
Vasculature: No abdominal aortic aneurysm. Prominent
splenorenal shunt is
noted with extensive varices along the left abdominal wall.
Osseous and Soft Tissue Structures: No concerning bone lesions.
There is
extensive fat stranding along the abdominal wall however, no
drainable
collection.
IMPRESSION:
Cirrhotic liver with features suggestive of portal hypertension.
No focal concerning lesion.
No acute intra-abdominal findings.
Transthoracic Echocardiogram ___
___ 24:00
CONCLUSION:The left atrial volume index is mildly increased.
There is no evidence for an atrial septal defect by
2D/colorDoppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricularhypertrophy with a
normal cavity size. There is normal regional and global left
ventricular systolic function.Overall left ventricular systolic
function is normal.The visually estimated left ventricular
ejectionfraction is 65-70%.Left ventricular cardiac index is
high (>4.0 L/min/m2). There is no resting leftventricular
outflow tract gradient. No ventricular septal defect is seen.
Normal right ventricular cavity size withnormal free wall
motion. Tricuspid annular plane systolic excursion (TAPSE) is
normal. The aortic sinusdiameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter isnormal with a normal descending aorta diameter. There
is no evidence for an aortic arch coarctation. Theaortic valve
leaflets (?#) appear structurally normal. There is no aortic
valve stenosis. There is no aorticregurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. There is nomitral regurgitation. The pulmonic valve
leaflets are normal. There is trivial pulmonic valve stenosis.
Thetricuspid valve leaflets appear structurally normal. There is
mild [1+] tricuspid regurgitation. The pulmonaryartery systolic
pressure could not be estimated. There is a very small
pericardial effusion. A left pleuraleffusion is
present.IMPRESSION: Mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global biventricular
systolic function. HIgh cardiac output. Tiny pericardial
effusion.
RELEVANT MICROBIOLOGY:
======================
___ 7:00 pm BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 6:27 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
___ 12:23 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 1:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Time Taken Not Noted ___ Date/Time: ___ 3:48 pm
ABSCESS ___ ABCESS.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Final ___:
PREVOTELLA SPECIES. MODERATE GROWTH. BETA LACTAMASE
POSITIVE.
Brief Hospital Course:
Mr. ___ is a ___ man with alcohol use disorder who
initially presented to ___ with 2 weeks of edema,
yellowing of his skin, and scant urine output for 3 days. He was
found to have a sodium of 111 and was transferred to ___ ICU
for close monitoring. On arrival he was found to have alcoholic
hepatitis with ___ score of 181.1, and new cirrhosis
likely secondary to alcohol and/or NASH (he reported no prior
knowledge of cirrhosis) with a MELD 38. He had an EGD which
showed no varices and was treated with a course of prednisone.
His sodium was slowly corrected over several days. Hospital
course complicated by perirectal abscess s/p I&D x2 and he was
IV diuresed for volume management.
ACTIVE ISSUES
=============
# Alcoholic hepatitis
MDF 181.1 on arrival. After infectious workup negative and EGD
showed no evidence of varices and active bleed ruled out, he was
started on prednisone 40mg daily. Lille score day 7 was 0.062
indicating good response. He completed a 28d course. He did not
meet malnutrition requirements for a dobhoff and demonstrated
acceptable PO intake.
# Acute decompensated cirrhosis ___ ETOH and/or NASH
Meld 38 on arrival, right upper quadrant ultrasound showed
sequelae of portal hypertension indicating likely underlying
cirrhosis. No tappable pocket on admission. No evidence of
hepatic encephalopathy. EGD on showed no varices. He underwent
liver transplant workup and his case will be reviewed after
discharge.
#Perirectal horseshoe abscess s/p I&D
S/p I&D x2 with placement of packing and ___ drain by ACS.
Also had wound exploration by ___ afterwards ___ with removal
of packing, ___ left ___ place which will allow for continued
drainage of existing fistula tracts and prevent accumulation of
any abscess. Educated patient and family on wound care
instructions. Will follow up with CRS as outpatient.
#Volume overload
Had ___ pitting edema tracking up to sacrum iso fluids from
several OR trips and albumin for HRS. Underwent course of active
diuresis with lasix gtt at 10 which was complicated by ___.
Transitioned to PO diuretics Lasix/spironolactone to 60/150. Dry
weight 295 lbs.
# Hyponatremia
Sodium 111, 117 on arrival to ___. Suspect beer potomania.
Asymptomatic. He was placed on a 2L fluid restriction and slowly
corrected over several days.
# Anxiety
# Concern for suicidal ideation
Significant anxiety related to an ongoing legal issues over the
past ___ years. He reported that he was falsely accused of a
crime. He expressed a desire to be dead, "I wish I drank more."
Psychiatry was consulted and they determined he had passive SI
and that rather than depression he likely had anxiety related to
his medical and legal issues. They recommended seroquel 12.5mg
BID, which was deferred due to prolonged QT interval. His mood
improved throughout the hospital course.
# Acute on chronic anemia
On admission there was initial concern for GI bleed and was
started on IV ceftriaxone, octreotide gtt, and IV PPI. However,
showed no evidence of active bleed and EGD showed no varices so
these medications were discontinued. Had second incident likely
___ blood loss from oozing + serosanguinous drainage from
gluteal/perirectal wound, which self-improved. He had persistent
anemia but was hemodynamically stable throughout this admission.
Was not B12 deficient.
# Alcohol use disorder
Reproted ___ drinks daily. No evidence of withdrawal during
admission. Social work and nutrition consulted. Started on high
dose thiamine, folate, multivitamin, and vitamin C.
# Leukocytosis
No clear infectious source during admission with negative
workup.
# Diarrhea
Reported significant large volume watery diarrhea despite
holding lactulose for several days. C diff negative. Controlled
with imodium PRN. Given zinc repletion for confirmed zinc
deficiency.
___
Cr 1.4 on admission. UNa<20. Received albumin resuscitation with
improvement. Likely multifactorial with HRS/pre-renal
physiology, ATN, which improved throughout hospital course.
# Coagulopathy
INR 4.4 on arrival likely secondary to cirrhosis. Completed
vitamin K challenge x2 with improvement.
#Internal hemorrhoids
Bowel regimen PRN.
CORE MEASURES:
==============
# CODE: Presumed FULL
# CONTACT: Name of health care proxy: ___: mother
Phone number: ___
TRANSITIONAL ISSUES
===================
DISCHARGE Cr: 1.0
DISCHARGE Weight: 296 lbs
[ ] Patient's candidacy for liver transplant will be reviewed
[ ] Follow up with Dr. ___ rectal surgical wound.
[ ] Started on diuretics, dry weight 296 lbs. Please assess
volume status, titrate diuretics based on chemistry panel and
exam.
[ ] No known risk factors for gluteal abscess with perirectal
extension, recommend MR enterography vs colonoscopy as
outpatient to investigate potential underlying etiology.
[ ] Recommend patient to seek comprehensive dental exam and
cleaning on outpatient bases, extraction of tooth #32 and
consultation for evaluation of ___ molars :#1, #16,#17 by an
oral surgeon
[ ] Nutrition:
Estimated Nutrition Needs:
343___ kcal daily (33-38 kcal/kg)
146-187g protein daily ( 1.4-1.8 kg/kg)
- Ensure enlive 3x/day
- zinc sulfate, last day ___
- On ___: recheck serum zinc, copper, CRP
- Vitamin D thru ___
[]Wound Care:
-cleanse I&D sites with commercial wound cleaner while opening
sites to irrigate depth.
-Pat sites dry with 4X4 gauze.
-Apply 1 inch AMD packing strip, lightly into all three sites,
to
assist with drainage, provide antimicrobial treatment to tissue
and prevent premature closure.
-cover with Sofsorb
-Secure with underwear
-change daily and prn after bowel movement and shower to
irrigate
out wound with warm water.
*Patient should shower daily with AMD packing removed and allow
water to run over site. Pat dry.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 60 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Spironolactone 150 mg PO DAILY
6. Thiamine 500 mg PO DAILY
7. Vitamin D ___ UNIT PO 1X/WEEK (___)
8. Zinc Sulfate 220 mg PO DAILY Duration: 14 Days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACUTE DECOMPENSATED CIRRHOSIS
ALCOHOLIC HEPATITIS
PERIRECTAL ABSCESS
HYPONATREMIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was our pleasure to take care of you at ___. You came to
the hospital because of swelling ___ your legs.
WHAT HAPPENED ___ THE HOSPITAL?
- You were admitted to the ICU for very low sodium levels.
- Your sodium was monitored closely and you gradually improved.
- We treated your liver disease with prednisone, a steroid.
- You were found to have a gluteal abscess extending to your
rectum. The surgical service cleaned out the pus and left the
wound open to drain and heal from the inside out.
- We found that you had a lot of extra fluid ___ your body.
- We gave you medications called diuretics to help you urinate
this extra fluid.
- You had multiple bruises, which are common ___ liver disease.
- We gave you vitamin C and vitamin K to help with the bruising.
WHAT SHOULD YOU DO WHEN YOU LEAVE?
- Please take all your medications as prescribed.
- If your weight changes by at least 3 pounds, please contact
your doctor.
- We've made several appointments for you, please see below.
- It is important for you to contact your parole officer after
you leave the hospital .
- We recommend that you stop drinking completely. At this stage
of liver disease, even small amounts of alcohol can lead to
irreversible damage and death.
We wish you the best!
Sincerely,
Your care team at ___
Followup Instructions:
___
|
10375110-DS-18 | 10,375,110 | 27,466,541 | DS | 18 | 2172-08-11 00:00:00 | 2172-08-11 17:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
EGD ___
Sigmoidoscopy with biopsy ___
attach
Pertinent Results:
ADMISSION LABS:
==============
___ 12:18PM BLOOD WBC-5.5 RBC-1.71* Hgb-7.1* Hct-21.1*
MCV-123* MCH-41.5* MCHC-33.6 RDW-17.4* RDWSD-76.4* Plt Ct-71*
___ 12:18PM BLOOD Neuts-59.7 ___ Monos-16.0*
Eos-2.2 Baso-0.4 Im ___ AbsNeut-3.28 AbsLymp-1.18*
AbsMono-0.88* AbsEos-0.12 AbsBaso-0.02
___ 08:57AM BLOOD ___ PTT-48.6* ___
___ 08:57AM BLOOD Glucose-97 UreaN-51* Creat-2.1*# Na-126*
K-5.6* Cl-97 HCO3-15* AnGap-14
___ 08:57AM BLOOD ALT-25 AST-44* AlkPhos-108 TotBili-6.2*
___ 08:57AM BLOOD Albumin-3.5 Calcium-8.8 Phos-5.2* Mg-2.3
DISCHARGE LABS:
==============
___ 06:14AM BLOOD WBC-3.9* RBC-2.32* Hgb-8.8* Hct-26.5*
MCV-114* MCH-37.9* MCHC-33.2 RDW-19.6* RDWSD-83.0* Plt ___
___ 06:14AM BLOOD ___ PTT-53.1* ___
___ 06:14AM BLOOD Glucose-122* UreaN-16 Creat-1.1 Na-135
K-3.8 Cl-96 HCO3-25 AnGap-14
___ 06:14AM BLOOD ALT-43* AST-60* AlkPhos-137* TotBili-6.2*
___ 06:14AM BLOOD Albumin-3.9 Calcium-9.3 Phos-4.3 Mg-2.0
IMAGING:
=======
RUQUS ___:
IMPRESSION:
1. Patent hepatic vasculature with flow reversed in the main and
right portal
veins. The left portal vein is patent with hepatopetal flow.
2. Cirrhotic liver with additional features of portal
hypertension including
splenomegaly and patent umbilical vein. Trace ascites.
CXR ___:
IMPRESSION:
Top normal heart size, pulmonary vascular congestion and
probable mild
pulmonary edema.
Sigmoidoscopy ___:
Impressions: erythema and erosion in the rectum (biopsy). There
was solid stool throughout the sigmoid colon. Within the limits
of the prep, there was normal appearing mucosa within the
visualized section of the distal sigmoid colon.
EGD ___:
Impressions: 1 cord of grade I varices seen in the distal
esophagus (not bleeding). Food was found in the stomach,
procedure was aborted due to food contents in the stomach.
PATHOLOGY:
==========
GASTROINTESTINAL MUCOSAL BIOPSY ___:
1 A. Rectum, biopsy:Colonic mucosa with mild crypt disarray; no
active inflammation present.
MICROBIOLOGY:
=============
Blood culture ___ x 2, ___: No growth
Urine culture ___: No growth
Stool culture ___: No growth
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY:
====================
___ is a ___ year old male with a history of alcoholic
cirrhosis c/b ascites, portal hypertensive gastropathy, and
grade I esophageal varices, presenting with 2 days of
orthostatic dizziness/weakness and 10-lb weight gain
accompanied by BRBPR and hematemesis likely due to coagulopathy
and hemolytic anemia secondary to cirrhosis underwent
colonoscopy showing evidence of proctitis. Also had EGD showing
1 cord of grade I varices that were non-bleeding otherwise
normal. Bleeding resolved and afterward he underwent agressive
IV diuresis given volume overload likely in setting of
non-adherence to low sodium diet. He was discharged on torsemide
40mg daily with discharge weight 316 pounds.
TRANSiTIONAL ISSUES:
==================
#CODE: Full (presumed)
#CONTACT: ___ (mother, HCP) ___
[ ] NEW/CHANGED/STOPPED MEDICATIONS
- Stopped furosemide 60mg daily and started torsemide 40mg daily
- Started thiamine 100mg daily
- Started folic acid 1mg daily
- Started multivitamin 1mg daily
Discharge weight: 316 lbs on ___
Discharge diuretic: Torsemide 40mg daily
Discharge Cr: 1.1
[] Please check standing weight at next office visit with PCP.
He is on a higher diuretic dose now, but may need further
titration in order to keep even and not over-diurese
[] Please check CBC at next office visit. He will likely require
intermittent transfusions as an outpatient.
[] Continue to re-inforce low sodium diet with patient
ACUTE ISSUES:
=============
#BRBPR
#Coffee ground emesis
#Coagulopathy
#Hemolytic anemia
Patient initially presented with BRBPR and question of coffee
ground emesis several days prior to admission. He underwent EGD
on ___ showing 1 cord of grade I varices that were
non-bleeding in the distal esophagus, otherwise was normal
without obvious source of bleeding. He also underwent flex
sigmoidoscopy showing patchy erythema in the rectum that was
biopsied and did not reveal the source of bleed. He had some
occasional epistaxis that may have been the cause of
coffee-ground emesis. Most likely cause of bleeding is
coagulopathy from severe liver disease and non-immune hemolytic
anemia due to systemic disease. H/H remained stable throughout
hospitalization, requiring intermittent transfusions. He
received CTX for SBP ppx x 7 days (D1: ___. He
was discharged on his home PPI omeprazole 20mg daily.
#Volume overload - Patient presented with significant volume
overload approximately 50-60 pounds above his dry weight. This
was likely due to dietary indiscretion as he states he was
eating high sodium foods such as potato chips and deli meats. He
was successfully diuresed with IV lasix 60mg QID and later
switched to PO regimen of torsemide 40mg PO Qday. He was
initially transitioned to torsemide 80mg PO QD however was
overdiuresed on this, therefore torsemide was decreased to 40mg
daily on day of discharge. The patient would benefit from
additional counseling about low sodium diet.
# Decompensated EtOH cirrhosis (MELD-Na 32 on admission) -
History of alcoholic cirrhosis decompensated with ascites,
portal hypertensive gastropathy, and known grade 1 esophageal
varices. Patient has previously been denied for transplant
listing due to likelihood of alcohol relapse, most recent EtOH
use a few weeks ago. Esophageal varices- grade 1 varices in
distal esophagus that were non-bleeding per EGD ___ and was
continued propranolol. He was started on multivitamin, folic
acid, and thiamine for alcohol use.
#Depression/anxiety - Continued home paroxetine 20 mg PO daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 60 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. PARoxetine 20 mg PO DAILY
4. Propranolol 60 mg PO BID
5. Spironolactone 150 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multiple] 1 capsule(s) by mouth once a
day Disp #*30 Tablet Refills:*1
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*1
4. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
5. Omeprazole 20 mg PO DAILY
6. PARoxetine 20 mg PO DAILY
7. Propranolol 60 mg PO BID
8. Spironolactone 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
Alcohol cirrhosis complicated by ascites, portal hypertensive
gastropathy, varices, thrombyctopenia, coagulopathy and
hemolytic anemia
Non-autoimmune hemolytic anemia associated with cirrhosis
Gastrointestinal bleed
SECONDARY DIAGNOSIS
=====================
Acute kidney injury
Volume overload
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you noticed weight
gain, and you had thrown up blood.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You were given 4 units of blood during your hospital stay.
- You had an upper endoscopy (a small camera down your throat)
that showed small varices (dilated veins in your throat). They
couldn't see all of your stomach because there was still some
food in there, but there was no blood in your stomach or clear
source of bleeding.
- You had a sigmoidoscopy done that showed that some of the
lining of your rectum was red. They took a biopsy of this that
showed chronic inflammation.
- Your kidney number was up, but this improved with giving you
back some blood.
- Because of your chest pain, we did blood tests of your heart
that came back as normal.
- You were given medications to help you urinate out extra fluid
(furosemide, or Lasix).
- You were started on torsemide 40mg once a day prior to your
discharge
- You were given antibiotics to protect you from infection since
you have liver disease and you were bleeding.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Continue to remain abstinent from alcohol
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight increases by more
than 1 pound in 1 day or 3 pounds in 1 week.
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately. It is especially dangerous if you vomit
blood or have blood in your stool. This can be a
life-threatening emergency.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10375135-DS-3 | 10,375,135 | 26,617,318 | DS | 3 | 2150-01-12 00:00:00 | 2150-01-13 17:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history of CAD, HFrEF (LVEF 20%, ischemic
cardiomyopathy, s/p ICD placement), T2DM, HTN, dyslipidemia, and
obesity who initially presented to ___ iso acute onset
hemoptysis, now transferred to ___ for further evaluation and
management.
Patient says that he began coughing up blood in the afternoon
___, at times enough to cover the surface area of his palm. He
has otherwise been in his usual state of health as of late other
than some mild increased ___ swelling. No issues with increasing
SOB (does have some orthopnea at baseline, also splinting
related
to an abdominal hernia which is quite bothersome) or chest pain.
No fevers/chills. No lightheadedness/dizziness. No joint pains
or skin rash. Given these concerning symptoms, patient brought
himself to ___. Initial vitals: 97.6 116/88 85 16 100% on RA.
___ labs were notable for Hb 15.1, WBC count 7.0, Cr 1.4, and
INR
1.4. Patient underwent CTA chest, which showed no PE, bilateral
hilar/mediastinal adenopathy, and diffuse bilateral interstitial
infiltrates/R pleural effusion. Of note, patient underwent CT
A/P ___ iso abdominal pain, hilar LAD was incidentally noted
(in addition to GGOs and small R pleural effusion). Decision
was
made to transfer patient to ___ ED for further evaluation and
management.
Past Medical History:
- CAD (Stentx7, ___
- HFrEF (LVEF 15%, ischemic cardiomyopathy, s/p ICD placement)
- Ventricular arrhythmia: ICD, amiodarone
- Obesity
- HTN
- Dyslipidemia
- T2DM
- Abdominal hernia
Social History:
___
Family History:
None reported
Physical Exam:
On day patient left AMA:
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM.
NECK: JVP elevated to ear lobe at 10 degrees in bed, not clearly
visualized otherwise
HEART: RRR, S1/S2, no murmurs, gallops, or rubs.
LUNGS: CTAB, no wheezes, rales, rhonchi.
ABDOMEN: Obese abdomen, +BS throughout, nondistended, tender
abdominal hernia just right of midline, no rebound/guarding.
EXTREMITIES: WWP. 2+ pitting edema to the knees bilaterally.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: No excoriations or lesions, no rashes.
Pertinent Results:
Admission Labs:
WBC-6.7 Hgb-13.7 Hct-43.5 Plt ___
Glucose-147* UreaN-21* Creat-1.2 Na-142 K-3.8 Cl-98 HCO3-27
AnGap-17
CK-MB-<1 cTropnT-<0.01 proBNP-5967*
Calcium-9.3 Phos-2.6* Mg-2.5
ANCA-NEGATIVE B
___
CTA ___
FINDINGS: Pulmonary Arteries: Enhance well without filling
defect.
Lungs: Diffuse bilateral interstitial infiltrates.
Pleura: Small right pleural effusion.
Mediastinum: Coronary artery calcification. Superior and right
para
tracheal adenopathy, anterior mediastinal and subcarinal
adenopathy.
Right para tracheal lymph node 3 cm. Mild increase since prior
study. Bilateral hilar adenopathy. Pacemaker.
Bones: No acute abnormality.
IMPRESSION: No acute pulmonary embolism.
Bilateral hilar and mediastinal adenopathy. Diffuse bilateral
interstitial infiltrates and tiny right pleural effusion.
These findings have increased. Differential diagnosis includes
sarcoidosis.
CT A/P ___
IMPRESSION: There are diffuse areas of ground-glass attenuation
throughout the lung bases especially on the right with a small
pleural effusion. An inflammatory process seems likely. There
are
enlarged hilar lymph nodes bilaterally which may be reactive.
There is fluid about the gallbladder and the gallbladder appears
mildly contracted. Suggest continued follow-up. There is are
no
dilated intrahepatic biliary ducts.
There are several umbilical hernias containing fat with the
largest
noted superior to the umbilicus. There is skin thickening over
the
region and increased density to the subcutaneous fat. There is
no
bowel within the hernias.
TTE ___
IMPRESSION: Severely abnormal echo.
Severe left ventricular enlargement and hypokinesis with a
calculated LVEF of 20% and with evidence of prior RCA territory
myocardial infarction.
The right ventricular function seems to be preserved.
No hemodynamically significant valve disease.
No pulmonary hypertension, with PASP of 25 mmHg.
This echo suggests severe ischemic cardiomyopathy and propensity
for congestive heart failure which may be the cause of the
patient's
symptoms during this admission.
Compared to prior echo report from Dr. ___,
these
findings are not new, but the ejection fraction may be slightly
worse
than what was observed previously.
CTA CHEST ___
Findings: The vascular windows shows no evidence for any
definite
pulmonary artery filling defects. The abundant soft tissue
degrades
the images somewhat. There are small bilateral pleural
effusions
which are larger now than on ___. There are areas of
ground-glass opacity of both lung bases. These ground-glass
opacities
are worse now than on ___. There are some coronary
artery
calcifications present. There are two 13 mm lymph nodes
adjacent to
the left lateral aspect of the pulmonary artery. There is a 21
mm
lymph node adjacent to the right side of the trachea. The lymph
nodes are stable and unchanged from ___. There is a
left-sided pacemaker defibrillator with a single electrode
extending
into the apex region of the right ventricle.
Impressions: No definite evidence for pulmonary emboli.
Small bilateral pleural effusions which are larger now than on
___. Ground-glass opacities in both lung bases most likely
represents interstitial edema which is worse now than on ___.
STRESS TEST ___
IMPRESSION:
1. Normal stress test based on strict EKG criteria. Poor
exercise tolerance for age in recovery. The patient has had
some PVCs during the test. His O2 sat remained more than 90% on
room air despite significant fatigue and shortness of breath.
Brief Hospital Course:
Patient is a ___ with history of CAD, HFrEF (LVEF 20%, ischemic
cardiomyopathy, s/p ICD placement), T2DM, HTN, dyslipidemia, and
obesity presenting with hemoptysis of unclear etiology though
with possible connection to ongoing HF exacerbation. Patient had
no continued hemoptysis following transfer to ___. Patient
received workup for hemoptysis and active treatment of volume
overload attributed to known heart failure, with good response
to diuresis treatment. At the time of leaving against medical
advice, patient still had signs and symptoms attributable to
heart failure exacerbation.
ACUTE ISSUES:
==============
# Hemoptysis: Patient transferred from outside hospital with
acute onset hemoptysis in the setting of bilateral
lymphadenopathy and interstitial infiltrates on imaging. CTA on
___ showed low concern for PE. Patient reported no prior
history of autoimmune disorders. Workup was sent including ___,
Anti-GBM, ANCA, quant gold. Malignancy could not be ruled out
with imaging in the setting of pulmonary edema and volume
overload. Interventional pulmonology was consulted with concern
for nonmassive hemoptysis given signs of volume overload and
recommended chest CT ___ weeks following discharge for workup of
malignancy given significant smoking history. Patient had no
signs of infection during admission on labs. Patient was treated
with diuresis as per heart failure exacerbation.
# Heart Failure with reduced Ejection Fraction: (LVEF 15%,
ischemic cardiomyopathy)- Admission exam notable for bilateral
bilateral edema and elevated jugular venous pressure. BNP on
admission of 5967. Interstitial infiltrates on CT chest (___)
may represent pulmonary edema. TTE (___) showing LV/RV motion
abnormalities,
LV/RV dilation and moderate MR regurgitation. He was treated
with intravenous Lasix with brisk response to diuresis. Patient
electrolytes monitored. Home losartan/spironolactone held given
renal injury. Patient still with signs of volume overload at the
time of discharge against medical advice. Weight was 115.3 kg on
day of discharge.
# Acute kidney injury - Patient with an elevated of Cr to 1.3
with unclear baseline (~1). Presentation most concerning for
cardiorenal syndrome given signs of volume
overload on exam. Pulmonary renal syndrome could not be ruled
out in
setting of pulmonary interstital findings on CT. Urinalysis and
urine culture collected. Renal function followed with labs.
Renal injury treated with diuresis for heart failure
exacerbation.
# Coagulopathy: Patient with elevated ___ of 15.1/1.4 on
admission. Patient with no signs of liver injury on labs.
CHRONIC ISSUES:
===============
# Coronary artery disease: With stenting x7 in ___. Home
medications continued with change of home ASA to 81mg dosing.
# Ventricular arrhythmia- Per outpatient cardiologist (Dr.
___ patient with history of ventricular arrhythmia
now
controlled with amiodarone and ICD. Patient continued on home
meds and monitored on telemetry during inpatient stay.
# Hypertension: Continued home carvedilol. Home
losartan/spironolactone held given ___.
# Dyslipidemia: Continued home meds
# Type II Diabetes Mellitus: Held home oral meds in place of
insulin sliding scale with fingerstick blood glucoses.
**** Pt abruptly left AMA on ___, citing events at home about
which he declined to further elaborate. He declined to remain
for discharge counseling and review of discharge paperwork, but
was clearly able to state the risks of discharge ("I could
die"). He received a printed list of discharge medications as he
stood waiting for the elevator. Team was unable to reach the
patient on his cell phone on the day after discharge, and is
awaiting a return phone call from his PCP's office.
Medications on Admission:
Medications before you came in:
1. Aspirin 325 mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. GlyBURIDE 5 mg PO DAILY
5. Furosemide 80 mg PO QAM
6. Furosemide 40 mg PO QPM
7. Spironolactone 12.5 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Carvedilol 25 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Atorvastatin 80 mg PO QPM
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
Medications before you came in:
1. Aspirin 325 mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. GlyBURIDE 5 mg PO DAILY
5. Furosemide 80 mg PO QAM
6. Furosemide 40 mg PO QPM
7. Spironolactone 12.5 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Carvedilol 25 mg PO BID
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Atorvastatin 80 mg PO QPM
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Updated Medication List:
Changed:
1. Aspirin 81mg PO DAILY
5. Furosemide 80 mg PO QAM QPM
The Same:
2. Amiodarone 200 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Heart failure exacerbation and hemoptysis of unclear etiology
Discharge Condition:
Against medical advice, no acute distress with pending treatment
Discharge Instructions:
*) Follow up with PCP ___ 1 week.
*) Follow up with outpatient cardiologist within 1 week.
Followup Instructions:
___
|
10375224-DS-9 | 10,375,224 | 26,067,174 | DS | 9 | 2189-12-26 00:00:00 | 2189-12-26 11:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain, chest pain radiating to back
Major Surgical or Invasive Procedure:
___ Replacement of ascending aorta and hemiarch with
22mm Dacron graft.
History of Present Illness:
Mr. ___ is a ___ yo gentleman who underwent a EVAR for repair
of an abdominal aortic disection with Dr. ___ 1 month ago.
His post op course was uncomplicated. A few days ago he began to
not feel well and developed abdominal pain and chest pain
radiating to his back with shortness of breath. He went to an
outside hospital where he had an abdominal CT scan which was
concerning
for a hematoma at the site of previous repair. He presented to
___ for further evaluation. He underwent a CTA which showed an
aortic dissection extending from the aortic root to just above
the previous repair.
Past Medical History:
Hyperlipidemia
hiatal hernia
h/o multiple rib fractures from bike accident
s/p EVAR of abdominal dissection
s/p hernia repair
Social History:
___
Family History:
Grandmother - MI & heart failure.
Mother - DM
Aunt - cancer
Physical Exam:
Pulse:78 Resp:14 O2 sat:98%
B/P Right:117/68 Left:110/70
Height:68" Weight:
General:anxious, pain free, no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRL [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] NO Murmur [x] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] NO Edema [x] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right:2+ Left:2+
___ Right:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Discharge vital signs:
temp 98 HR 72, BP 116/71 resp 16 RA sats 93%
Weight: 74.6kg
Pertinent Results:
___ In comparison with the study of ___, there are
improved lung volumes. Again there is a high position of the
right hemidiaphragm with loops of colon below it. Opacification
at the left base is again consistent with pleural effusion and
volume loss in the left lower lobe.
No evidence of pulmonary vascular congestion.
CTA ___
VASCULATURE: Study is slightly limited as it is a single phase
study, with no noncontrast portion. Patient is status post
aorto bi-iliac stent graft of an infrarenal aortic dissection.
There is a crescent shaped hypodensity surrounding the aorta
extending from the proximal aspect of the stent graft to the
ascending aorta, consistent with intramural hematoma, with small
foci of questionable internal hyperdensity, concerning for
contrast extravasation and partial dissection (2:48).
Additionally, at the level of the stent graft, there are several
foci of hyperdensity within the excluded in aortic sec,
concerning for endoleak (2:162).
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus. The heart, pericardium, and great vessels
are within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: There is a small left and trace right
nonhemorrhagic pleural effusion and adjacent compressive
atelectasis at the lung bases. No pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of
parenchymal
opacification. The airways are patent to the level of the
segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN:
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 shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: 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: There is a small hiatal hernia. Small bowel
loops
demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. The
appendix is normal. There is no free intraperitoneal fluid or
free air.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGINS: The prostate and seminal vesicles are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
BONES AND SOFT TISSUES: There is no evidence of worrisome
osseous lesions or acute fracture. The abdominal and pelvic
wall is within normal limits.
IMPRESSION:
1. Study is limited in the evaluation of the aorta as it is a
single phase
study with no noncontrast scan. There is a crescent shaped
hypodensity
surrounding the aorta extending from the proximal aspect of the
infrarenal
stent graft to the ascending aorta, consistent with intramural
hematoma, with small foci of questionable internal hyperdensity,
concerning for contrast extravasation and partial dissection.
2. At the level of the stent graft, there are several foci of
hyperdensity
within the excluded in aortic sec, highly suspicious for
endoleak.
3. Small left and trace right nonhemorrhagic pleural effusions
and adjacent compressive atelectasis.
.
___ Preliminary report of Intra-op TEE
Conclusions
PREBYPASS
There is a small PFO with left-to-right shunt across the
interatrial septum is seen at rest. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aortic wall is thickened consistent with an intramural
hematoma distal to sinus of valsalva. The hematoma becomes quite
large as it extends through the descending thoracici aorta.
There is a large left pleuralm effusion . The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation.
POSTBYPASS
There is a tube graft positioned in the ascending aorta.
Biventricular systolic function remains normal. The study is
othereise unchanged from prebypass
.
___ 05:40AM BLOOD WBC-11.2* RBC-3.12* Hgb-9.3* Hct-29.2*
MCV-94 MCH-29.8 MCHC-31.8* RDW-14.7 RDWSD-49.5* Plt ___
___ 09:21PM BLOOD WBC-14.5* RBC-2.29*# Hgb-7.1*# Hct-21.7*
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.2 RDWSD-45.8 Plt ___
___ 10:50AM BLOOD WBC-27.3* RBC-3.38* Hgb-10.4* Hct-32.1*
MCV-95 MCH-30.8 MCHC-32.4 RDW-13.1 RDWSD-45.3 Plt ___
___ 10:20AM BLOOD ___ PTT-29.8 ___
___ 10:50AM BLOOD ___ PTT-31.6 ___
___ 09:32AM BLOOD ___ PTT-29.7 ___
___ 01:17AM BLOOD ___ PTT-31.3 ___
___ 05:40AM BLOOD Glucose-100 UreaN-7 Creat-0.4* Na-137
K-3.9 Cl-98 HCO3-28 AnGap-15
___ 03:08AM BLOOD Glucose-115* UreaN-11 Creat-0.4* Na-133
K-3.7 Cl-97 HCO3-25 AnGap-15
___ 01:17AM BLOOD ALT-9 AST-14 LD(LDH)-140 AlkPhos-85
Amylase-26 TotBili-0.9
___ 05:40AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.1
Brief Hospital Course:
Presented to outside hospital with abdominal and chest pain
radiating to back. Transferred for evaluation was noted for
type A dissection and taken emergently to the operating room.
He was transferred to the intensive care unit for post operative
management on neosynephrine, levophed and vasopressin. Over the
next few hours he was weaned off all pressors except levophed.
He was weaned from sedation awoke neurologically intact and was
extubated without complications. He remained in the intensive
care unit and was progressively weaned off the levophed on post
operative day one. He was started on betablocker and diuretic.
He was clinically stable and transitioned to the post operative
floor on post operative day two. Chest tubes and epicardial
wires were removed per protocol. He worked with physical
therapy on strength and mobility with recommendation for rehab.
CTA of abdomen and pelvis was obtained and showed no significant
change from previous. He will continue to follow with Vascular
Surgery with regular scans as directed.
The patient was discharged to ___ On The ___ POD 6.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Furosemide 20 mg PO DAILY Duration: 3 Days
4. Metoprolol Tartrate 25 mg PO TID
5. Polyethylene Glycol 17 g PO DAILY
hold for loose stool
6. Potassium Chloride 20 mEq PO DAILY Duration: 3 Days
7. Ranitidine 150 mg PO BID
8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Type A aortic dissection s/p Replacement of ascending aorta and
hemiarch with 22mm Dacron graft.
Secondary diagnosis
Hiatal hernia
h/o multiple rib fractures from bike accident
s/p EVAR of abdominal dissection
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating- deconditioned
Incisional pain managed with Tramadol
Incisions:
Sternal & axillary - healing well, no erythema or drainage
Edema- none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10375735-DS-17 | 10,375,735 | 23,378,246 | DS | 17 | 2162-01-29 00:00:00 | 2162-01-29 20:45:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
speech episodes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ RHD F w/ PMH HTN, HLD, DM c/b neuropathy, CKD, bipolar
She reports headache, tingling, slurred speech since yesterday.
Some of her symptoms started yesterday. She noticed that
starting
around ___ she has intermittently been having speech that
has been slurred and stuttering. These symptoms occur at the
same
time. It started around 4pm yesterday. It has been intermittent
since then and she has had many episodes, she is not sure the
exact frequency but more than >5 times. She notices it for a few
seconds at a time. She doesn't stutter normally. She has a hard
time getting the first syllable of the word out at times. She is
not sure if she is having trouble finding the word she wants to
say. She feels like her speech is significantly slurred. Her
family member at bedside did not feel that her speech was
significantly slurred. No similar symptoms in the past. She also
notes that yesterday she had a Headachethat resolved and is
coming back now, she thinks it is because she has not eaten yet,
as she gets headaches if she doesn't eat. She also Reports some
tingling in the L chest. The tingling has occurred a few times.
She feels dizzy when she sits up too fast. The dizziness is
characterized by lightheadedness and spinning. It also occurs
when she stands. This has been going on for months at least. She
states she has been under some stress lately related to her
mother. While in the ED she had a few more of these episodes of
the speech issue. She was initially enrolled in the TIA pathway
by the ED, but then un-enrolled by the ED after she had more of
these episodes.
ROS:
On neurological review of systems, the patient denies confusion,
difficulties producing or comprehending speech, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the patient denies recent fever,
chills, night sweats, or recent weight changes. Denies cough,
shortness of breath, chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. Denies dysuria, or recent change in bowel or bladder
habits. Denies arthralgias, myalgias, or rash.
Past Medical History:
HTN
HLD
DM c/b neuropathy
bilateral carpal tunnel
Lithium induced DI
CKD
hyperparathyroidism
gout
Obseity
Bipolar
endometrial cancer stage ___ s/p TAH BSO ___
Social History:
___
Family History:
Mother ___
father ___
Physical Exam:
INITIAL EXAM
Vitals: T99.0 HR76 BP140/79 RR18 Spo299% 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: 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 ___. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Skips ___ in MOYB but otherwise ok.
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: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: R NLFF, slight facial weakness. patient states not clearly
present in the past
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 5 5 5 ___ 5 5 5 5
R 5 5 5 5 5 ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, temperature,
vibrationthroughout. No extinction to DSS. ___ absent.
-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. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing
=======
DISCHARGE EXAM
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. Has two bony non-mobile lesions in frontal/forehead
region, these are non-tender
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 x3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent, at times with mild heistation,
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. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Subtle right NLFF, activation is 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 5 5 5 ___ 5 5 5 5
R 5 5 5 5 5 ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, temperature,
vibrationthroughout. No extinction to DSS. Romberg absent.
-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. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Pertinent Results:
___ 07:50AM BLOOD WBC-5.4 RBC-4.33 Hgb-12.9 Hct-41.0 MCV-95
MCH-29.8 MCHC-31.5* RDW-13.5 RDWSD-46.7* Plt ___
___ 07:50AM BLOOD Glucose-122* UreaN-14 Creat-1.1 Na-146
K-4.5 Cl-112* HCO3-18* AnGap-16
___ 07:50AM BLOOD ALT-29 AST-26 LD(LDH)-206 CK(CPK)-228*
AlkPhos-109* TotBili-0.2
___ 07:50AM BLOOD Triglyc-202* HDL-46 CHOL/HD-3.2
LDLcalc-63
====================
IMAGING STUDIES
MRI HEAD W/O CONTRAST
No acute infarct or hemorrhage
TTE
: Normal study. Normal biventricular cavity sizes and
regional/global biventricular
systolic function. No valvular pathology or pathologic flow
identified. Normal estimated
pulmonary artery systolic pressure. No structural cardiac source
of embolism identified.
CTA Head/neck
IMPRESSION:
1. No acute intracranial abnormality.
2. Left-sided persistent trigeminal artery. Patent circle of
___.
3. Patent cervical arteries.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White
Paper of the ACR Incidental Findings Committee". J ___
___ ___
12:143-150.
CXR - No acute process
Brief Hospital Course:
BRIEF SUMMARY: Ms. ___ is a ___ year old right handed woman
with a past medical history of hypertension, hyperlipidemia,
diabetes complicated by neuropathy, chronic kidney disease, and
bipolar disease who presented to ED with 1 day history of
intermittent episodes of slurred/stuttering speech since ___
per her report.
Overall, etiology for her symptoms were most likely due to TIA,
given the description of the episode, timing (she had been off
aspirin within the last month), and her risk factors. Stress
reaction was another possibility, as she mentioned being under a
lot of emotional stress recently. Later it was discovered that
the patient has a history of seizures, that her CK was elevated
in ED, and that she has not been taking her antiepileptic drugs.
Therefore it is possible that she had brief seizures/post-ictal
state.
=====================
HOSPITAL COURSE:
#Intermittent episodes of slurred/stuttering speech- On initial
presentation to ER, her neurologic exam was essentially normal,
apart from mild right nasolabial fold flattening (which is also
present in her driving license picture). However, while in the
ED, she developed another speech episode. Given her risk factors
(HTN, HLD, DM), she underwent TIA workup. Workup was notable
for CT angiography showing no acute intracranial abnormality,
normal TTE, and MRI revealing no evidence of stroke. Notably,
patient had been taken off of aspirin about 1 month ago (___).
She was placed on aspirin for secondary prevention. Etiology for
the TIA was felt to be due to small vessel disease.
Moving forward, she was placed on a Zio patch to evaluate for
arrhythmia. She will need a referral to see a neurologist within
the Atrius system. Her PCP was contacted to facilitate this and
updated about hospitalization.
=========================
TRANSITIONAL ISSUES:
- Follow up results of the zio patch
- Please continue aspirin 81mg daily for secondary prevention
- Otherwise continue home medications
- Follow up with PCP ___ ___ weeks
==========================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =63 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
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 in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. Colchicine 0.6 mg PO BID:PRN gout flare
3. Allopurinol ___ mg PO DAILY
4. CloNIDine 0.1 mg PO BID
5. CarBAMazepine 200 mg PO BID
6. Pravastatin 20 mg PO QPM
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Atenolol 40 mg PO DAILY
9. amLODIPine 10 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Allopurinol ___ mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. Atenolol 40 mg PO DAILY
6. CarBAMazepine 200 mg PO BID
7. CloNIDine 0.1 mg PO BID
8. Colchicine 0.6 mg PO BID:PRN gout flare
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Pravastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Transient Ischemic Attack (TIA)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted due to episodes concerning for slurred speech
and right facial asymmetry. On admission, your minimal facial
asymmetry was felt to be normal as you have had this on prior
review of your license picture. Your speech symptoms were felt
to be due to Transient ischemic attack (TIA).
This is a condition where a blood vessel providing oxygen and
nutrients to the brain is transiently 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.
TIA/Stroke can have many different causes, so we assessed you
for medical conditions that might raise your risk of having
stroke. In order to prevent future strokes, we plan to modify
those risk factors. Your risk factors are:
high blood pressure
high cholesterol
We are changing your medications as follows:
> we will start on you aspirin, anti-platelet agent to reduce
the risks of future strokes/TIA
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
It was a pleasure taking care of you.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
10375816-DS-12 | 10,375,816 | 24,026,359 | DS | 12 | 2174-12-07 00:00:00 | 2174-12-09 08:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache, opiate withdrawal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ y/o woman with hx of IVDU, HBV(denies)/HCV, liver
disease, MI/CM. She has been clean off of heroin for the past
___ years (hx detox with methadone), and relapsed 16 days ago
using 1gm/day IV heroin. She has been off her home meds
(topamax, klonopin, baclofen, bentyl, doxapin, neurontin) since
relapse. She tried to stop cold ___ 2 days ago and began
having withdrawal symptoms, then self-treated her withdrawal
with 300mg of street heroin. Her last heroin use at 4 am on
___. Given withdrawal symptoms and new-onset severe
headache, patient walked herself to ED from miles away.
.
Patient reports her heart "racing," left-sided chest pain,
nausea and intermittent epigastric abdominal pain, fatigue,
malaise, myalgias, and diaphoresis. Denies diarrhea, but has
rhinorrhea and runny eyes. She also has a headache that started
around 2 ___ yesterday and has been gradually worsening, it is
diffuse but began in back of head, now radiating throughout head
and down into neck, throbbing type of pain and associated with
blurred vision in both eyes and (+) photophobia.
.
Also states her arms are sore at the site of injections.
Reports a brown mark about the size of a tennis ball width that
she reports appeared 2 weeks ago and hurts when she touches it.
Also states bilaterally leg pain and that she can't stop moving
her legs around. Reports increased stressors of family life
that led to her relapse after 10 clean years. Feels that all she
does is be a ___ to her grandchildren, and that her daughter
is mean to her and does not appreciate her. She is regretful
about her recent relapse, and hopes to never to drugs again
.
In the ED, initial VS: 99.0 120 139/89 18 96% RA Pain 10.
Initial labs notable for K of 3.0, positive urine opiates, She
received Vanc and Zosyn as well as KCL 40meq PO and Omeprazole
20mg PO. She had a CXR and CT scan in ED, as well as LP with OP
of 31. Reports decreased headache following LP and vision less
blurry in right eye following LP.
.
Currently, she is alert and tearful, reports that she "feels
awful" and that she is withdrawing. Feels pain all over
Past Medical History:
-Cardiomyopathy ___ drug use in the ___, specifics are
unclear though per patient she was told her heart had recovered.
- H/o MI ___ drug use in late ___
-Chronic hepatitis C
-Chronic hepatitis B
-Hx spinal fracture
-Angina
-Anxiety
-Fibromyalgia
-Cholecystectomy (___)
Social History:
___
Family History:
Family history obtained not contributory to current presentation
Physical Exam:
Admission exam
VS - 99.3 ___ 20 100%/RA
GENERAL - Tearful woman in NAD, closing eyes during interview,
moving legs around
HEENT - Pupils dilated at 5 mm bilaterally, sclerae anicteric,
MMM, OP clear.
NECK - Supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, ___ murmur best heard in left upper sternal border
ABDOMEN - Soft, tender diffusely with voluntary guarding, no
masses or HSM, no rebound or involuntary guarding, 5 cm brown
patch on skin on left epigastrium
EXTREMITIES - Track marks on arms, DP and ___ pulses intact
SKIN - No rashes or lesions
LYMPH - No cervical LAD
NEURO - Awake, CNs II-XII grossly intact
Discharge exam
VS - 98.5 105/70 82 20 100%/RA
GENERAL - Tearful woman in NAD, closing eyes during interview,
moving legs around
HEENT - Pupils dilated at 5 mm bilaterally, sclerae anicteric,
MMM, OP clear.
NECK - Supple, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no mrg
ABDOMEN - Soft, tender diffusely with voluntary guarding, no
masses or HSM, no rebound or involuntary guarding, 5 cm brown
patch on skin on left epigastrium
EXTREMITIES - Track marks on arms, DP and ___ pulses intact
SKIN - No rashes or lesions
LYMPH - No cervical LAD
NEURO - Awake, CNs II-XII grossly intact
Pertinent Results:
Admission labs
___ 08:55AM BLOOD WBC-4.7 RBC-4.12* Hgb-12.9 Hct-38.6
MCV-94 MCH-31.3 MCHC-33.3 RDW-12.3 Plt ___
___ 08:55AM BLOOD Neuts-77.0* Lymphs-17.9* Monos-4.1
Eos-0.6 Baso-0.5
___ 08:55AM BLOOD Glucose-124* UreaN-17 Creat-0.9 Na-135
K-3.0* Cl-102 HCO3-26 AnGap-10
___ 08:55AM BLOOD ALT-52* AST-39 AlkPhos-87 TotBili-0.4
___ 08:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 09:10AM BLOOD Lactate-1.3
Discharge labs
___ 06:57AM BLOOD WBC-2.0*# RBC-3.98* Hgb-12.4 Hct-37.4
MCV-94 MCH-31.1 MCHC-33.0 RDW-12.5 Plt ___
___ 06:57AM BLOOD Neuts-43.4* Lymphs-45.5* Monos-7.1
Eos-3.5 Baso-0.5
___ 06:57AM BLOOD Glucose-92 UreaN-9 Creat-0.7 Na-139 K-4.2
Cl-109* HCO3-26 AnGap-8
___ 06:57AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.0
Studies
CXR: The cardiac silhouette size is normal. The mediastinal and
hilar contours are normal. Lungs are clear and the pulmonary
vascularity is normal. No pleural effusion or pneumothorax is
present. There are no acute osseous abnormalities. IMPRESSION:
Normal chest radiograph.
Head CT w/o contrast: There is no evidence of hemorrhage, edema,
mass,
mass effect, or infarction. Ventricles and sulci are normal in
size and
configuration. No fracture is identified. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION: Normal study.
CSF sample
___ 11:00
Report Comment:
TUBE 3
ANALYSIS
WBC, CSF 1 #/uL
CLEAR AND COLORLESS
RBC, CSF 1* 0 - 0 #/uL
Polys 0 %
33 CELL DIFFERENTIAL
Lymphs 88 %
Monocytes 12 %
Total Protein, CSF 30 15 - 45 mg/dL
Glucose, CSF 67 mg/dL
Micro:
HIV Antibody (-); Viral Load (-)
Blood Cultures and CSF cultures (-)
Brief Hospital Course:
ASSESSMENT & PLAN: Ms ___ is a ___ y/o woman with hx of IVDU,
HBV(denies)/HCV, MI/CM, with recent heroin relapse, p/w symptoms
of opiate withdrawal, last use of heroin 4am day of admission
.
#) Opiate withdrawal - Patient has several symptoms that are
attributable to opioid withdrawal syndrome - tachycardia in ED;
nausea and non-specific belly discomfort; headache with
photophobia; fatigue; malaise; myalgias; diaphoresis;
rhinorrhea; sensation of leg restlessness. She was controlled
initially with valium 5mg PO q6, then clonidine 0.1mg q4h PRN
___ scale > 10. Nausea controlled with ondansetron, diarrhea
(minimal) controlled with loperamide. She was agitated and
wanted to leave AMA to use heroin, but agreed to go to detox
instead. HIV serology and viral load negative.
.
#) ? new murmur - ED thought they heard a new murmur, and given
h/o IVDU she was given vanc/zosyn in the ED. However upon
admission to the floor, there was a barely discernable murmur,
more likely related to respirations than a new murmur. She was
afebrile, blood cultures to date are negative, and there no
physical exam findings of endocarditis ___ spots, ___
lesions, ___ nodes, splinter hemorrhage, etc...) Antibiotics
were discontinued. Her blood cultures are negative
.
#) New headache - Likely from opiate withdrawal. Received a CT
Head in ED, which was normal. Neurology consulted and evaluated
her, said normal neuro exam and no focal neurologic deficits, so
no need for further head imaging such as MRI/MRV because
suspicion for mass lesion or hemorrhage is low. Given her
headache, an LP was performed which revealed increased OP, but
per neuro note, positioning was incorrect to evaluate the OP.
LP results did not show elevated protein or WBCs, or decreased
glucose, and she had no fever or meningismus, so suspicion for
meningitis is low.
.
#) Hx hepatitis - Stable. Patient currently not on treatment
and asymptomatic. AST slightly elevated at 52.
- f/u with PCP regarding further treatment
.
#) Fibromyalgia - home meds briefly held during detox
.
#) Psych - Patient reports psychosocial stressors at home
leading to relapse.
.
================================
Transitional issues
# Continued management of heroin abuse
Medications on Admission:
Had been off for 1 week
- Topamax 300mg PO BID (mood control)
- Klonapin 1mg TID PRN anxiety
- Baclofen 10mg TID
- Bentyl 25mg PO daily
- Doxapine 50mg PO qHS prn insomnia
- Neurontin 600mg TID (for fibromyalgia)
Discharge Medications:
1. Topamax 100 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*0*
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
3. baclofen 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
4. Bentyl 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. doxepin 50 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia.
Disp:*30 Capsule(s)* Refills:*0*
6. Neurontin 600 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Heroin withdrawal
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 heroin withdrawal. You were treated for
this with medications, and you will go to a ___ facility for
further treatment.
No changes were made to your medications
Followup Instructions:
___
|
10375816-DS-16 | 10,375,816 | 22,804,875 | DS | 16 | 2180-11-30 00:00:00 | 2180-11-30 16:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
haldol, prolixin
Attending: ___.
Chief Complaint:
Right chest wall redness and pain
Major Surgical or Invasive Procedure:
___: debridement of manubrium and sternum as well as left pec
advancement flap and JP drain placement.
History of Present Illness:
___ year old female with
schizoaffective disorder and posttraumatic stress disorder
complicated by suicidal ideation, substance abuse including
IVDU,
chronic HCV and HBV, fibromyalgia, hypothyroidism, and recent
admission for mediastinal abscess and MSSA sepsis who presents
with left chest wall pain and erythema with imaging concerning
for possible sternoclavicular joint and first costochondral
junction osteomyelitis.
Patient had two recent admissions, the first for MSSA
bacteremia,
left sternoclavicular septic arthritis, and neck abscess with
superior mediastinal extension in ___ and the second for
suicidal ideation in ___. During her admission for
mediastinal abscess and MSSA sepsis, patient underwent US guided
drainage from left neck collection and surgical debridement and
removal of left sternoclavicular joint with I&D of left neck
abscess on ___. Cultures of the sternoclavicular tissue were
significant for coagulase + staph and blood cultures significant
for MSSA, for which she was discharged on IV cefazolin for 6
weeks.
During her more recent admission, it was noted that her surgical
wound was draining, and thoracic surgery was consulted. At that
time, they felt as though the wound was healing appropriately.
Patient reports that she had been doing well until about a week
ago, when she noted chest pressure and worsening of her chronic
cervical neck pain. On the evening prior to presentation, the
patient noted severe throbbing pain that in her chest associated
with purulent drainage from her left sternoclavicular surgical
wound. She notes that the wound had been draining since surgery,
but more recently started draining "yellow pus." Given the
throbbing pain was unresponsive to her standard oxycodone, she
sought medical attention.
She reports subjective fevers since yesterday however never took
her temperature. She also endorses ___ throbbing pain in the
upper chest, bilateral shoulders, and cervical spine as well as
some mild nausea without vomiting. She denies diarrhea,
constipation, shortness of breath, dysphagia, and changes in her
voices.
In the ED, initial vitals: T-98 HR-96 BP-176/90 RR-20 SpO2-100%
RA
- Exam notable for: Scant yellow drainage on left chest wall
dressing
- Labs notable for: WBC 7.8, HCO3 17, Trop <0.01, lactate 1.9
- Imaging notable for: Interval erosive changes and adjacent
sclerosis at the posteriolateral aspect of the manubrium on the
left at the level of the sternoclavicular joint, as well as
abutting the first costochondral junction, concerning for
osteomyelitis. Increase amount of stranding in the anterior
mediastinum. Left clavicular head with interval development of
adjacent periosteal reaction
- Pt given:
Oxycodone 5mg x1
Oxycodone 10mg x2
Famotidine IV
Acetaminophen 1000mg PO
NS 1000mL
Vancomycin 1g IV
Ciprofloxacin 400mg IV
- Vitals prior to transfer: T-100.5 HR-93 RR-16 BP-102/56
SpO2-99%RA
On the floor, patient confirms the above history. She is
complaining of ___ throbbing pain in her upper chest,
bilateral
shoulders, and cervical spine that was unresponsive to the
oxycodone she received in the ED. She was intermittently tearful
during the interview.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
Hypothyroidism
Mediastinal abscess
Hypertension
GERD
Fibromyalgia
?IBS
Schizoaffective disorder
Posttraumatic Stress Disorder
Substance abuse
Chronic HCV
Chronic HBV
Social History:
___
Family History:
Twin brother- schizoaffective disorder
Mother- unspecified mental illness
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 99.0 123 / 84 89 16 98 Ra
General: Well-developed, well-nourished female laying in bed.
Intermittently tearful. Appears to be in moderate distress.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Cervical spine and bilateral trapezius moderately tender to
palpation without erythema. No step offs noted.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Left clavicular head surgical wound with bandage in
place, purulent drainage noted without surrounding erythema.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: As noted above. No other lesions or rashes noted.
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities, grossly normal sensation. AAOx3
DISCHARGE PHYSICAL EXAM:
VITALS: 97.6 PO 114 / 80 88 18 100 Ra
General: walking around room, awake and alert
HEENT: no conjunctival pallor, anicteric sclera, MMM
NECK: surgical scar across sternum and clavicles with erythema
around wound with JP drain draining serosanginous fluid
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, expiratory wheezes at right lower lung
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: no lower extremity edema, warm and well perfused
SKIN: as above
NEURO: A/O x3, grossly intact
LINES: PICC in RUE, 1 JP drain in place
Pertinent Results:
ADMISSION LABS:
___ 10:00AM BLOOD WBC-7.8 RBC-3.97 Hgb-11.6 Hct-36.1 MCV-91
MCH-29.2 MCHC-32.1 RDW-13.2 RDWSD-43.4 Plt ___
___ 10:00AM BLOOD Neuts-62.4 ___ Monos-5.1 Eos-0.5*
Baso-0.3 Im ___ AbsNeut-4.89# AbsLymp-2.45 AbsMono-0.40
AbsEos-0.04 AbsBaso-0.02
___ 10:00AM BLOOD Plt ___
___ 06:55AM BLOOD ___ PTT-27.0 ___
___ 10:00AM BLOOD Glucose-97 UreaN-11 Creat-0.9 Na-141
K-4.1 Cl-106 HCO3-17* AnGap-18
___ 06:55AM BLOOD ALT-34 AST-31 AlkPhos-141* TotBili-0.4
___ 06:55AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0
___ 06:55AM BLOOD CRP-19.1*
___ 07:14AM BLOOD Vanco-39.7*
___ 11:00AM BLOOD ASA-NEG Barbitr-NEG Tricycl-NEG
___ 06:55AM BLOOD HBV VL-NOT DETECT HCV VL-6.6*
___ 12:31AM BLOOD ___ pO2-222* pCO2-47* pH-7.37
calTCO2-28 Base XS-1 Comment-GREEN TOP
___ 10:54AM BLOOD Lactate-1.9
PERTINENT LABS:
___ 06:55AM BLOOD HBV VL-NOT DETECT HCV VL-6.6*
___ 05:50AM BLOOD Vanco-20.0
___ 12:07PM BLOOD Vanco-19.1
___ 06:45AM BLOOD Vanco-19.9
___ 03:20PM BLOOD Vanco-26.7*
___ 07:22AM BLOOD Vanco-31.6*
___ 03:10PM BLOOD Vanco-25.5*
___ 12:47PM BLOOD Vanco-21.9*
___ 07:14AM BLOOD Vanco-39.7*
DISCHARGE LABS:
___ 05:00AM BLOOD WBC-4.6 RBC-3.06* Hgb-8.8* Hct-26.9*
MCV-88 MCH-28.8 MCHC-32.7 RDW-13.2 RDWSD-42.5 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-103* UreaN-21* Creat-0.7 Na-139
K-4.3 Cl-104 HCO3-24 AnGap-11
___ 05:00AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8
___ 05:50AM BLOOD Vanco-20.0
IMAGING:
___: CT CHEST with contrast
1. Interval erosive changes and adjacent sclerosis at the
posteriolateral
aspect of the manubrium on the left at the level of the
sternoclavicular
joint, as well as abutting the first costochondral junction.
These findings
are new since prior postoperative study on ___, and
concerning
for osteomyelitis.
2. Increased amount of stranding seen in the anterior
mediastinum is worse
compared to prior study, however there is no evidence of
discrete fluid
collection.
3. Left clavicular head demonstrates evidence of postsurgical
changes
following prior resection, as well as interval development of
adjacent
periosteal reaction. While these findings ___ be reactive,
infection cannot
be excluded.
___: CT CHEST with contrast parotids
1. No evidence of discrete, drainable fluid collection within
the soft tissues
of the neck.
2. Please see dedicated report from CT chest performed on the
same day for
findings in the upper mediastinum.
___: MRI C spine
1. The vertebral bodies are normal in number and
interrelationship. No
abnormal bone marrow signal intensity or epidural/paraspinal
collections to
suggest infection/osteomyelitis of the cervical spine.
2. There is mild multilevel degenerative changes of the cervical
spine most
marked at the C2-3 and C3-4 levels as described above.
3. Please note that the saturation band obscures the anterior
neck and chest
and please refer to reports of dedicated CT soft tissue neck of
___ and chest MR done ___ at 16:45.
___: MRI Chest wall with and without contrast
1. Findings are compatible with osteomyelitis of the left
proximal clavicle
and manubrium with soft tissue phlegmon or early abscess
involving the left
sternoclavicular joint.
2. Soft tissue thickening posterior to the manubrium
demonstrating markedly
low T2 signal and no enhancement ___ represent fibrosis in the
context of
prior mediastinal abscess and surgical intervention.
___: CTA NECK with and without contrast
1. Unremarkable cervical carotid and vertebral arteries,
without evidence of
stenosis or occlusion. The left vertebral artery is dominant a
normal
anatomic variant.
2. Findings compatible with known history of prior left
sternoclavicular
joint debridement, including cortical irregularity of the medial
left clavicle
and overlying soft tissue defect.
3. On the current study, there is no evidence of a rim
enhancing collection
in the region of the left sternoclavicular joint.
4. Incidental note of a prominent main pulmonary artery, which
can be seen
with pulmonary arterial hypertension.
MICRO:
___: Blood cx negative x 2
___: urine cx YEAST. >100,000 CFU/mL.
___: Path The specimen is received fresh in a container
labeled with the
patient's name, the medical record number, and is additionally
labeled "sinus tract." The specimen
consists of a 6.9 cm x 1.8 cm elliptical piece of tan skin
excised to a depth of 0.3 cm. The specimen
is remarkable for a full-thickness defect measuring 2.2 cm x 0.6
cm, extending within 0.4 cm of the
specimen margin. The specimen is serially sectioned, and
represented in cassette 1A.
___ 11:04 pm TISSUE LEFT STERNAL CLAVICULAR JOINT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
__________________________________________________________
___ 9:50 am BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:15 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:15 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:43 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:47 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:53 am BLOOD CULTURE Source: Line-picc.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:02 pm BLOOD CULTURE Source: Line-picc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:03 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:15 pm BLOOD CULTURE SET#2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
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 ___ @ 0635 ON ___ -
___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
__________________________________________________________
___ 6:32 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:47 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:05 pm BLOOD CULTURE Source: Line-L PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BREVUNDIMONAS VESICULARIS. FINAL SENSITIVITIES.
MEROPENEM MIC OF <=1 MCG/ML. Cefepime MIC OF >= 16
MCG/ML.
AMIKACIN MIC OF >=32 MCG/ML. test result performed by
Microscan.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BREVUNDIMONAS VESICULARIS
|
AMIKACIN-------------- R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>32 R
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN--------- <=0.5 S
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- <=1 S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=2 S
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___, ___, ON
___ AT
17:50 ___.
__________________________________________________________
___ 11:04 pm TISSUE LEFT STERNAL CLAVICULAR JOINT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ year old female with schizoaffective
disorder, IVDU history, recent MSSA bacteremia, and recent left
sternoclavucular joint/neck/mediastinal abscess who presented
with one day of worsening right chest wall and neck pain and
erythema associated with fevers and reported purulent drainage
with imaging concerning for osteomyelitis, confirmed on MRI,
with thoracic debridement ___.
#Osteomyelitis of manubrium
Presented with worsening upper chest pressure and increased
drainage from prior surgical site. Patient hemodynamically
stable without leukocytosis and afebrile. Initial CT concerning
for osteomyelitis of the manubrium, with MRI recommended by
thoracic team on ___ compatible with osteomyelitis of the left
proximal clavicle and manubrium with soft tissue phlegmon or
early abscess involving the left sternoclavicular joint. No e/o
recurrent neck abscess. Previous culture data from
sternoclavicular tissue significant for coagulase + staph s/p 6
week course of IV cefazolin completed on ___. Blood cx
negative. ID involved, being treated with Vancomycin. Thoracic
surgery and plastic surgery consulted and patient went to OR on
___ for debridement of manubrium and sternum as well as left
pec advancement flap and JP drain placement. The patient's blood
cultures ___ grew gram negative rods so she was initially
placed on cefepime but after speciation yieleded brevundimonas
vesicularis, patient switched to meropenem. Patient then
switched to ertapenem and given one dose in the hospital without
issue and will finish a ___lood cultures ___
with coagulase negative staph. The patient's PICC was removed
given her bacteremia and new PICC placed after 48 hours. The
patient was continued on vancomycin throughout admission and
upon discharge for a total 6 week course. The patient will be
followed by infectious disease for further monitoring. One JP
drain pulled prior to discharge and second will be removed by
plastic surgery when stitches removed at follow up appointment.
# Fevers
Patient with fever one day after surgery. Chest x-ray showed
atelectasis, so likely etiology of fever. Patient given
incentive
spirometer. Blood culture with Brevundimonas and coag neg staph
as above. Urine cultures negative. Plastic surgery team did not
think erythema around wound was the cause of her fever as it
would be too early for post surgical infection at this time.
Urine cx with mixed flora.
#Pain management
#Anxiety
Patient has complex pain history with fibromyalgia and opioid
abuse, reportedly supposed to be initiated on suboxone recently.
Patient reported wanting to reduce her dose of opioids and
convert to suboxone, and this was confirmed with her PCP ___
at ___ for the homeless. Most recently prescribed
10mg q4hr oxycodone with plan for reducing 5mg every 3 days but
this never happened. During admission, due to pain from osteo
site regimen, increased to 12.5mg q4h PRN with 2mg dilaudid
every 6 hours. However, the patient was able to wean herself
down to oxycodone 10mg q3h and was discharged on this regimen.
For her anxiety, patient was kept on home clonazepam and given
an extra 0.5mg PRN dose.
#Capacity
#Poor coping
#Code Purple
Psych knows her well from prior admissions, were consulted
early. Recommended redirecting when patient threatening to leave
___. Patient with code purple overnight ___ for leaving
hospital and agitation. Required extra thorazine dose, seclusion
order, 1:1 sitter. Psych reevaluated her ___ and seclusion
order discontinued. Code purple again ___ for agitation over
clonazepam orders but patient calmed within minutes. Patient had
no other acute psychiatric issues throughout admission.
#leukopenia:
Patient with WBC to 3.8 ___ On multiple medications that could
cause cytopenias such as vancomycin so obtained differential
which was normal.
___ edema
2+ edema on exam prior to surgery. Likely i/s/o poor caloric
intake and adequate fluids. Low concern for cardiac etiology as
normal CV and Respiratory exam. However, given edema as well as
pulmonary HTN on CTA, should consider outpatient workup for
right sided HF. The patient received Lasix 20mg PO PRN.
Chronic/Stable Medical Conditions
=================================
#Schizoaffective disorder
#Post-traumatic Stress Disorder
Continued chlorpromazine, clonazepam (additional 0.5mg PRN daily
), topiramate, oxcarbazepine, doxepin, and Prazosin at home
doses. PRN Cogentin for restlessness. Social work consulted in
setting of homelessness, substance abuse history. Patient did
not show any suicidal ideation or intent.
#Anion gap metabolic acidosis: Resolved
Resolved after receiving fluids. Lactate was normal. pH on VBG
7.37. No ketonuria. No recurrence throughout admission
#HCV
#HBV
During admission ___, labs were notable for positive HCV Ab
and positive HBsAb and HBcAb. HCV VL positive, HBV
nondetectable. HIV checked in ___ and negative. Hepatology
follow up as outpatient.
#HTN
Continued clonidine
#Hypothyroidism
Continued synthroid
#GERD
Continued omeprazole
#Cervicalgia, chronic
#Fibromyalgia
Continued baclofen for possible muscle spasm component.
Continued gabapentin
TRANSITIONAL ISSUES
===================
[ ] please follow up positive HCV Ab and positive HBsAb and
HBcAb
[ ] please consider outpatient ECHO/workup for right sided heart
failure
[ ] please continue to assess psych status
[ ] per psych, avoid escalating opioids or benzos, redirect when
patient threatening to leave AMA, would favor thorazine ___
tid PRN for acute agitation
[ ] continue to get daily CBC to evaluate leukopenia
[ ] please arrange follow up with PCP ___
[ ] please arrange follow up with ___, NP at ___
___ Tel: ___
[ ] please obtain weekly CBC with differential, BUN, Cr,
Vancomycin trough,CRP and fax results to ATTN: ___ CLINIC
- FAX: ___
#Code status: Full code (confirmed)
#Health care proxy/emergency contact:
Name of health care proxy: ___
___: Daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID
2. Bisacodyl 10 mg PO DAILY
3. ChlorproMAZINE 50 mg PO TID
4. ClonazePAM 1 mg PO BID Anxiety
5. CloNIDine 0.1 mg PO TID
6. DICYCLOMine 20 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Doxepin HCl 100 mg PO HS
9. Gabapentin 800 mg PO TID
10. Levothyroxine Sodium 75 mcg PO DAILY
11. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
13. Prazosin 2 mg PO QHS
14. Senna 17.2 mg PO BID:PRN Constipation
15. Topiramate (Topamax) 75 mg PO BID
16. OXcarbazepine 300 mg PO BID
17. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. ertapenem 1 g IV DAILY Duration: 1 Day
RX *ertapenem [Invanz] 1 gram 1 g IV daily Disp #*1 Vial
Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Nicotine Patch 21 mg TD DAILY
4. Vancomycin 1250 mg IV Q12H
5. Bisacodyl ___AILY:PRN constipation
6. ClonazePAM 1 mg PO BID:PRN Anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth twice daily Disp #*6
Tablet Refills:*0
7. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
RX *clonazepam 0.5 mg 1 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
8. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth every 3 hours Disp #*24
Tablet Refills:*0
9. Baclofen 10 mg PO TID
10. ChlorproMAZINE 50 mg PO TID
11. CloNIDine 0.1 mg PO TID
12. DICYCLOMine 20 mg PO BID
13. Docusate Sodium 100 mg PO BID
14. Doxepin HCl 100 mg PO HS
15. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times daily
Disp #*9 Tablet Refills:*0
16. Levothyroxine Sodium 75 mcg PO DAILY
17. Omeprazole 20 mg PO DAILY
18. OXcarbazepine 300 mg PO BID
19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
20. Prazosin 2 mg PO QHS
21. Senna 17.2 mg PO BID:PRN Constipation
22. Topiramate (Topamax) 75 mg PO BID
23.Outpatient Lab Work
M86.0
please obtain weekly CBC with differential, BUN, Cr, Vancomycin
trough,CRP and fax results to ATTN: ___ CLINIC - FAX:
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Osteomyelitis of manubrium
Secondary Diagnosis:
Anxiety/Agitation
Schizoaffective disorder
Post-traumatic Stress Disorder
Anion gap metabolic acidosis
Hepatitis C
Hepatitis B
Hypertension
Hypothyroidism
Gastroesophageal Reflux Disease
Fibromyalgia
Cervicalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I ADMITTED?
You were admitted because you were having chest wall pain that
indicated your bone was infected
WHAT WAS DONE WHILE I WAS HERE?
We gave you antibiotics and performed surgery to get rid of your
infected bone
We had the psych team come see you and help with your psych meds
WHAT SHOULD I DO NOW?
-You should take your medications as instructed
-You should go to your doctor's appointments as below
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
10375816-DS-17 | 10,375,816 | 25,822,133 | DS | 17 | 2181-01-02 00:00:00 | 2181-01-02 22:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
haldol, prolixin
Attending: ___.
Chief Complaint:
Pain, inpatient IV abx administration
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ year old female with complicated past medical
history, including schizoaffective disorder and posttraumatic
stress disorder complicated by suicidal ideation, substance
abuse
including IVDU, chronic HCV and HBV, fibromyalgia,
hypothyroidism, and recent admission for mediastinal abscess and
MSSA sepsis, discharged ___. More recently, she was admitted
for
suicidal ideation (d/c'ed ___, and again ___ after
presenting with left chest wall pain and erythema with imaging
concerning for possible sternoclavicular joint and first
costochondral junction osteomyelitis.
On ___, she underwent debridement of manubrium and sternum as
well as left pec advancement flap and JP drain placement; she
was
discharged to ___ on ___ with plan for 6 weeks of IV
antibiotics. Patient reports that, due to a behavioral issue at
___, she was administratively dismissed today; her PICC was
removed, and she was discharged without prescriptions for any
medications. She did not provide details of her dismissal in the
ED.
In the ED, initial vital signs were: T 98.4 P ___ BP 131/86 R 16
O2 100% RA sat.
- Exam notable for:
---neck and back paraspinal mm ttp
---well healing sternal incision c/d/i
---otherwise unremarkable
- Labs were notable for:
lactate 2.0
normal chem7 (cr 0.6)
LFTs with AP 157, otherwise normal
WBC 3.9, Hct/Hgb 9.0/27.8, plts 384.
BCx collected
- Patient was given oxycontin 10mg, oxycodone 10mg x 2,
meropenem
500mg, vancomycin 1250mg, lidocaine 5% patch, nicotine patch,
miralax, baclofen 10mg x 2, chlorpromazine 50mg x 2, clonidine
0.1mg x 2, dicyclomine 20mg, gabapentin 800mg x 2, levothyroxine
75mg, omeprazole 20mg, oxcarbazepine 300mg, topiramate 75mg,
clonazepam 1mg.
- Vitals on transfer: T 98.3 P 90 BP 106/68 R 16 O2 100% RA
Upon arrival to the floor, the patient was very somnolent but
arousable. When questioned about the circumstances of her
discharge from ___, she states she was involved in a fight
with another patient, placed in a 48 hour hold where she was
limited on where she could go, and was accused of breaking the
restriction, prompting the facility to discontinue her PICC
line.
She went to her daughter's home after discharge and her daughter
took her immediately to ___ ED. Currently she endorses 9 out
of
10 pain over her surgical site. Denies any constipation, fevers.
Past Medical History:
Hypothyroidism
Mediastinal abscess
Hypertension
GERD
Fibromyalgia
?IBS
Schizoaffective disorder
Posttraumatic Stress Disorder
Substance abuse
Chronic HCV
Chronic HBV
Social History:
___
Family History:
Twin brother- schizoaffective disorder
Mother- unspecified mental illness
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Physical Exam:
Vitals:
___ 1445 Temp: 98.4 PO BP: 119/81 HR: 94 RR: 16 O2 sat: 96%
O2 delivery: RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. PERRLA. No conjunctival
pallor,
sclera anictericor injection. Moist mucous membranes. Oropharynx
w/o injection, exudate. Good dentition.
NECK: supple
CHEST: Surgical incision sites at the inferior neck and sternum
appear well healing, without erythema, warmth, or drainage.
There
is mild tenderness to palpation.
CARDIAC: RRR no m/g/r. No JVD.
LUNGS: CTA B/L. No wheeze/rhonchi/rales
BACK: no spinous process tenderness. no CVA tenderness.
ABDOMEN: Obese abdomen, NTND to palpation.
EXTREMITIES: No clubbing, cyanosis, or edema. Symmetric in
appearance. Pulses DP/Radial 2+ bilaterally. Dressing over prior
RUE ___
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: AOx3
DISCHARGE PHYSICAL EXAM
=======================
Vitals: ___ 0816 Temp: 97.8 PO BP: 110/74 HR: 122 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: Well appearing, NAD.
HEENT: NC/AT. No icterus or injection. MMM.
CHEST: Well healed surgical scar on upper sternum. No erythema,
warmth, or drainage.
CV: RRR, no murmurs, rubs or gallops appreciated.
LUNGS: No increased WOB. CTAB, No wheezes, rales or ronchi.
ABDOMEN: Obese, no tenderness to palpation diffusely, no rebound
or guarding.
EXTREMITIES: Warm, no c/c/e, no stigmata of endocarditis. No
PICC line in place, 2mm bruise over insertion site on left arm,
no warmth or tenderness
NEUROLOGIC: Alert, oriented, attentive. Speech clear. CN intact.
Normal gait and coordination.
PSYCH: Euthymic affect. Cooperative. Thought linear.
Pertinent Results:
ADMISSION LABS:
___ 04:20AM BLOOD WBC-3.9* RBC-3.26* Hgb-9.0* Hct-27.8*
MCV-85 MCH-27.6 MCHC-32.4 RDW-13.2 RDWSD-41.3 Plt ___
___:20AM BLOOD Neuts-39.3 ___ Monos-6.2 Eos-4.1
Baso-0.5 Im ___ AbsNeut-1.52* AbsLymp-1.92 AbsMono-0.24
AbsEos-0.16 AbsBaso-0.02
___ 07:50AM BLOOD ___ PTT-25.9 ___
___ 04:20AM BLOOD Glucose-115* UreaN-12 Creat-0.6 Na-142
K-4.1 Cl-107 HCO3-23 AnGap-12
___ 04:20AM BLOOD ALT-38 AST-38 AlkPhos-157* TotBili-<0.2
___ 05:19AM BLOOD Lactate-2.0
PERTINENT LABS:
___ 05:55AM BLOOD calTIBC-560* Ferritn-15 TRF-431*
IMAGING REPORTS:
================
___ CXR PICC PLACEMENT:
FINDINGS:
The tip of the left PICC line projects over the mid to distal
SVC. The right PICC line and left chest tube have been removed.
There are low bilateral lung volumes with no focal
consolidation, pleural
effusion or pneumothorax identified. The size of the
cardiomediastinal
silhouette is within normal limits.
IMPRESSION: The tip of the new left PICC line projects over the
mid to distal SVC. No pneumothorax.
Chest XR ___
IMPRESSION:
Left PICC line tip is at the level of mid SVC. Heart size and
mediastinum are stable. Lungs are clear. There is no pleural
effusion. There is no
pneumothorax.
MICRO STUDIES:
==============
BLOOD AND URINE CULTURES: ALL NEGATIVE
___ 06:01AM BLOOD HIV Ab-NEG
Discharge Labs:
================
___ 06:13AM BLOOD WBC-5.9 RBC-3.32* Hgb-8.5* Hct-26.7*
MCV-80* MCH-25.6* MCHC-31.8* RDW-17.0* RDWSD-46.2 Plt ___
___ 06:13AM BLOOD ___ PTT-26.1 ___
___ 06:13AM BLOOD Glucose-95 UreaN-21* Creat-0.7 Na-139
K-4.0 Cl-103 HCO3-25 AnGap-11
___ 06:13AM BLOOD Calcium-9.1 Phos-5.0* Mg-1.8
___ 06:13AM BLOOD CRP-3.4
___ 06:13AM BLOOD Vanco-17.1
Brief Hospital Course:
Summary:
====================================================
Ms. ___ is a ___ year-old female with schizoaffective
disorder, IVDU history, recent MSSA bacteremia, left
sternoclavucular joint/neck/mediastinal abscess, who again
recently presented with right chest wall and neck pain, with
thoracic debridement on ___, and who was discharged to
___ on ___, returning now as was dismissed from ___
because of a fight with another patient and allegedly breaking a
48 hour hold, without acute change in medical status, and
admitted for IV antibiotics. She had a PICC placed and was
continued on vancomycin with appropriate goal troughs. Her
sutures were removed by plastic surgery.
ACUTE ISSUES:
======================================================
#Osteomyelitis of manubrium
The patient was admitted while on her 6-week course of
Vancomycin for MSSA osteomyelitis of the manubrium and left
sternoclavicular joint. There was no evidence of worsening
infection, and her surgical scar from ___ appeared well healed
throughout her admission. She remained afebrile. Pain near her
surgical scar was attributed to pectoralis flap during her
surgery, and there was no fluctuance, erythema, or drainage to
suggest active infection. She completed her 6-week course of
vancomycin on ___. Routine weekly monitoring for vancomycin
showed therapeutic levels, and no evidence of kidney dysfunction
or elevated CRP. Outpatient surgical ___ arranged.
#Opioid abuse disorder
#Pain management
#Anxiety
The patient has complex pain history with fibromyalgia and
opioid abuse, confirmed with her PCP ___ at ___
___ for the homeless. The patient's opioid pain regimen
was tapered from a combination of long and short-acting agents
to short-acting agents per PCP preference and for facilitation
of visiting nurse dispensary as well as transition to suboxone
after narcotic taper as outpatient. Clonazepam was consolidated
from TID to BID dosing due to facilitation of visiting nursing
dispensary. Upon discharge, the patient's pain was managed well
enough that she could carry out daily functions without
restrictions of pain and anxiety. She will taper and eventually
transition to suboxone, which was discussed with the patient,
PCP, and her outpatient care team at length. She was in
agreement and excited with this plan as she would like to not be
on narcotics long-term.
#Schizoaffective disorder
#Post-traumatic Stress Disorder
The patient was evaluated by psychiatry while inpatient, who
recommended no changes to her outpatient regimen, except for
dosing of clonazepam to twice daily from TID in order to
facilitate visiting nursing dispensary of this controlled,
high-street-value substance for the patient's safety. We
continued chlorpromazine 50 mg TID, topiramate 75 mg BID,
oxcarbazepine 300 mg BID, doxepin 100 mg QHS, prazosin 2 mg QHS,
PRN Cogentin for restlessness. She was also evaluated by social
work to facilitate safe discharge and coordination with out
patient social work.
#Hypertension: continued clonidine 0.1 mg TID.
#Hypothyroidism: continued synthroid 75 mcg daily
#GERD: continued omeprazole 20 mg daily
#Cervicalgia, chronic
#Fibromyalgia
Continued baclofen 10 mg TID, and gabapentin 800 mg TID
#HCV
#HBV
During admission ___, labs were notable for positive HCV Ab
and positive HBsAb and HBcAb. HCV VL positive, HBV
nondetectable. HIV checked in ___ and negative. The patient
___ benefit from hepatology follow up as an outpatient.
- Hepatology to follow up as outpatient.
TRANSITIONAL ISSUES:
=====================
CHANGED MEDS:
Oxycodone 15mg PO TID
STOPPED MEDS:
Oxycontin
[ ] Pt. with prior Hep B and Hep C infection. ___, Hep C
with positive viral load and Hep B with negative viral load.
Please ensure patient has hepatology follow up for work up and
treatment of her HCV and HBV.
[ ] Surgery ___: Pt. to see Dr. ___ in
___ for her multiple sternoclavicular join / sternum
debridements as well as left pectoralis muscle flap and skin
graft
[ ] Please monitor patient's continued opioid use and taper as
tolerated. Plan to complete taper and then transition to
Suboxone with, PCP, ___.
[ ] The patient ___ benefit from complementary medicine for pain
control, such as acupuncture or reeki.
[ ] Surgery ___: Pt. to see Dr. ___ in
___ for her multiple sternoclavicular join / sternum
debridements as well as left pectoralis muscle flap and skin
graft
#Code status: Full code (confirmed)
#Health care proxy/emergency contact: ___ (Daughter)
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Baclofen 10 mg PO TID
2. Bisacodyl ___AILY:PRN constipation
3. ChlorproMAZINE 50 mg PO TID
4. ClonazePAM 1 mg PO BID:PRN Anxiety
5. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
6. CloNIDine 0.1 mg PO TID
7. DICYCLOMine 20 mg PO BID
8. Docusate Sodium 100 mg PO BID
9. Doxepin HCl 100 mg PO HS
10. Gabapentin 800 mg PO TID
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. OXcarbazepine 300 mg PO BID
14. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain -
Moderate
15. Prazosin 2 mg PO QHS
16. Senna 17.2 mg PO BID:PRN Constipation
17. Topiramate (Topamax) 75 mg PO BID
18. Lidocaine 5% Patch 1 PTCH TD QAM
19. Nicotine Patch 21 mg TD DAILY
20. Vancomycin 1250 mg IV Q12H
21. ertapenem 1 g IV DAILY
22. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing/SOB
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff INH four times
a day Disp #*1 Inhaler Refills:*0
2. ClonazePAM 1 mg PO QAM
RX *clonazepam 1 mg 1 tablet(s) by mouth in the morning, and at
night Disp #*30 Tablet Refills:*0
3. ClonazePAM 1.5 mg PO QHS
RX *clonazepam 0.5 mg 1 tablet(s) by mouth at night Disp #*15
Tablet Refills:*0
4. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 15 mg PO Q6H pain - severe
RX *oxycodone 15 mg 1 tablet(s) by mouth every 6 hours Disp #*30
Tablet Refills:*0
6. Baclofen 10 mg PO TID
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
7. ChlorproMAZINE 50 mg PO TID
RX *chlorpromazine 50 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
8. CloNIDine 0.1 mg PO TID
RX *clonidine HCl 0.1 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
9. DICYCLOMine 20 mg PO BID
RX *dicyclomine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
11. Doxepin HCl 100 mg PO HS
RX *doxepin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
12. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
13. Levothyroxine Sodium 75 mcg PO DAILY
RX *levothyroxine 75 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 once a day Disp #*30 Patch
Refills:*0
16. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*1
Capsule Refills:*0
17. OXcarbazepine 300 mg PO BID
RX *oxcarbazepine 300 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a
day Disp #*30 Packet Refills:*0
19. Prazosin 2 mg PO QHS
RX *prazosin [Minipress] 2 mg 1 capsule(s) by mouth at bedtime
Disp #*30 Capsule Refills:*0
20. Senna 17.2 mg PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 2 tablets by mouth twice a day
Disp #*60 Tablet Refills:*0
21. Topiramate (Topamax) 75 mg PO BID
RX *topiramate 25 mg 3 capsule(s) by mouth twice a day Disp
#*180 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
OSTEOMYELITIS OF THE MANUBRIUM
SECONDARY DIAGNOSIS
===================
OPIOID ABUSE DISORDER
CHRONIC PAIN
ANXIETY
SCHIZOAFFECTIVE DISORDER
POST TRAUMATIC STRESS DISORDER
HYPERTENSION
HYPOTHYROIDISM
GASTROESOPHAGEAL REFLUX DISEASE
FIBROMYALGIA
HEPATITIS C INFECTION
HEPATITIS B INFECTION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you during this admission.
WHY WERE YOU ADMITTED?
=======================
You were admitted because you needed to continue antibiotics for
your prior infection in your chest bone.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
===============================================
-You had another PICC placed and were kept on your antibiotics.
-We checked labs which showed your antibiotic dose was
appropriate.
-The plastic surgeons who did your surgery saw you while you
were here and removed your stitches. They thought your wound was
healing well.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
==================================================
-Take your medications as directed. A visiting nurse ___ manage
your pain medications for your safety.
-Follow up with your primary care doctor, ___.
-Once Dr. ___ you can manage your medications safely on
your own, you will not need a visiting nurse to dispense meds.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10375816-DS-18 | 10,375,816 | 26,193,169 | DS | 18 | 2181-12-03 00:00:00 | 2181-12-03 13:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
haldol, prolixin / cyclobenzaprine / fluphenazine /
metronidazole / quetiapine / Haldol
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with a complicated psychiatric
history including schizoaffective disorder, PTSD, opiate use
disorder with IV heroin, and suicidal ideation, and a medical
history notably for chronic Hep C, as well as history of sternal
osteomyelitis, who is admitted from ___ for chest pain, found
to have a large RML pneumonia. ___ was in her normal state of
health until about a month ago, when she began to feel more "run
down", with myalgias. She did not make much of this, because she
was having considerable life stressors -- she left her abusive
husband and was living outside again, as well as relapsing into
IVDU. Because of her worsening social situation, she was
admitted to ___. The details of this hospitalization
are not available, though she tells me she was "getting better."
Three days, ago, she tells me, she started to develop severe
chest pain in her right chest, underneath her breast, and a
severe cough. She also developed a high fever. This worsened
over the next several days, and she was transferred on a ___ to ___. In the ED, afebrile with VSS. WBC 19.5.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative. CTA was obtained
out of concern for PE, which showed:
1. No evidence of pulmonary embolism or aortic abnormality. 2.
Multiple round, consolidative opacities in the right upper lobe
concerning for pneumonia in the appropriate clinical setting. 3.
A discrete nodule at the hilum measures 2.2 x 2.2 cm, possibly
reflecting reactive lymphadenopathy. Given that the pulmonary
findings are readily seen on chest radiographs, recommend
followup with repeat chest radiograph in ___ weeks following
completion of treatment to ensure complete resolution. 4. Prior
debridement at the left sternoclavicular and first costochondral
joints, which appears similar in extent to the prior study. No
enhancing collections or significant stranding to indicate
active infection.
CXR was also obtained, which showed a RUL PNA.
She was given ceftriaxone, azithromycin, and admitted to
medicine.
Past Medical History:
1. Opiate use disorder with IV opiate use -- last one month ago
2. PTSD
3. Schizoaffective disorder
4. History of suicidal ideation
5. History of sternal osteomyelitis s/p mediastinal debridement
6. Hep C
7. ?history Hep B
Social History:
___
Family History:
Twin brother- schizoaffective disorder
Mother- unspecified mental illness
Physical Exam:
ADMISSION:
=========
VITALS: 97.7 PO ___ 18 97 RA
GENERAL: Alert, in no obvious distress
EYES: Anicteric, pupils equally round
ENT: OP clear, no tonsillar exudates
CV: S1, S2, RRR, no murmurs, rubs or gallops. Midline T-scar on
chest.
RESP: Absent breath sounds in RML, otherwise symmetrical chest
rise.
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 Oslers and Janeways, no splinter hemorrhages.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE:
=========
___ 0803 Temp: 97.5 PO BP: 124/95 R Sitting HR: 76 RR: 18
O2
sat: 100% O2 delivery: Ra
GENERAL: Alert, in no obvious distress
EYES: Anicteric, pupils equally round
ENT: OP clear, no tonsillar exudates
CV: S1, S2, RRR, no murmurs, rubs or gallops. Midline T-scar on
chest.
RESP: CTA b/l without rhonchi or wheeze.
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 Oslers and Janeways, no splinter hemorrhages.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly
intact throughout
PSYCH: irritable, paranoid, but generally re-directable
Pertinent Results:
LABS ON ADMISSION:
=================
___ 10:20AM BLOOD WBC-19.5* RBC-4.13 Hgb-12.0 Hct-35.8
MCV-87 MCH-29.1 MCHC-33.5 RDW-13.8 RDWSD-43.7 Plt ___
___ 10:20AM BLOOD Neuts-78.6* Lymphs-15.3* Monos-5.0
Eos-0.1* Baso-0.2 Im ___ AbsNeut-15.36* AbsLymp-2.98
AbsMono-0.98* AbsEos-0.02* AbsBaso-0.03
___ 10:20AM BLOOD Glucose-98 UreaN-12 Creat-0.7 Na-137
K-4.7 Cl-99 HCO3-23 AnGap-15
___ 10:30AM BLOOD Lactate-0.9
MICRO:
=====
___ 11:00 am BLOOD CULTURE #1 & #2.
Blood Culture, Routine (Pending): No growth to date.
IMAGING:
=======
CXR ___
There is consolidation in the right upper lobe, which is
concerning for
pneumonia. A there is no pleural effusion or pneumothorax. The
cardiomediastinal silhouette is normal limits. No acute osseous
abnormalities are identified.
IMPRESSION: Right upper lobe pneumonia.
CTA ___
1. No evidence of pulmonary embolism or aortic abnormality.
2. Multiple round, consolidative opacities in the right upper
lobe concerning for pneumonia in the appropriate clinical
setting.
3. A discrete nodule at the hilum measures 2.2 x 2.2 cm,
possibly reflecting reactive lymphadenopathy. Given that the
pulmonary findings are readily seen on chest radiographs,
recommend followup with repeat chest radiograph in ___ weeks
following completion of treatment to ensure complete resolution.
4. Prior debridement at the left sternoclavicular and first
costochondral
joints, which appears similar in extent to the prior study. No
enhancing
collections or significant stranding to indicate active
infection.
LABS ON DISCHARGE:
=================
___ 07:15AM BLOOD WBC-7.4 RBC-4.13 Hgb-11.6 Hct-36.3 MCV-88
MCH-28.1 MCHC-32.0 RDW-13.5 RDWSD-43.4 Plt ___
Brief Hospital Course:
Ms. ___ is a ___ female with a history of
schizoaffective disorder and PTSD, currently admitted at ___,
admitted with a community-acquired pneumonia.
# Community-acquired pneumonia.
Presentation is consistent with CAP, without risk factors for
pseudomonas. Great response to ceftriaxone and azithromycin,
with complete resolution of leukocytosis. Vital signs remained
completely stable, including 100% oxygen saturation on RA. Blood
Cultures without growth > 48h, thus no concern for baceteremia.
Transitioned from IV CFTX to PO cefpodixine for 5d total abx
(day 1 = ___ last day = ___ - continue azithro for 5d total
(day 1 = ___ last day = ___. Plan to finish treatment at
___.
#Schizoaffective disorder
#PTSD
#History of SI
Currently denies SI. Continuing her regimen from ___.
Evaluated by BEST team prior to return to ___.
#Opiate use disorder.
Patient previously on methadone, but conflicting reasons as to
why she stopped. Discussed with current inpatient psychiatry
attending at ___ who will look into resumption of methadone
or Suboxone for both opioid use disorder as well as treatment of
chronic pain.
TRANSITIONAL ISSUES:
====================
[ ] to complete 5d of antibiotics for pneumonia (cefpodoxime
400mg BID and azithro 250mg) with last day ___.
[ ] Recommend f/u CXR in ___ weeks to assess for full resolution
of pneumonia.
[ ] Recommend consideration of resumption of methadone or
suboxone for both opioid use and chronic pain.
> 30 mins spend in the planning and coordination of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID
2. CloNIDine 0.2 mg PO TID
3. Gabapentin 800 mg PO TID
4. DICYCLOMine 20 mg PO QID
5. ChlorproMAZINE 100 mg PO TID
6. Benztropine Mesylate 2 mg PO TID
7. Baclofen 10 mg PO TID:PRN Pain - Mild
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
2. Cefpodoxime Proxetil 400 mg PO Q12H
3. Baclofen 10 mg PO TID:PRN Pain - Mild
4. Benztropine Mesylate 2 mg PO TID
5. ChlorproMAZINE 100 mg PO TID
6. ClonazePAM 1 mg PO TID
7. CloNIDine 0.2 mg PO TID
8. DICYCLOMine 20 mg PO QID
9. Gabapentin 800 mg PO TID
Discharge Disposition:
Extended Care
Discharge Diagnosis:
# Community Acquired Pneumonia:
# Schizoaffective disorder:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with pneumonia and responded
wonderfully to antibiotic treatment. It is now safe to return to
Arbour for ongoing treatment.
Please complete all antibiotics as prescribed.
We wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10375831-DS-22 | 10,375,831 | 23,860,631 | DS | 22 | 2130-01-02 00:00:00 | 2130-01-03 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dysuria, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient was a ___ year old male sent from his PCP's office
for concern for urosepsis. In the office, the patient reportedly
had +UA, tender prostate on exam, and was hypotensive. The
patient reported poor appetite and weakness with subjective
fevers and chills since ___. He had been taking tylenol the
past two days for the weakness, roughly 2 pills every ___ hours,
roughly 10 pills per day. He also reported some lower abdominal
pain with dysuria and frequency. The patient denied chest pain,
cough, and shortness of breath. Despite his poor appetite, the
patient reported good fluid intake. He did report that he does
hot yoga daily for decades, but has not been doing this since
___.
.
In the ED, initial vital signs were 97.2 57 97/59 18 99% RA. He
was found to a have leukocytosis to 11.9 (N72%), a mild
hyponatremia to 130, anion gap of 13, creatinine of 1.8 ___
1.2-1.4), ALT 66 AST 73, lipase of 152, lactate of 1.6, and a UA
significant for large leukesterase, trace blood, >182 WBC, and
moderate bacteria. The patient had no abdominal tenderness on
exam, a non-tender prostate with heme neg stool, no CVAT, and a
non-focal neuro exam.
Past Medical History:
Hypertension treated from ___ to ___ with verapemil and
atenolol
Diabetes mellitus
Gout
Social History:
___
Family History:
Father died of MI at ___
Mother with ___, kidney problems
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: ___ 108/62 58 18 98%RA
Gen: NAD well-appearing jolly gentleman of stated age
HEENT: Sclera anicteric, MMM, OP clear
Neck: Supple without LAD
Pulm: Clear to auscultation bilaterally, without wheezes, ronchi
Cor: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abd: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
MSK: No CVAT
Extrem: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 grossly intact, motor function grossly normal
.
PHYSICAL EXAM ON DISCHARGE:
VS: Tm&c99.1 115/63 75 18 100%
Gen: NAD
HEENT: sclera anicteric EOMI MMM
Neck: Supple without LAD
Pulm: CTA b/l without wheeze or rhonchi
Cor: RRR (+)S1/S2 no m/r/g
Abd: Soft, non-distended, NTP, NABS
MSK: No CVAT
Extrem: No ___ edema
Pertinent Results:
CXR (___): No acute cardiopulmonary process.
RUQ U/S (___): Gallstones, without acute cholecystitis.
.
LABS ON ADMISSION
___ 01:38PM BLOOD WBC-11.9* RBC-4.72 Hgb-14.7 Hct-43.4
MCV-92 MCH-31.2 MCHC-33.9 RDW-12.6 Plt ___
___ 01:38PM BLOOD Neuts-71.9* ___ Monos-5.4 Eos-0.9
Baso-0.7
___ 01:38PM BLOOD ___ PTT-29.6 ___
___ 01:38PM BLOOD Glucose-171* UreaN-29* Creat-1.8* Na-130*
K-4.4 Cl-92* HCO3-25 AnGap-17
___ 01:38PM BLOOD ALT-66* AST-73* AlkPhos-108 TotBili-0.5
___ 01:38PM BLOOD Lipase-152*
___ 01:38PM BLOOD Albumin-4.2
___ 01:45PM BLOOD Lactate-1.6
.
LABS ON DISCHARGE
___ 06:15AM BLOOD WBC-12.0* RBC-4.08* Hgb-12.4* Hct-37.4*
MCV-92 MCH-30.3 MCHC-33.0 RDW-12.7 Plt ___
___ 06:15AM BLOOD Glucose-125* UreaN-37* Creat-1.3* Na-133
K-5.0 Cl-102 HCO3-22 AnGap-14
___ 06:15AM BLOOD ALT-48* AST-41* AlkPhos-89 TotBili-0.3
___ 06:15AM BLOOD Lipase-91*
Brief Hospital Course:
Patient is a ___ year old male with history of diabetes mellitus,
hypertension, and gout presented to PCP with weakness,
subjective fever and chills, and dysuria since ___, found to
have urosepsis.
.
ACUTE ISSUES
#Urosepsis:
The patient reported weakness, subjective fever and chills, and
dysuria and frequency since ___. It was reported that the
patient had prostate tenderness on exam at PCP, but patient
denied tenderness and the pain was not be reproduced in the ER.
The patient's UA was suggestive of UTI with large leukesterase,
WBC, and bacteria. He had a mild leukocytosis to 11.9. There was
no CVAT on exam. Given low blood pressure at the PCP office and
UA findings, patient found to have urosepsis. While inpatient,
the patient's pressure remained between 110-115 systolic with
stable vital signs. He was started on ceftriaxone and given IVF
for pressure support. By HD#2, the patient reported improved
symptoms and his vital signs remained stable. He was discharged
on a course of ciprofloxacin and ___ was recommended with
his PCP.
.
#Acute-on-chronic kidney disease
Patient with baseline creatinine 1.2-1.4 per OMR, found to be
1.8 on admission. The patient had a history of diabetes and
hypertension, and was on an ACEI at home. He denied decreased
fluid intake, but did report that he was doing hot yoga for some
time. The patient's medications were renally-dosed, he was given
IV fluids, and his creatinine was trended. By HD#2, his
creatinine improved to 1.3.
.
#Elevated LFTs
Patient with elevated ALT, AST, lipase and without RUQ pain,
tenderness or jaundice/icterus on exam. A RUQ U/S did not show
acute process. Patient reportedly took 10 tylenol per day for
the two days prior to admission. He had no history of liver
disease. It was thought that his elevated LFTs were most likely
because of tylenol ingestion. By day two, his labs had trended
downward.
.
CHRONIC ISSUES
#Diabetes mellitus
History of DM, controlled on glipizide and metformin at home.
A1c of 6.7% in ___.
His metformin and glipizide were held and she was started on
sliding-scale insulin. He was offered a diabetic diet while
inpatient.
.
#Hypertension
History of hypertension, on atenolol and lisinopril at home.
Baseline systolic pressure was 120-130, trended around 110-115
systolic while inpatient. His home meds were held while admitted
and patient was discharged with these medications held until he
followed-up with his PCP.
.
#Cardiac risk factors
History of hyperlipidemia, on simvastatin and aspirin at home.
These were continued while inpatient.
.
TRANSITIONAL ISSUES
#Patient was discharged with blood pressure medications held
until PCP ___.
#Urine cultures remained pending at the time of discharge.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Atenolol 50 mg PO DAILY
2. GlipiZIDE 20 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Simvastatin 40 mg PO DAILY
6. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Simvastatin 40 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. GlipiZIDE 20 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Urosepsis
Acute on chronic kidney disease
Secondary diagnoses:
Diabetes mellitus
Hyptertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted because you had an infection of your urinary
tract causing your blood pressure to be low. In the hospital,
you were given antibiotics and fluids by IV, and you improved
clinically. You have been discharged on an antibiotic to take by
mouth -- please finish all of the pills.
Please START ciprofloxacin 500mg twice daily for 7 days
Please STOP your atenolol and lisinopril until you see your PCP
___ CONTINUE your other home medications
Please ___ with your PCP within one week to ensure your
infection is cleared. Please call ___ to schedule an
appointment.
Please LIMIT your Tylenol use and use only as directed. This
means for Extra Strength Tylenol, you can only take up to 6
pills per day.
Followup Instructions:
___
|
10375831-DS-24 | 10,375,831 | 23,595,417 | DS | 24 | 2134-04-07 00:00:00 | 2134-04-07 15:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o man with h/o DM2, HTN, CKD stage 2,
Gout, with recent admission for PNA/diarrhea/hypoNA w/ c/f
parkinsonian traits, who presents with failure to thrive.
Patient was recently admitted ___ - ___ for diarrhea and
weight loss. He was found to have a PNA and proctocolitis and
was treated with a 5 day course of levofloxacin. There was some
concern for ___ as patient had new shuffling gait,
memory loss, and new mouth tremor. He was evaluated by ___ and
was cleared to go home. Of note, a stool O&P returned positive
for blastocystis and was not treated.
Since discharge, he reports generalized weakness to the point
where he has difficulty walking. He endorses a poor appetite and
thus has not been able to eat much food. He has lost about 30
pounds in the past 6 months and almost 10 pounds since his last
admission. His diarrhea is improved, but he continues to have
___ loose bowel movements a day. He denies any fevers or chills,
abdominal pain, dysuria, urinary frequency, cough, or shortness
of breath. His outpatient team has tried to arrange for maximal
support at home but despite these efforts, he has been unable to
fully care for himself. Per ___, he cannot walk or stand too
long to make breakfast. He is eating grapes, OJ, and ice water.
In the ED, initial vitals were: 97.7 107 102/63 18 99%RA
- labs significant for: Na 128 and 132 on repeat, wbc 15.1, plt
625, h/h 11.6/34.4
- CXR without acute cardiopulmonary process
- patient given 600mg ibuprofen, IVF, and flagyl for +
blastocysitis on stool specimen and admitted for further care
On the floor, patient reports that he is already feeling better.
He ate lunch in the hospital and said it was "delicious" and he
is looking forward to his next meal. He reports that he used to
do 1 hour of yoga, 1 hr of cardio training, and 1 hour of
walking a day. However, as he has felt week, he stopped doing
this at the beginning of the month. He continues to feel very
weak in the legs.
ROS: positive per HPI, otherwise negative
Past Medical History:
- DIABETES TYPE II
- HYPERTENSION
- LEFT BUNDLE BRANCH BLOCK
- CHRONIC KIDNEY DISEASE
- GOUT
- SUBCLINICAL HYPOTHYROIDISM
- ERECTILE DYSFUNCTION
Social History:
___
Family History:
Father died of MI at ___
Mother with ___, kidney problems, died of "natural causes" in
___
Sister with breast cancer
Physical Exam:
Admission exam:
VS: T 97.2 BP 124/74 HR 84 RR 16 O2 sat 97%RA
General: thin man, no acute distress
HEENT: PERRL, EOMI, oropharynx is clear, there is minimal
temporal wasting bilaterally, neck is supple
CV: r/r/r, soft systolic murmur best heard right sternal border
Lungs: CTA bilaterally
Abd: soft, nontender, nondistended, normoactive bowel sounds
Ext: wwp, no edema
Neuro: CN II-XII intact, strength ___ bilateral hip
flexion/extension, ___ bilateral plantarflexion/extension, no
cogwheeling appreciated
Psych: mood and affect appear appropriate
Discharge Exam:
VS: T 98.1 PO BP 134/75 HR 68 RR 18 O2 sat 100 RA
General: well appearing man, sitting up in bed, no acute
distress
HEENT: Anicteric, eyes conjugate, there is no temporal wasting
noted
Cardiovascular: RRR ___ SEM, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: non-tender, non-distended, bowel sounds present
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Skin: there are no lesions or rashes noted anywhere
Psychiatric: pleasant, appropriate affect
Pertinent Results:
Admission labs:
___ 12:00PM BLOOD WBC-15.1* RBC-3.85* Hgb-11.6* Hct-34.4*
MCV-89 MCH-30.1 MCHC-33.7 RDW-12.7 RDWSD-41.4 Plt ___
___ 12:00PM BLOOD Neuts-79.3* Lymphs-11.7* Monos-7.0
Eos-0.8* Baso-0.3 Im ___ AbsNeut-11.99* AbsLymp-1.76
AbsMono-1.05* AbsEos-0.12 AbsBaso-0.05
___ 12:00PM BLOOD Glucose-150* UreaN-21* Creat-1.2 Na-128*
K-5.4* Cl-91* HCO3-20* AnGap-22*
___ 12:00PM BLOOD ALT-43* AST-44* AlkPhos-106 TotBili-0.5
___ 12:00PM BLOOD TotProt-6.6 Albumin-2.8* Globuln-3.8
Discharge labs:
___ 06:30AM BLOOD WBC-14.2* RBC-3.30* Hgb-9.6* Hct-29.1*
MCV-88 MCH-29.1 MCHC-33.0 RDW-13.4 RDWSD-42.6 Plt ___
___ 06:30AM BLOOD Glucose-314* UreaN-27* Creat-0.9 Na-131*
K-4.8 Cl-95* HCO3-23 AnGap-18
___ 06:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.7
___ 06:30AM BLOOD CRP-121.8*
Imaging:
___ CXR:
IMPRESSION:
No acute cardiopulmonary process.
___ CT chest:
IMPRESSION:
No lymphadenopathy, mass or infiltrates.
___ bilateral ___:
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Brief Hospital Course:
Mr. ___ is a ___ y/o man with h/o DM2, HTN, CKD, Gout,
hypothyroidism, with recent admission for PNA/diarrhea/hypoNA w/
c/f parkinsonian traits, who presents with failure to thrive at
home.
# Failure to thrive / weakness
# Febrile episode
Per documentation, outpatient providers have tried to increase
patient's access to resources in the community but patient
continues to fail at home. He has lost approximately 30 pounds
in the past 6 months and has lost 8 pounds since his last
discharge. Unclear regarding the cause. Work-up this
hospitalization included TSH, B12/MMA, free K/L ratio, UPEP
(pending), CT chest, bilateral ___ and these were all negative
for any acute process. Patient had 1 noted febrile episode to
101.6, which self-resolved and did not recur. An infectious
workup including urinalysis, urine culture, blood cultures, and
CXR was done without any source. A CRP was checked in this
setting and was elevated to 144, however, no inflammatory source
was found. As patient did not have any localizing complaints,
passed ___ to return home, and did not have any acute medical
issues, further work-up was deferred to the outpatient setting.
# Diarrhea
Previous stool O and P grew blastocystis and patient had
persistent diarrhea on admission. Repeat stool cultures were
again positive for blastocystis. He completed a 5 day treatment
of metronidazole with resolution of his diarrhea.
# leukocytosis
# thrombocytosis
Persistent elevation this month of unclear etiology. Persistent
after treatment of blastocystitis. No other localizing signs or
symptoms of infection at this time and all cultures were no
growth during hospitalization. Likely reactive in setting of
underlying process, though what process is unclear at this time.
# Gout
On presentation, patient complained of left toe pain consistent
with gout. He was treated with ibuprofen in the ED and pain
improved. It did not recur.
# Hyponatremia
Patient mildly hyponatremic to 128 on admission and
intermittently during hospitalization as well. Improved with IVF
administration and thus thought to be due to hypovolemia in
setting of failure to thrive as above. Discharge Na noted to be
131. Please continue monitoring as outpatient.
# CKD stage 3
Baseline creatinine appears to be 1.0 - 1.2. CrCl is 44
according to ___ equation. His Cr dropped below his
baseline with fluids and PO intake and on discharge his Cr was
0.9.
# T2DM
He was treated with ISS during admission. He will continue
Glipzide and Metformin on discharge.
# HTN
Stable blood pressures during his admission without
anti-hypertensives. Given his recent weight loss and
normotension noted during hospitalization, home lisinopril and
amlodipine were both held at discharge. Please restart as
needed.
>30 minutes were spent on discharge planning and care
coordination.
Transitional issues:
- UPEP pending at discharge
- free K/L ratio found to be elevated, likely reflecting MGUS,
please f/u with hematology as scheduled
- amlodipine and lisinopril held at discharge, please restart as
needed
- please monitor CRP, WBC, and PLT as outpatient
- please continue work-up as much as tolerated as outpatient,
including possible EGD/colonoscopy for odynophagia and colon
cancer screening
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 20 mg PO DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Lisinopril 2.5 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. GlipiZIDE 20 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Multivitamins W/minerals 1 TAB PO DAILY
7. HELD- amLODIPine 10 mg PO DAILY This medication was held. Do
not restart amLODIPine until you see your PCP ___ ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Failure to thrive
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 you during your stay at ___. You
were admitted for difficulty eating at home. You were treated
with fluids and seen by the physical therapist. You had an
extensive work-up including a CT of your chest and ultrasound of
your legs and nothing abnormal was found. Please follow-up with
your doctors as listed below.
Please do NOT take your home lisinopril and amlodipine as your
blood pressure was normal during your hospitalization. Your PCP
___ notify you when to restart these medications.
It has been a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10375831-DS-25 | 10,375,831 | 20,892,410 | DS | 25 | 2134-07-03 00:00:00 | 2134-07-07 14:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with recent hx of parkinsonism and HTN who presented to the
ED with complaints of dizziness and a fall on ___. He
stated he fell on ice but he was not dizzy prior to his fall.
Patient complains of dizziness on and off for a few weeks now.
Since his fall, he has not seen any healthcare provider.
He denies any symptoms of vertigo, but he reported no tinnitus,
hearing loss or visual changes . He has no headaches but stated
when he fell 2 weeks ago he had a scalp laceration that he took
care of at home with a Band-Aid and ointment. He reported no
loss of consciousness.
Patient denies any chest pain or shortness of breath. He also
denies any palpitations. He reports no hx of DVT or PE. He
doesn't have hemoptysis or black tarry stools. He states that he
has been drinking orange juice and powdered energy drinks, but
he has not been eating well.
In the ED, initial VS were T 97.2, BP 131/60, P 88, RR 14, and
O2sat 100% on RA.
Exam notable for VSS, MMM, PERRLA, EOMI with slight nystagmus at
horizontal level when he looks to the left. Visual fields
normal.
Neuro: alert, oriented x3, cranial nerve {II-X11)intact to the
extent of the exam. Bilateral upper and lower limb strength is
equal ___. He displays coordination with finger to nose and heel
to shin. His gait is stable and he denies any dizziness at this
time. Lungs CTA, CV RRR, abdomen soft and nontender, skin
diaphoretic, and no ankle swelling or calf tenderness.
Labs showed UA with glucose + 150, BMP with Cl 21, BUN 23, Cr
1.1, Glucose 37, WBC 11.6, and H/H 11.6/36.3.
Imaging showed:
CXR- No acute cardiopulmonary process.
CT Spine w/o contrast
1. No acute traumatic malalignment or acute fracture. No
prevertebral soft tissue swelling.
2. Multilevel degenerative disease of the cervical spine,
including posterior longitudinal ligament calcification and
posterior intervertebral osteophyte seen at C5-C6 causes
moderate to severe bilateral neural foramina and central canal
narrowing.
CT Head w/o contrast:
1. No acute intracranial hemorrhage.
2. Diffuse cortical atrophy and intraparenchymal sequela of
chronic microvascular ischemic disease
Patient's BG was low at 37 and he was provided with oral glucose
and a diet.
Transfer VS were T 97.8, P 74, BP 111/70, RR 16, and O2sat 100%
on RA
___ and case management was consulted.
Due to his hypoglycemia, worsening memory status and inability
to take PO meds appropriately, it was felt that patient was not
safe for discharge. Patient was admitted for proper diabetes
control. Decision was made to admit to medicine for further
management.
On arrival to the floor, patient reports that he feels a lot
better right now and endorses above history.
Past Medical History:
- DIABETES TYPE II
- HYPERTENSION
- ANEMIA
- CKD Stage 2
Social History:
___
Family History:
Father died of MI at ___
Mother with EtOH, kidney problems, died of "natural causes" in
___
Sister with breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
VS: T 98.2, BP 147/72, P 79, RR 18, and O2sat 98% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, coin shaped lesion with scabbing on occipital portion of
head with no bleeding/drainage
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, systolic murmur in RUSB radiating to carotids
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
NEURO: no focal neurological deficits, minimal horizontal
nystagmus on
gaze to both left and right, Romberg is normal, and he has good
stability but does walk with a wide based get
DICHARGE PHYSICAL EXAM:
===========================
VS: T 97.6, BP 139-156/74-82, P 59-72, RR 18, O2sat 97-99% on
RA
GENERAL: NAD
HEENT: AT/NC, EOMI, +nystagmus, anicteric sclera, pink
conjunctiva, MMM, coin shaped lesion with scabbing on occipital
portion of head with no bleeding/drainage
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, systolic murmur in RUSB radiating to carotids
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: grossly intact, wide based gait
Pertinent Results:
ADMISSION LABS:
======================
___ 12:10PM BLOOD WBC-11.6* RBC-4.08* Hgb-11.6* Hct-36.3*
MCV-89 MCH-28.4 MCHC-32.0 RDW-15.5 RDWSD-51.1* Plt ___
___ 12:10PM BLOOD Neuts-49 Bands-0 ___ Monos-3* Eos-2
Baso-1 ___ Myelos-0 AbsNeut-5.68 AbsLymp-5.22*
AbsMono-0.35 AbsEos-0.23 AbsBaso-0.12*
___ 12:10PM BLOOD Plt Smr-NORMAL Plt ___
___ 12:10PM BLOOD Glucose-37* UreaN-23* Creat-1.1 Na-139
K-4.1 Cl-103 HCO3-21* AnGap-19
___ 12:10PM BLOOD ALT-11 AST-14 AlkPhos-96 TotBili-0.2
___ 12:10PM BLOOD cTropnT-<0.01
___ 12:10PM BLOOD Albumin-4.2 Calcium-10.1 Phos-3.5 Mg-1.7
___ 12:10PM BLOOD TSH-6.8*
___ 03:31PM URINE Color-Straw Appear-Clear Sp ___
___ 03:31PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
OTHER RELEVANT LABS:
========================
URINE CULTURE (Final ___: < 10,000 CFU/mL.
DISCHARGE LABS:
====================
___ 08:00AM BLOOD WBC-7.3 RBC-4.08* Hgb-11.6* Hct-36.9*
MCV-90 MCH-28.4 MCHC-31.4* RDW-15.9* RDWSD-52.8* Plt ___
___ 08:00AM BLOOD Glucose-246* UreaN-28* Creat-1.1 Na-137
K-4.7 Cl-100 HCO3-22 AnGap-20
IMAGING:
====================
CT Head w/o contrast (___) IMPRESSION:
1. No acute intracranial hemorrhage.
2. Diffuse cortical atrophy and intraparenchymal sequela of
chronic
microvascular ischemic disease.
CT C-Spine w/o contrast (___) IMPRESSION:
1. No acute traumatic malalignment or acute fracture. No
prevertebral soft tissue swelling.
2. Multilevel degenerative disease of the cervical spine,
including posterior longitudinal ligament calcification and
posterior intervertebral osteophyte seen at C5-C6 causes
moderate to severe bilateral neural foramina and central canal
narrowing.
CXR (___) IMPRESSION: No acute cardiopulmonary process
EKG (___): Sinus rhythm. Left bundle-branch block. Compared to
the previous tracing of ___ no significant interim change.
Brief Hospital Course:
___ with type 2 DM who presented to the ED with complaints of
dizziness and a fall on ___. He was found to be
hypoglycemic in the ED.
Patient was found to exhibit orthostatic hypotension and IVF
resuscitation was attempted but patient refused. Lisinopril held
at discharge due to orthostatic hypotension.
Patient's metformin was increased to ___ mg daily and his
sulfonylurea was stopped to minimize risk of recurrent
hypoglycemia when he leaves the hospital.
Patient was monitored on telemetry overnight with no
abnormalities noted. Patient was observed on fall and delirium
precautions. ___ evaluated patient and recommended home with ___,
however patient insisted on leaving the hospital AMA prior to
services being arranged. Per OT's evaluation, patient did well
on cognitive testing.
Problem summary:
Problems:
- hypoglycemia likely ___ to sulfanylurea + poor po intake -
resolved.
- dehydration
- Mild symptomatic orthostatic hypotension
- mild leukocytosis - resolved
- Systolic murmur concerning for aortic stenosis
- mild nystagmus and wide based gate: possibly ___ to vestibular
dysfunction
- cervical spinal stenosis: degenerative changes and osteophyte
at C5-C6 causing moderate to severe bilateral neural foramina
and
central canal narrowing.
- cortical atrophy and evidence of diffuse microvascuar disease
-
per CT head
- recent diagnosis of ___ disease - no clinical evidence
or
concern for ___ disease on our assessment during this
admission.
Chronic:
- DMII (on glipizide, metformin) HbA1c 7.4 ___
- HTN
- CKD (Base line Cr?)
- gout
- subclinical hypothyroidism
- distant ETOH abuse
- recent dx of ___ disease
- MGUS - plan to follow with out patient heme-onc.
Transitional issues:
======================
- Stopped meds: Glipizide, lisinopril
- Changed meds: Metformin increased from 1000 daily to 1000 mg
BID
- Continue to monitor blood glucose and blood pressure as an
outpatient
- Patient with systolic murmur at RUSB radiating to carotids,
c/f aortic stenosis, which could be contributing to symptoms.
Please consider outpatient TTE.
-Further work-up for wide-based gait and nystagmus per PCP's
discretion.
- TSH 6.8, please continue to monitor in outpatient setting and
start treatment if clinically indicated
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. GlipiZIDE 20 mg PO DAILY
5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. amLODIPine 10 mg PO DAILY
8. Lisinopril 2.5 mg PO DAILY
Discharge Medications:
1. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Multivitamins W/minerals 1 TAB PO DAILY
7. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until you are told to resume it by
your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Hypoglycemia
Orthostatic hypotension
Failure to thrive
Type 2 Diabetes Mellitus
Secondary
Chronic kidney disease
Subclinical Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were feeling
lightheaded. You were found to have low blood sugar and to be
dehydrated. We changed your medication regimen to help your
sugars stay stable. We tried to give you IV fluids but you
refused. We wanted to evaluate and treat your symptoms further
but you declined to receive further evaluation and decided to
leave the hospital against our medical advice.
It is very important that you follow up with your PCP soon after
you leave the hospital.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10375986-DS-16 | 10,375,986 | 20,891,210 | DS | 16 | 2173-08-21 00:00:00 | 2173-08-22 09:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS, hypoglycemia
Major Surgical or Invasive Procedure:
Intubation
Lumbar Puncture
History of Present Illness:
___ with a PMHx of T1DM, HTN, HLD, Multiple Myeloma, DVT on
warfarin, and prior right-sided CVA with residual left arm
wekaness who was found unresponsive at home. He was last seen on
___ evening and last spoken to on ___ morning at around 9:00
am by a friend. He was normal during that conversation. At 10:30
am, his daughter found him minimally repsonsive and on
fingerstick his blood sugar was only reported as "low." EMS was
called who gave him 2 amps of D50 with BS afterwards only 36. He
was taken to ___ where initial fingerstick was normal.
There, had seizure-like activity with left gaze deviation. This
apparently broke on its own. Although there is no documentation,
his daughter reports that his blood sugar was rechecked at that
time and was low again. Labs there showed trop 0.05, tox
negative, BUN/Cr 39/2.6, H/H 11.4/35, and plt 187. He had a CT
head and c-spine which were negative for acute process but
showed old right posterior frontal and anterior parietal
infarct, old left thalamic infarct. He was intubated, placed on
D5 drip at 500/hour, and then transferred to ___. En route he
received midazolam boluses for agitation.
In the ED,
- VS were T 98.8 rectal, HR 76, BP 156/83, RR 17, SaO2 100% on
CMV
- Labs were notable for WBC 11.9, H/H 11.8/35.0, Plt 148, INR
3.0, UA neg leuk/nitrite, mod blood, 100 prot, lactate 2.0, trop
0.07, BUN/Cr 40/2.4, HCO3 21 (AG=14), AST/ALT 61/59
- STox/UTox negative, CVO2 86%
- He was given 2g ceftriaxone to initially cover for meningitis,
but upon further discussion givne lack of infectous symptoms
further antibiotics were not given
- He was noted to have left knee swelling, but single-view x-ray
showed no acute fracture
- He was started on D5 NS, fentanyl, and midazolam drips
- Per report from daughter, he has had very brittle diabetes
with both hypo- and hyperglycemia. He was recently given a
steroid injection (in the setting of chemo?) and his sugars have
been "all over the place". She denies any recent infectious
symptoms or sick contacts.
On arrival to the MICU, he is intubated and sedated on midazolam
and fentanyl.
Past Medical History:
- Multiple Myeloma
- Type I Diabetes
- DVT on warfarin
- Hypertension
- Hyperlipideami
- Anemia, gets Procrit injections weekly
- H/o right-sided CVA in setting of subtherapeutic INR, has mild
left-sided deficits
- Bilateral cataracts
- H/o right-sided rotator cuff tear
- Osteoarthritis
- Peripheral neuropathy
- CKD, stage IV per daughter
- ___
Social History:
___
Family History:
Mother had diabetes.
Physical Exam:
ADMISSION PE:
Vitals: T 99.3 BP 185/78 HR 80 SaO2 on CMV 500x14 5 40%
FSBG 137
GENERAL: Intubated, sedated on 100 fentanyl 5 versed
HEENT: pupils equally round 2mm but minimally repsonsive
bilaterally, no scleral icterus, no conjunctival injection or
pallor, ET tube in place
NECK: ___ collar in place
LUNGS: no wheezing, rhonchi, or rales
CV: RRR, normal s1/s2, no m/r/g
ABD: soft, nondistended, hypoactive bowel sounds, no HSM or
masses
EXT: no clubbing or edmea, 2+ DP pulses bilaterally
SKIN: several excoriations and ecchymoses on left arm and
bilateral knees, venous stasis on bilateral legs
NEURO: moves all 4 extremities to noxious stimuli and
spontaneously, does not follow commands
DISCHARGE PE:
Vitals: T 97 BP 136/103 HR 69 RR 18 O2 100RA
GENERAL: opens eyes to command and speaking in sentences
sometimes incomprehensible but better in the afternoon/evenings,
not following physical commands
HEENT: PERRL ~2mm, no scleral icterus, no conjunctival injection
or pallor, occasionally forces eyes closed when checking pupils
LUNGS: no wheezing, rhonchi, or rales
CV: RRR, normal s1/s2, no m/r/g
ABD: G tube present, soft, nondistended, nontender
EXT: no clubbing or edmea, 2+ DP pulses bilaterally
NEURO: moves all 4 extremities to noxious stimuli and
spontaneously, does not follow commands
Pertinent Results:
ADMISSION LABS:
___ 05:10PM BLOOD WBC-11.9* RBC-3.56* Hgb-11.8* Hct-35.0*
MCV-98 MCH-33.1* MCHC-33.7 RDW-15.7* Plt ___
___ 05:10PM BLOOD Neuts-92.7* Lymphs-3.3* Monos-3.6 Eos-0.4
Baso-0
___ 05:10PM BLOOD Plt ___
___ 05:10PM BLOOD ___ PTT-30.2 ___
___ 05:10PM BLOOD Glucose-121* UreaN-40* Creat-2.4* Na-141
K-3.6 Cl-106 HCO3-21* AnGap-18
___ 05:10PM BLOOD ALT-59* AST-61* CK(CPK)-551* AlkPhos-115
TotBili-0.5
___ 05:10PM BLOOD cTropnT-0.07*
___ 05:10PM BLOOD Lipase-11
___ 05:10PM BLOOD Albumin-3.8
___ 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:16PM BLOOD ___ pO2-56* pCO2-44 pH-7.42
calTCO2-30 Base XS-3
___ 05:12PM BLOOD Lactate-2.0
___ 05:16PM BLOOD O2 Sat-86
___ 05:10PM URINE Color-Straw Appear-Clear Sp ___
___ 05:10PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 05:10PM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 05:10PM URINE Mucous-RARE
___ 05:10PM URINE Hours-RANDOM
PERTINENT LABS:
___ 01:50AM BLOOD VitB12-1124*
___ 03:15PM BLOOD calTIBC-160* Ferritn-511* TRF-123*
___ 05:55AM BLOOD Hapto-303*
___ 03:05AM BLOOD Triglyc-86
___ 03:20PM BLOOD Ammonia-43
___ 01:50AM BLOOD TSH-2.3
___ 01:50AM BLOOD Free T4-0.84*
___ 05:55AM BLOOD Cortsol-20.5*
___ 04:40AM BLOOD ANCA-NEGATIVE B
___ 04:40AM BLOOD ___
___ 05:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:50AM BLOOD COPPER (SERUM)-Test Normal
___ 04:07AM BLOOD VITAMIN B1-Test Normal
___ METANEPHRINES, FRACTIONATED, 24HR URINE NEGATIVE
___ CATECHOLAMINES NEGATIVE
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-5.7 RBC-2.54* Hgb-8.0* Hct-24.5*
MCV-96 MCH-31.5 MCHC-32.7 RDW-15.8* Plt ___
___ 06:05AM BLOOD ___ PTT-36.5 ___
___ 06:05AM BLOOD Glucose-167* UreaN-50* Creat-2.4* Na-138
K-4.0 Cl-103 HCO3-25 AnGap-14
___ 06:05AM BLOOD Calcium-10.1 Phos-2.2* Mg-1.9
MICRO:
___ 05:10PM URINE Color-Straw Appear-Clear Sp ___
___ 05:10PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 05:10PM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
Lumbar Puncture:
___ CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2* Polys-0
___ ___ CEREBROSPINAL FLUID (CSF) TotProt-39 Glucose-127
All of the follow negative:
___ CEREBROSPINAL FLUID (CSF) VARICELLA DNA (PCR)-Test
___ CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS DNA,
QUALITATIVE, PCR-Test
___ CEREBROSPINAL FLUID (CSF) ___ VIRUS (JCV) DNA
QUANTITATIVE PCR-Test
___ CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-Test
Name
___ CEREBROSPINAL FLUID (CSF) ___ VIRUS, QUAL TO
QUANT, PCR-Test Name
All of the following negative:
___ VARICELLA DNA (PCR) (see report)
___ CYTOMEGALOVIRUS DNA, QUALITATIVE, PCR (see report)
___ ___ VIRUS (JCV) DNA QUANTITATIVE PCR (see report)
___ HERPES SIMPLEX VIRUS PCR (see report)
___ ___ VIRUS, QUAL TO QUANT, PCR (see report)
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE
___ URINE CULTURE-FINAL INPATIENT NEGATIVE
___ Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-FINAL NEGATIVE
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL
NEGATIVE
___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; Enterovirus
Culture-FINAL NEGATIVE
___ CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-FINAL NEGATIVE
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST} NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE
___ URINE CULTURE-FINAL NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE
___ URINE CULTURE-FINAL NEGATIVE
___ BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE
STUDIES/IMAGING:
___ CXR:
1. Endotracheal tube in standard position.
2. Streaky left basilar opacity, potentially atelectasis.
3. Thickening of the right minor fissure could be due to fluid.
4. Gaseous distention of the stomach for which enteric tube
placement is
recommended.
___ EEG:
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study due to diffuse slowing of the background activity with
occasional suppressive bursts indicative of a moderate-severe
encephalopathy which is non-specific with regard to etiology.
There is a single generalized sharp wave that does not recur
during the course of the study, suggestive of generalized
cortical irritability. However, there are no electrographic
seizures in this recording.
___ CT Head: Two small foci of hypodensity in the right
frontal lobe could reflect infarcts, possibly embolic given
multiplicity. Alternatively, these could be areas of confluent
white matter microvascular disease. Other possibilities such as
focal mass lesions can also not be excluded. An MRI if not
contra-indicated would be helpful for further evaluation.
No acute intracranial hemorrhage or mass effect. Moderate
frontal and mild right spheno-ethmoidal mucosal thickening with
some fluid in the frontal sinus.
___ MRI head:
1. There is no evidence of acute intracranial hemorrhage or
diffusion
abnormalities to indicate acute or subacute ischemic changes.
2. Scattered foci of high signal intensity in the subcortical
white matter are nonspecific and may reflect changes due to
small vessel disease.
___ EEG:
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study due to diffuse slowing of the background activity with
occasional suppressive bursts, indicative of a moderate-severe
encephalopathy, which is non-specific with regard to etiology.
There is minimal improvement of the background activity by the
end of the recording. There are rare generalized, frontally
predominant broad-based sharp and slow wave discharges,
indicative of underlying cortical irritability. There are no
clear electrographic seizures.
___ MR ___ spine:
1. Evaluation is significantly limited due to motion artifacts.
2. Multilevel degenerative changes of the cervical spine as
described above, most prominent at C3-4 and C6-7 with mild
spinal canal stenosis due to disc protrusion and hypertrophy of
the ligamentum flavum at C6-7.
3. Moderate right-sided neural foraminal stenosis at C3-4 and
C4-5.
4. No definite cord compression identified. Evaluation for
myelopathy limited due to motion artifact.
___ MRI head:
1. No evidence of acute hemorrhage, acute infarction, or mass
effect.
2. Unchanged scattered foci of T2/FLAIR signal hyperintensity
in the periventricular, subcortical, and deep white matter which
are nonspecific but likely on the basis of chronic small vessel
ischemic disease.
3. Unchanged chronic micro hemorrhage in the right frontal
lobe.
___ Renal U/S with doppler:
1. No sonographic signs of renal artery stenosis.
2. 6.5 cm right adrenal lesion may represent a
pheochromocytoma. Further evaluation with MRI is recommended
3. Multiple bilateral renal cysts. A 2.3cm lesion in the upper
pole of the right kidney appears complex and may represent a
complex cyst. Attention should be paid to this lesion on MRI to
exclude a cystic renal cell carcinoma.
___ CT head noncon:
No acute intracranial abnormality. Chronic changes of small
vessel disease and cerebral atrophy.
___ EEG:
IMPRESSION: This is an abnormal continuous video ICU monitoring
study because diffuse slowing of the background activity,
indicative of a mild to moderate encephalopathy, which is
non-specific with regard to etiology but may be due to various
causes, such as medication effects, toxic/metabolic disturbances
or infection. There are no epileptiform discharges or
electrographic seizures.
___ EEG:
IMPRESSION: This is an abnormal continuous video ICU monitoring
study because of diffuse slowing of the background activity.
During the early morning to mid-day, lower voltage theta rhythm
is evident which evolves to a moderate voltage by the late
afternoon. This is indicative of a mild to moderate
encephalopathy which improves by the afternoon, and it is
non-specific with regard to etiology, but may be due to various
causes such as medication effect, toxic/metabolic disturbances,
or infection. There are no epileptiform features or
electrographic seizures. There are no pushbutton activations.
___ MRI head:
1. No acute intracranial abnormality.
2. Stable changes related to prior right anterior and posterior
frontal remote infarcts. Stable hemosiderin staining associated
with posterior right frontal lobe area of injury.
3. Paranasal sinus disease as described.
___ MRI abdomen:
1. Normal adrenal glands.
2. 7.2 cm right upper pole renal mass correlating with the prior
ultrasound abnormality, incompletely evaluated due to
respiratory motion and lack of intravenous contrast. CT may be
helpful to assess for macroscopic fat within the mass. Lack of
bulk fat would favor a renal cell carcinoma, in particular clear
cell type, as the most likely diagnosis, whereas the presence of
bulk fat could indicate a hemorrhagic angiomyolipoma.
3. Numerous bilateral simple and hemorrhagic renal cysts likely
relating to chronic kidney disease.
4. Subcentimeter gallbladder polyp versus gallstone.
___ CT abdomen noncon:
1. 5.3 x 6.6 x 7.7 cm heterogeneous, soft tissue density mass
exophytic off of the upper pole of the right kidney with areas
of peripheral calcification and coarse central calcification
corresponding to the lesion of interest on prior MRI, consistent
with a renal cell carcinoma. No macroscopic fat is visualized
within the lesion.
2. Multiple additional hypodense and hyperdense lesions
scattered throughout both kidneys are incompletely evaluated on
the current exam. Please refer to the prior MRI of the abdomen
for more complete characterization.
3. Gallbladder sludge versus cholelithiasis.
Brief Hospital Course:
___ with DM, HTN, MM, CKD (baseline 2.5 creatitine), DVT on
coumadin, ?RA vs gout, recent R CVA now found down at home,
seizing in the setting of hypoglycemia (11 when found).
Intubated in OSH ED and transferred to ___ for further
management.
# Respiratory failure - Intubated at ___ in the setting
of a hypoglycemic seizure with no hypoxia or hypercarbia.
Oxygenated well on CMV but remained intubated due to
persistently altered mental status. Extubated successfully on
___.
# AMS - As per HPI, pt found down and found to be hypoglycemic.
Had seizure like activity at OSH. Daughter reports a prior
seizure once in the past in the setting of hypoglycemia. Based
on his history, seizure seems to be most likely from
hypoglycemia. He has no infectious symptoms. CT head without
mass or hemorrhage. Tox screen negative for ingestion. Initial
EEG showed slow, supressive bursts, no sz activity. MRI Head
showed no acute intracranial process. Neurology was consulted
and LP was performed. Results did not show any evidence of
infection, malignancy, or inflammatory process. He was
empirically covered with vancomycin and cefepime. However, in
the absence of any infectious source, these were discontinued on
___ and ___, respectively. In the setting of persistent
hypertension, there was concern for PRES and/or increased
intracranial pressure. However, repeat MRI was unchanged and BP
with improved control and no change in mental status. B12, TSH
were WNL. Unlikely to be vasculitis as ___ wnl. Received IV
thiamine but thiamine level returned wnl. While some changes on
DWI MRI can be seen in the setting of severe hypoglycemia,
neurology noted that absence of these findings on MRI does not
rule out profound hypoglycemia as a cause of persistent AMS.
Rare cases of encephalopathy due to hyperviscosity or high blood
levels of ammonia, in the absence of liver involvement, have
been reported with MM. However, Ammonia level normal. AM
cortisol level adequate. Copper level wnl. CT scan on ___
without evidence of acute process. Repeat EEG without signs of
seizure. Repeat MRI without change. On ___ patient began
speaking single words. Over the course of the week prior to
discharge, the patient began speaking in sentences. Sometimes
mumbling and at times confused but progressively more verbal,
especially in the afternoon. Overall picture was felt to be
hypoglycemia induced brain injury in a patient with poor reserve
given multiple comorbidities. Mental status slowly improving on
discharge.
# Nutrition: patient was fed through Dobhoff/NG tube during most
of hospital course and then G tube was placed on ___. Prior to
discharge he was able to tolerate ground solids and thin liquids
with 1:1 feeding as a supplement to full tube feeds.
# Diabetes - Patient has a history of diabetes which per his
daughter is very difficult to control with both hypo- and
hyperglycemia. He was given multiple amps of dextrose and
started on ___ for hypoglycemia in the ED. Monitored
fingersticks q2H on arrival and patient's sugars stabilized.
Daughter states Type I insulin dependent, but notes are
conflicting. Last oncology note states Type II so this is more
likely. He takes lantus 34U nightly only if his blood sugar is >
180, but it is not clear if this is what his PCP determined or
___ parameters. Last A1C was 6.7%. Received NPH 10
units @ Breakfast and NPH 12 units @ Bedtime with sliding scale.
# Hypernatremia: Intermittently hypernatremic while inpatient.
Patient depleted of free water in setting of NPO with tube feeds
and also wih hyperglycemia and likely glucosuria causing
diuresis. Patient lost dobhoff x 2 on ___ so did not receive
tube feeds or free water so became hypernatremic to 149 on ___.
Received D5W and Na normalized. Hypernatremic again on ___ with
Na 150 resolved with IVF. Required free water flushes at 250 Q4
and D5W whenever NPO.
# Renal mass: U/S with 6.5 cm right renal vs. adrenal lesion.
Initially concerning for pheo given difficult to controll HTN.
However 24hr urine metanephrines, catecholamines negative. Per
daughter patient has known renal mass. CT abdomen consistent
with renal cell carcinoma. Next step in treatment would be
resection. However, patient not a candidate for this given poor
prognosis from MM and current function status.
# Hypercalcemia: not a candidate for bisphosphonates due to
renal impairment. Received IVF and lasix prn Calcium elevated.
# Hypertension: Poorly controlled at baseline. No renal artery
stenosis on U/S. Initially required amlodipine and captopril for
SBPs 170-180s. Discontinued once SBPs 110-120s. Was on labetalol
800mg PO TID, decreased to 600 TID home dose. Was on hydralazine
100mg PO TID but decreased to 50mg TID and holding parameters
for SBP<120s. Discontinued amlodipine and captopril when SBPs
120s. Continued home Clonidine 0.4 mg PO BID. Also focused on
pain control.
# ___ on CKD: Per daughter, stage IV and thinks baseline is
around 2.5. Cr 2.4 on arrival here. Cr bumped to 2.9 on ___.
S/p 1L NS on ___ with drop in Cr to 2.7. Resolved back to 2.5
on ___.
# DVT - Right leg, on warfarin at home 3mg and 4mg daily
alternating. While initially held in the setting of a
supratherapeutic INR, he was restarted on warfarin on ___. His
daily INR goal was ___ and his previous outpatient regimen was
warfarin 3mg MWF and warfarin 4mg TTSS. Discharged on 3mg daily
given INR 3.3
# Dyspepsia - Per family has had recent weight loss, poor
appetite, and indigestion. He may have gastroparesis related to
neuropathy. He was continued on famotidine and calcium carbonate
while intubated, omeprazole and metoclopromide were held. The
patient had emesis with TF. He was started on erythromycin
temporarily with good effect. Erythromycin DCed due to prolonged
QTc. Patient tolerated tube feeds well.
# Hypertension - Baseline BP is 140-150s at best but often much
higher at home. Initially continued home clonidine, labetalol,
hydralazine. Increased labetalol dose to 800 TID, but the
patient had persistent HTN. Labetalol was increased to 800 QID,
amlodipine 5mg was added, and captopril 6.25mg TID was added. It
was also noted that some of the patient's HTN may have been ___
pain. His oxycodone was uptitrated during his hospital course.
# Multiple Myeloma - last oncologist notes, diagnosed in ___
with MGUS and then progressed to MM on BM biopsy. He was started
on lenalinomide and dexamethasone in ___ but he
developed severe pesudogout exacerbations and was changed to
cyclophosphamide, velcade, and dexamethasone. His last
chemotherpay was ___ but his treatment was stopped at his
daughter's request after recovering from a stroke. Continued
acyclovir prophylaxis and oxycodone for bone pain.
# Depression - Continued venlafaxine
# RA - Continued hydroxychloroquine
# HCP: daughter ___ ___
# Code: Full Code
**Transitional Issues**
- Restart epogen 10,000units SC once weekly
- Continue to adjust warfarin to goal INR ___
- Continue to address goals of care given overall poor prognosis
and can offer palliative care/hospice if not improving
- Ongoing speech and swallow evaluation
- Continue finger sticks QID given fluctuating blood glucose
- If NPO for any time period, will need D51/2NS IVF given
propensity for hypernatremia
- If hypercalcemic, can give IVF and lasix (cannot receive
bisphosphonates given poor renal function)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydroxychloroquine Sulfate 200 mg PO BID
2. Omeprazole 20 mg PO BID
3. Famotidine 20 mg PO DAILY
4. CloniDINE 0.4 mg PO BID
5. Labetalol 600 mg PO TID
6. Acyclovir 200 mg PO Q8H
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. HydrALAzine 100 mg PO TID
9. Venlafaxine XR 37.5 mg PO DAILY
10. Glargine 34 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Calcium Carbonate 500 mg PO TID
13. Magnesium Oxide 400 mg PO TID
14. Metoclopramide 10 mg PO QIDACHS
15. Atorvastatin 40 mg PO QPM
16. Vitamin D 1000 UNIT PO DAILY
17. Warfarin 3 mg PO 3X/WEEK (___)
18. Warfarin 4 mg PO 4X/WEEK (___)
Discharge Medications:
1. Acyclovir 200 mg PO Q8H
2. Atorvastatin 40 mg PO QPM
3. CloniDINE 0.4 mg PO BID
4. Famotidine 20 mg PO DAILY
5. HydrALAzine 50 mg PO TID
6. Hydroxychloroquine Sulfate 200 mg PO BID
7. NPH 10 Units Breakfast
NPH 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Labetalol 600 mg PO TID
hold for SBP<100
9. Metoclopramide 5 mg PO TID
10. Venlafaxine XR 37.5 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Warfarin 3 mg PO DAILY16
13. Acetaminophen 650 mg PO Q8H
14. Docusate Sodium 100 mg PO BID
15. Glucose Gel 15 g PO PRN hypoglycemia protocol
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. OxycoDONE Liquid 5 mg PO Q6H:PRN pain
18. Polyethylene Glycol 17 g PO DAILY
19. Pyridoxine 100 mg PO DAILY
20. Senna 8.6 mg PO BID
21. Fluticasone Propionate NASAL 1 SPRY NU DAILY
22. Omeprazole 20 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypoglycemia
Seizure
Persistent altered mental status
Acute on chronic kidney injury
Multiple myeloma
Hypercalcemia
Hypernatremia
Renal mass likely renal cell carcinoma
Diabetes
Hypertension
DVT on warfarin
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at ___. You were
admitted after being found down at home. You had severe
hypoglycemia. You had persistent altered mental status while in
the hospital which slowly improved to the point where you were
able to speak sentences prior to discharge. You had an extensive
neurological work up including multiple EEGs, MRIs, a lumbar
puncture, and extensive lab work all of which was unrevealing
for a cause of your altered mental status. While inpatient it
was discovered that you have a tumor in your kidney which is
likely a cancer called renal cell carcinoma. Unfortunately given
your progressive multiple myeloma and poor functional status,
you are not a candidate for any treatment for this tumor. You
also have complications of your multiple myeloma including
anemia requiring blood transfusions and hypercalcemia which we
can only treat with IV fluid at this point. You had a feeding
tube placed as you were not able to take in enough food. You are
being discharged to a long term acute care facility for ongoing
care.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
10376286-DS-18 | 10,376,286 | 26,862,263 | DS | 18 | 2128-01-11 00:00:00 | 2128-01-11 18:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
penicillin G / Sulfa(Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
PICC Insertion ___
History of Present Illness:
___ man with a history of stage IIB testicular seminoma
status post orchiectomy and XRT to RP nodes with recurrence in a
left cervicothoracic mass s/p 4 cycles EP completed ___ found
today to have retroperitoneal recurrence with L sided
hydronephrosis.
___ says that he has been having L lower back pain of
late,, it is beside the spinal column and not directly in the
midline. He points up and down his L paraspinal muscles in
lumbar
region when asked to show location of pain. He denies any other
sx. YEsterday his urine started looking somewhat yellowish and
he
started consuming more water.
His parents who are at his bedside nudge him to reveal his
alcohol and marijuana use. He drinks about ___ glasses of beer
PLUS ___ drinks of whiskey/hard liqor 'every other day'. He does
not smoke cigarettes, has a Marijuana card that he uses to
obtain
marijuana to smoke.
No other sx. ROS below.
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. POSITIVE for constipation.
GU: No dysuria or change in bladder habits.
MSK: Left low back pain. No urnary retention. normal strength
and
sensation in lower extremities.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
Past Medical History:
Medical History:
Stage IIb seminoma
Patent ductus arteriosus
ADHD
Asthma
Surgical History:
Left eye: "lazy eye"
L Orchiectomy/Prosthesis
Social History:
___
Family History:
Mother and father are healthy, no FH of cancer. Older sister is
healthy.
Physical Exam:
=======================
ADMISSION PHYSICAL
=======================
General: NAD
VITAL SIGNS:98.5 PO 120 / 70 93 18 93 RA
HEENT: MMM, no OP lesions, no thrush.
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB, no wheezes
ABD: BS+, soft, no masses or hepatosplenomegaly
Negative CVAT. No pain to palpation. tenderness mostly on L
lumbar paraspinal muscles. No pain on ballotment of kidneys,
Minimal tenderness on deep palpation of abdomen in epigastric
region.
LIMBS: No edema, clubbing, tremors,
SKIN: No rashes or skin breakdown
=======================
DISCHARGE PHYSICAL
=======================
98.1 130 / 73 83 16 93 RA
General: NAD
HEENT: MMM, no OP lesions, no thrush.
CV: RR, NL S1S2 no MRG
PULM: CTABL
ABD: BS+, soft, ND/NT, no HSM
Back: no spinous process tenderness
LIMBS: No ___ edema, clubbing
SKIN: No rashes or skin breakdown
Neuro: speaking fluently, responds appropriately to questions
Access: PICC, non inflamed
Pertinent Results:
========================
ADMISSION LABS
========================
___ 12:07AM BLOOD WBC-8.8# RBC-3.69* Hgb-11.4* Hct-34.1*
MCV-92 MCH-30.9 MCHC-33.4 RDW-13.2 RDWSD-45.2 Plt ___
___ 12:07AM BLOOD Neuts-74.1* Lymphs-13.3* Monos-9.6
Eos-2.5 Baso-0.2 Im ___ AbsNeut-6.48*# AbsLymp-1.16*
AbsMono-0.84* AbsEos-0.22 AbsBaso-0.02
___ 12:07AM BLOOD ___ PTT-34.6 ___
___ 12:07AM BLOOD Glucose-102* UreaN-9 Creat-0.8 Na-135
K-3.7 Cl-97 HCO3-24 AnGap-18
___ 12:07AM BLOOD ALT-50* AST-35 LD(LDH)-473* AlkPhos-134*
TotBili-1.0
___ 12:07AM BLOOD Albumin-4.2 Calcium-9.0 Phos-3.2 Mg-2.2
UricAcd-5.0
___ 12:07AM BLOOD HCG-<5
___ 12:07AM BLOOD AFP-1.6
___ 09:09PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:09PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG
___ 09:09PM URINE RBC-3* WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
=========================
DISCHARGE LABS
=========================
___ 06:03AM BLOOD WBC-3.5*# RBC-3.47* Hgb-10.7* Hct-32.6*
MCV-94 MCH-30.8 MCHC-32.8 RDW-13.2 RDWSD-45.7 Plt ___
___ 06:03AM BLOOD ___ PTT-29.0 ___
___ 06:03AM BLOOD Glucose-114* UreaN-11 Creat-0.6 Na-136
K-4.0 Cl-101 HCO3-22 AnGap-17
___ 06:03AM BLOOD ALT-103* AST-31 LD(LDH)-320* AlkPhos-108
TotBili-0.8
___ 06:03AM BLOOD ALT-103* AST-31 LD(LDH)-320* AlkPhos-108
TotBili-0.8
___ 06:03AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2 UricAcd-3.2*
=========================
IMAGING
=========================
___ CT Torso
FINDINGS:
The imaged base of neck including the thyroid gland appear
normal. There is no mediastinal, hilar or axillary
lymphadenopathy. A retrocrural lymph node just below the hiatus
measures up to 1 cm in short axis better assessed on same-day CT
abdomen pelvis.
The heart is normal in size and shape without pericardial
effusion. Residual thymic tissue is seen in the anterior
mediastinal space. The thoracic aorta is normal in course and
caliber without appreciable atherosclerosis. The main pulmonary
artery is normal in size with patent central branches. The
airways centrally patent. Trace left pleural effusion is noted
with adjacent mild atelectasis. No right-sided effusion or
pericardial effusion.
The lungs are clear without worrisome nodule, mass, or
consolidation.
Please refer to same-day dedicated CT abdomen pelvis for
findings below the diaphragm.
Bones: No acute lytic or blastic osseous lesion.
IMPRESSION:
1. No evidence of metastatic disease within the chest. Please
refer to CT
abdomen pelvis performed same day reported separately for
further details.
2. Trace left pleural effusion with adjacent atelectasis.
LOWER CHEST: Please refer to separate report of CT chest
performed on the same day for description of the thoracic
findings.
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 shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of focal renal lesions.
There is mild left hydronephrosis. The ureter is tethered to
necrotic retroperitoneal lymph nodes that are described below.
This is best seen on series 601b, ___ 36 There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal
limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate gland is normal. The patient
is status post left orchiectomy.
LYMPH NODES: The left para- aortic region on the left will of
the renal
vessels there is a 4.3 x 3.9 cm. Centrally necrotic mass. This
appears to infiltrate the psoas muscle. As seen on series 2 ___
72. Enlarged lymph node is identified anterior to the aorta on
series 2 ___ 71 this measures 1.2 cm and is round in appearance.
There is retroperitoneal lymphadenopathy at the level of the
aortic bifurcation. A mass posterior to the vessels measures
4.5 x 2.8 cm. A 1.5 and 1.2 cm are centrally necrotic lymph node
is seen in the left common iliac region on series 2, ___ 88. A
left external iliac lymph node measures 1.8 x 1.6 cm on series
2, ___ ___ VASCULAR: There is no abdominal aortic
aneurysm. Mild atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. Small sclerotic foci are seen in the femoral
head bilaterally and the acetabulum on the left. These are most
consistent with bone islands.
SOFT TISSUES: There is fat stranding in the anterior abdominal
wall of the
left on series 2 ___ at ___ close to the left groin
with a a small linear calcified structure likely representing a
suture.
IMPRESSION:
1. Retroperitoneal and pelvic lymphadenopathy concerning for
metastatic
disease
2. There is mild left hydronephrosis, the left ureter is
tethered to the
adenopathy
___ ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF = 65%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no pericardial effusion.
IMPRESSION: normal study
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of stage IIB
testicular seminoma s/p orchiectomy/XRT with disease recurrence
s/p EP chemotherapy who presented with back pain. CT torso
showed new pelvic and retroperitoneal lymphadenopathy with
associated left-sided hydronephrosis, which was concerning for
new metastatic disease. He was treated with TIP chemotherapy
which he tolerated well, and will likely have an auto-transplant
in the near future.
#Stage IIB testicular seminoma
Initially diagnosed in ___ and treated with orchiectomy
and 22 radiation treatments to his para-aortic and left iliac
lymph nodes, which he completed ___. In ___
surveillance CT showed he had disease recurrence in the
intrathoracic, anterior mediastinum, and cervical region. He
then received 4 cycles of EP chemotherapy (bleomycin withheld
given marijuana use), which he completed in ___. He then
developed back pain a few days prior to his current admission,
which on CT torso was likely explained by new pelvic and
retroperitoneal lymphadenopathy, which was concerning for new
metastatic disease. He was initiated on TIP chemotherapy, which
he tolerated well (no signs of tumor lysis and daily urinalysis
were normal). He will likely undergo auto-transplant in the near
future, final plan to be determined as outpatient.
#Hydronephrosis, left-sided
Likely secondary to tethering of pelvic lymph node to ureter.
His creatinine was stable and there was no signs or symptoms of
renal failure. Will monitor on sequential scans
#Transaminitis
Pt w/mild elevated of ALT over admission, peaked at 133, most
likely ___ chemotherapy. There were no signs of liver disease on
his CT torso. INR/TBili were wnl. Will monitor LFTs as
outpatient.
#Behavioral Health:
Psychiatry consulted for depression, anxiety, distressing
thoughts, and alcohol/cannabis use. They recommended starting
low-dose Seroquel for his chronic depression/anxiety given
concerns for potential SSRI-induced mania and limited short-term
benefit of SSRI. Social work is to follow up with patient
regarding outpatient mental health follow up, and PCP ___
schedule ___ referral.
***TRANSITIONAL ISSUES***
#New medication: Seroquel 25mg QHS, Zofran 8mg TID:PRN, Neulasta
#Pt will need outpatient psych follow up, Psych evaluated while
inpatient, have already discussed with PCP who will need to make
referral, SW gave resources . Started on Quetiapine 25mg qhs,
consider uptitration to 50mg qhs as tolerated
#Pt had mild transaminitis over admission, please monitor LFTs,
Electrolytes, will have labs checked on ___
#Pt will need to complete auto-transplant workup, TTE and EKG
were done during this hospitalization, unable to get PFTs.
#Pt will f/u with ___ for Neulasta on ___
#HCP: ___, mother, ___
#Code status: full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation QID:PRN
Discharge Medications:
1. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth TID:PRN Disp #*30
Tablet Refills:*0
2. Pegfilgrastim Onpro (On Body Injector) 6 mg SC ONCE
Duration: 1 Dose
RX *pegfilgrastim [Neulasta] 6 mg/0.6 mL 6 mg SC once Disp #*1
Syringe Refills:*0
3. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth qhs:prn Disp #*30
Tablet Refills:*0
4. albuterol sulfate 90 mcg/actuation inhalation QID:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: stage IIB testicular seminoma
Secondary diagnosis: low back pain, left sided hydronephrosis,
transaminitis, normocytic anemia, patent ductus arteriosus,
attention deficit hyperactivity disorder, alcohol use disorder,
cannabis use, anxiety disorder NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ from ___ to ___.
===========================================
Why did you come to the hospital?
===========================================
-Your back hurt.
===========================================
What happened at the hospital?
===========================================
-A scan of your torso showed that your testicular cancer
returned.
-We started a chemotherapy regimen called "TIP" and your back
pain resolved.
-Our social work staff helped you get approved with Mass Health
-We started a medication called Seroquel (quetiapine), which was
recommended by our psychiatry service.
-You had an ultrasound of your heart (which was normal) in
preparation for bone marrow transplant.
==================================================
What needs to happen when you leave the hospital?
==================================================
-Follow up with your oncologist regarding future chemotherapy
plans and the further testing that is needed before your bone
marrow transplant.
"If you are ever in psychiatric crisis, or are interested in
referrals for various levels of psychiatric care including day
programs, clinics, or crisis units, you can always reach out to
the BEST ___ Emergency Services Team, ___
It was a pleasure taking care of you!
Your ___ oncology team.
Followup Instructions:
___
|
10376494-DS-4 | 10,376,494 | 21,496,892 | DS | 4 | 2153-01-09 00:00:00 | 2153-01-14 16:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
___ with atrial fibrillation, hypertension, and BPH presenting
with an acute onset of SOB and 'indigestion'. Pt reported that
his symptoms started earlier ___. He was recently seen in
the ED for similar symptoms and cardiac work up with
unrevealing. Patient currently denies CP, diaphoresis, or N/V.
Patient report that he recently received a call that he was
going to receive oxygen at home. Pt reports that he has
exertional dyspnea and was told that his oxygen level drops
while walking. When asked why, he reports that 'his lungs are
fine'.
He reports that he was unable to eat because of the indigestion.
He feels that he is retaining gas and feels full up to his
throat but cannot burp. He denies difficulty swallowing. His
last bowel movement was yest morning and patient reports that he
is very regular.
In the ED, initial vitals were 98.2 72 130/52 18 99%RA. Labs
showed a creatinine of 1.4, which is at baseline. Hematocrit was
36, which is also at baseline. INR was 2.4 on coumadin. Troponin
was negative x 2. Urine was significant for ketones of 10. Chest
X-ray was unremarkable. Patient's initial ECG was unremarkable,
but a second tracing showed ST depressions in V3-V6, while the
patient was having symptoms. Patient reports that while in the
ED, there was ___ minutes when he felt his heart was beating
so fast that he felt like he was dying; he also felt short of
breath. Patient was guaiac negative. Cardiology was consulted
and recommended administering aspirin and atorvastatin, and
requested a stress echocardiogram. Stress echocardiogram showed
findings concerning for RCA disease and it was decided to admit
the patient for possible catheterization.
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. S/he denies recent fevers, chills or
rigors. S/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 current
chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope.
On arrival to the floor, the patient reports that he feels a
little tired from the stress test, but otherwise feels well.
Past Medical History:
1) Hypertension
2) Diabetes Mellitus Type II- diet controlled
3) Gross hematuria/retention in ___- urine cytology
negative, cystoscopy negative
4) Prior history of elevated PSA in ___ (prior biopsy negative)
5) Colon polyps, s/p resection ___ (3 benign adenomas)
6) Benign Prostatic Hypertrophy
7) Microalbuminuria
8) Hypothyroidism, diagnosed 2 months prior to this admission,
taking Levothyroxine
9) Prostatitis
10) Atrial fibrillation
11) Chronic kidney disease
Social History:
___
Family History:
Positive for diabetes and CAD
Physical Exam:
ADMISSION:
VS: 97.0, 138/64, 60, 20, 98% RA; weight 78.6 kg
Gen: Pleasant, calm, no respiratory distress
HEENT: Mild conjunctival pallor. No icterus. MMM. OP clear. Poor
dentition
NECK: Supple, No LAD. JVP 7-8cm.
CV: PMI in ___ intercostal space, mid clavicular line. RRR w/
occasional ectopy. Normal S1,S2. No murmurs, rubs, clicks, or
gallops
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
EXT: WWP, NO CCE. Full distal pulses bilaterally. No femoral
bruits.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. Preserved sensation
throughout. ___ strength throughout.
PSYCH: Mood was euthymic.
DISCHARGE:
VS: 98.5/98.2, 113/59-153/63, 62-78, 20, 97% RA
Tele: occasional PVCs
79.3kg <- 79.6kg <- 79.8kg <- 78kg
FSBG 116, 150
Gen: NAD NT ND
NECK: Supple, No LAD. JVP not visible.
CV: RRR no m/r/g
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM.
EXT: WWP, NO CCE.
SKIN: No rashes/lesions, ecchymoses.
NEURO: alert, fluent, linear, prompt
Pertinent Results:
LABS:
___ 05:20AM BLOOD WBC-7.2 RBC-4.09* Hgb-11.7* Hct-36.3*
MCV-89 MCH-28.5 MCHC-32.1 RDW-19.4* Plt ___
___ 07:55AM BLOOD WBC-6.9 RBC-3.87* Hgb-10.9* Hct-34.2*
MCV-88 MCH-28.2 MCHC-31.9 RDW-19.1* Plt ___
___ 05:20AM BLOOD ___ PTT-37.8* ___
___ 07:30AM BLOOD ___ PTT-57.0* ___
___ 07:10AM BLOOD ___ PTT-39.0* ___
___ 07:55AM BLOOD ___ PTT-32.6 ___
___ 05:20AM BLOOD Glucose-107* UreaN-26* Creat-1.4* Na-143
K-4.5 Cl-104 HCO3-27 AnGap-17
___ 07:10AM BLOOD Glucose-88 UreaN-16 Creat-1.1 Na-144
K-4.0 Cl-111* HCO3-25 AnGap-12
___ 07:55AM BLOOD Glucose-95 UreaN-16 Creat-1.2 Na-142
K-3.8 Cl-106 HCO3-29 AnGap-11
___ 05:20AM BLOOD ALT-17 AST-29 AlkPhos-78 TotBili-0.4
___ 01:12AM BLOOD CK(CPK)-77
___ 05:20AM BLOOD CK(CPK)-67
___ 05:20AM BLOOD cTropnT-<0.01
___ 11:40AM BLOOD cTropnT-<0.01
___ 01:12AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:20AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:20AM BLOOD Albumin-4.2
___ 05:20AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.1
___ 07:55AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.5
___ 06:00AM URINE Color-Straw Appear-Clear Sp ___
___ 06:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 06:00AM URINE
.
STUDIES:
EKG: NSR w/ PACs/PVCs, normal axis, normal intervals, normal R
wave progression, T wave inversions in ___ leads c/w
prior, no ST elevations
2D-ECHOCARDIOGRAM:
Stress Echo ___:
IMPRESSION: average functional exercise capacity. ischemic ECG
changes with 2D echocardiographic evidence of inducible RCA
ishemia at achieved workload.
ETT ___:
IMPRESSION: Probable ischemic ECG changes noted in the setting
of
abnormal baseline ECG. No anginal type symptoms. BLutned
hemodynamic
response. Echo report sent separately. Compared to prior study
of ___, ECG changes are similar, but functional capacity
increased. Findings discussed with cardiology consult fellow in
person.
Cardiac Cath ___:
1. No angiographically apparent CAD.
2. Normal LV function with no wall motion abnormalities.
3. Normal left heart filling pressures.
Brief Hospital Course:
___ with atrial fibrillation, hypertension, and BPH presenting
with an acute onset of SOB and "indigestion," found to have
ischemic ECG changes with 2D echocardiographic showing evidence
of inducible RCA ischemia at achieved workload. Initially we
started aspirin and atorvastatin. Patient had no chest pain or
SOB on the floor. He did have indigestion, which resolved with
belching and simethicone. Cardiac catheterization was not
performed until INR trended down to 1.8 (warfarin was held
during admission). Left-heart catheterization showed no
evidence of coronary artery disease. Aspirin and atorvastatin
were stopped. Warfarin was restarted. Lisinopril 5mg daily was
started for better blood pressure control. Chronic kidney
disease was at baseline. Patient was in sinus rhythm during the
hospitalization. Patient was full code during this
hospitalization. He will follow up with his PCP and his
cardiologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 4 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO UNDEFINED
daily on ___
4. Metoprolol Succinate XL 50 mg PO DAILY
5. tadalafil *NF* 5 mg Oral daily
6. Warfarin 4 mg PO 5X/WEEK (___)
7. Zolpidem Tartrate 10 mg PO HS
8. saw ___ *NF* unknown dose Oral daily
9. Levothyroxine Sodium 50 mcg PO UNDEFINED
daily on ___
10. Warfarin 5 mg PO 2X/WEEK (MO,FR)
11. melatonin *NF* 3 mg Oral daily
12. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Doxazosin 4 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO UNDEFINED
daily on ___
4. Zolpidem Tartrate 10 mg PO HS
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Simethicone 80 mg PO QID:PRN indigestion
DO NOT take within an hour of taking levothyroxine
RX *simethicone 80 mg 1 tablet by mouth QID PRN Disp #*120
Tablet Refills:*0
7. Ferrous Sulfate 325 mg PO BID
DO NOT take within an hour of taking levothyroxine
8. Levothyroxine Sodium 50 mcg PO UNDEFINED
daily on ___
9. melatonin *NF* 3 mg Oral daily
10. saw ___ *NF* 0 dose ORAL DAILY
11. tadalafil *NF* 5 mg Oral daily
12. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
___:
Chest pain
Atrial fibrillation
Hypertension
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 chest pain. You were
found to have a positive stress test suggestive of coronary
artery disease. You had a cardiac catheterization that did not
show any evidence of coronary artery disease. You were started
on a medication called lisinopril for hypertension.
Please follow up with your doctors as ___ below.
Please call ___ to have your INR checked on ___.
Followup Instructions:
___
|
10376609-DS-7 | 10,376,609 | 22,700,526 | DS | 7 | 2174-07-03 00:00:00 | 2174-07-03 21:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
propoxyphene
Attending: ___.
Chief Complaint:
Abdominal distension; ascites
Major Surgical or Invasive Procedure:
-Therapeutic Paracentesis ___
-Therapeutic Paracentesis ___
- EGD ___
History of Present Illness:
Ms. ___ is a very pleasant ___ year-old lady with history of
rheumatoid arthritis, type 2 diabetes mellitus, who presents on
___ from ___ with a 3 week history of increasing
abdominal distention, found to have new ascites and cirrhosis.
Patient started noticing her stomach growing in size 4 weeks
ago. She denies any abdominal pain, but rather describes it as a
"discomfort" which she attributes to her stomach stretching. She
reports several months of yellowy watery stools, intermittent
fevers to 100.6F for several weeks (particularly at night). She
had previously had intentional weight loss of 100 lb over the
past year.
She went to her rheumatologist yesterday, who did some lab work
and sent her to ___ for an MRI. Following those results,
she was sent to ___ where her labwork was repeated and
she was transferred to ___ for evaluation of new ascites.
Denies excessive alcohol or acetaminophen intake, IVDU, blood
transfusions. She has a 40 pack yr smoking history. She has had
a colonoscopy, pap smear, and mammogram many years ago that were
reportedly unremarkable.
In the ED, initial VS were: T 98.5 HR 104 BP 103/55 RR 20 SpO2
96% RA
Past Medical History:
Type 2 diabetes
Rheumatoid arthritis
Hypertension
Social History:
___
Family History:
Denies family history of liver disease
Son has rheumatoid arthritis and fibromyalgia
Physical Exam:
=============================
ADMISSION PHYSICAL EXAMINATION
=============================
24 HR Data (last updated ___ @ 940)
Temp: 98.0 (Tm 99.5), BP: 111/72 (111-121/61-72), HR: 100
(100-110), RR: 17 (___), O2 sat: 93% (93-94), O2 delivery: Ra,
Wt: 222.3 lb/100.84 kg
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, ejection systolic murmur on the RUSB, gallops,
or rubs
PULM: CTAB, bibasilar rales.
GI: abdomen soft, distended, tensely protuberant abdomen,
nontender, notable for shifting dullness; organomegaly could not
be assessed.
EXTREMITIES: no cyanosis, clubbing. 2+ peripheral edema
bilaterally
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric.
DERM: warm and well perfused, no excoriations or lesions, no
rashes.
=============================
DISCHARGE PHYSICAL EXAMINATION
=============================
24 HR Data (last updated ___ @ ___
Temp: 98.8 (Tm 98.8), BP: 101/67 (84-101/48-67), HR: 84
(82-92), RR: 18, O2 sat: 96% (96-99), O2 delivery: Ra
NECK: supple, no LAD
CV: RRR, S1/S2, ejection systolic murmur on the RUSB, gallops,
or rubs
PULM: CTAB, bibasilar rales.
GI: abdomen soft, abdominal distention decreased, nontender,
notable for shifting dullness; organomegaly could not be
assessed.
EXTREMITIES: no cyanosis, clubbing. her peripheral edema
improved
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric.
DERM: warm and well perfused, no excoriations or lesions, no
rashes.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 06:47PM BLOOD WBC-5.8 RBC-3.12* Hgb-10.5* Hct-30.8*
MCV-99* MCH-33.7* MCHC-34.1 RDW-15.0 RDWSD-53.7* Plt ___
___ 06:47PM BLOOD Neuts-89* Bands-1 Lymphs-10* Monos-0
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-5.22 AbsLymp-0.58*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 06:47PM BLOOD ___ PTT-32.3 ___
___ 06:47PM BLOOD Glucose-131* UreaN-20 Creat-0.9 Na-140
K-4.0 Cl-101 HCO3-24 AnGap-15
___ 06:47PM BLOOD ALT-19 AST-38 AlkPhos-86 TotBili-1.8*
___ 05:35AM BLOOD TotProt-5.5* Albumin-2.6* Globuln-2.9
Calcium-8.2* Phos-2.8 Mg-1.5*
============
NOTABLE LABS
============
___ 04:35AM BLOOD WBC-3.2* RBC-2.24* Hgb-7.6* Hct-22.0*
MCV-98 MCH-33.9* MCHC-34.5 RDW-14.8 RDWSD-50.5* Plt Ct-44*
___ 04:35AM BLOOD Neuts-62 Bands-0 ___ Monos-8 Eos-3
Baso-0 ___ Myelos-0 AbsNeut-1.98 AbsLymp-0.86*
AbsMono-0.26 AbsEos-0.10 AbsBaso-0.00*
___ 06:47PM BLOOD Lipase-15
___ 06:47PM BLOOD proBNP-54
___ 12:55PM BLOOD TSH-1.4
___ 12:55PM BLOOD T4-7.5
___ 06:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS*
___ 06:40AM BLOOD AMA-NEGATIVE Smooth-POSITIVE A
___ 07:35AM BLOOD AFP-2.3
___ 06:40AM BLOOD ___
___ 06:47PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG
___ 05:40AM BLOOD CMV VL-NOT DETECT
___ 06:40AM BLOOD HCV Ab-NEG
___ 04:35AM BLOOD Folate-19 Hapto-121
==============
DISCHARGE LABS
==============
___ 06:06AM BLOOD WBC-3.3* RBC-2.65* Hgb-8.9* Hct-26.6*
MCV-100* MCH-33.6* MCHC-33.5 RDW-15.7* RDWSD-55.4* Plt ___
___ 06:06AM BLOOD Neuts-49.6 ___ Monos-11.3 Eos-6.1
Baso-0.3 Im ___ AbsNeut-1.62 AbsLymp-1.05* AbsMono-0.37
AbsEos-0.20 AbsBaso-0.01
___ 06:06AM BLOOD ___
___ 06:06AM BLOOD Glucose-144* UreaN-11 Creat-0.7 Na-142
K-3.9 Cl-107 HCO3-25 AnGap-10
___ 06:06AM BLOOD ALT-11 AST-23 TotBili-0.9
___ 06:06AM BLOOD Calcium-8.2* Phos-2.0* Mg-1.6
=======
IMAGING
=======
DUPLEX DOPPLER/US ABDOMEN/PELVIS - ___
1. Patent hepatic vasculature.
2. Cirrhotic liver without visualized focal lesions.
3. Moderate volume ascites fluid.
4. Mild splenomegaly measuring up to 13.5 cm.
5. Cholelithiasis without evidence of cholecystitis.
CT ABDOMEN WITH & WITHOUT CONTRAST - ___
1. Cirrhotic liver with findings of portal hypertension
including moderate
volume ascites, portosystemic collaterals, portal colopathy, and
splenomegaly.
2. Limited study due to suboptimal late arterial phase timing
and exclusion of
inferior hepatic tip on delayed phase. Given the limitation, no
focal hepatic
lesions meeting OPTN criteria for HCC within the visualized
liver.
3. Cholelithiasis without cholecystitis.
4. No acute process within the abdomen and pelvis.
5. Please see separate report performed on same day for detailed
evaluation of
the chest.
CT CHEST W/ CONTRAST - ___
Multiple hypodense lesions within the thyroid could be related
to multinodular
goiter. ___ be further evaluated by an ultrasound if
indicated.
No lunG nodules.
EGD - ___
Grade 1 esophageal varices.
=================
PATHOLOGY & MICRO
=================
PERITONEAL FLUID - CYTOLOGY - ___
NEGATIVE FOR MALIGNANT CELLS - Reactive mesothelial cells and
red blood cells.
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION
___ 8:30 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
SUMMARY
========
Ms. ___ is a very pleasant ___ year-old lady with history of
rheumatoid arthritis, type 2 diabetes mellitus, who presents
with ascites and newly discovered liver cirrhosis.
ACUTE ISSUES:
===============
# Ascites
# Liver cirrhosis
The patient presents to the emergency department on ___ with
abdominal distention of 4-week duration. She thought she was
gaining weight and was waiting for regular follow-up appointment
with Rheumatologist Dr. ___. Abdomen U/S (___) showed
cirrhotic liver without evidence of concerning focal lesions.
Diagnostic paracentesis at ___ did not show signs of
spontaneous bacterial peritonitis (ascitic WBC: 190). The
patient underwent a therapeutic paracentesis on ___, and 4
liters of fluid were drawn. The patient was given albumin 25%
37.5g after the procedure. A second paracentesis was performed
on ___ by interventional radiology, and 3 liters of fluid
was drained. The etiology of liver cirrhosis seems to be
multifactorial in the setting of metabolic syndrome (fatty
liver; patient used to be obese with intentional 100 lbs loss,
type 2 diabetes) and treatment with methotrexate since ___.
Viral hepatitis work up was negative for an active infection.
Methotrexate was stopped during this hospital admission. The
patient was discharged on Lasix 20mg and spironolactone 50mg
daily (of note , the patient had hypotension with furosemide 40
and spironolactone 100).
- Hepatic encephalopathy (HE): the patient did not exhibit
symptoms of HE during this hospital admission
- Esophageal varices: Grade 1 varices without red signs - EGD on
___ - Beta blockers were deferred
- INR: 1.5 on discharge
#Pancytopenia
#low grade nocturnal fevers
Hospital course was complicated by pancytopenia. on admission
___, WBC count: 5.8K, ANC: 5.22, Hb: 10.5 and platelet count
203. Blood counts reached a nadir on ___, WBC count: 2.2K,
ANC: 0.77, Hb: 7.8 and platelet count 45.
After ___, blood counts improved gradually and on discharge
ANC:1.6, and plts: 109. Blood smear reviewed by Heme/onc showed
burr cells. No signs of hemolysis were noted. The etiology of
pancytopenia remains uncertain but given improvement, it thought
to be viral in nature. VZV, EBV and herpes viral loads were
negative. Parvo virus ab is pending.
# Hypotension
# low grade fever (resolved)
On ___, the patient triggered for low blood pressure of
70-80s/50s. Low
blood pressure was thought to be due to hypovolemia (received
furosemide 40 and spironolactone 100). The patient also spiked
intermittent low grade fevers nightly prior ___. The patient
was given cefepime 2g IV Q8H for febrile neutropenia. Cefepime
was stopped on ___.
# Rheumatoid arthritis
Prior to this admission, the patient used to takes Methotrexate
15mg weekly, Humira shots every other week. She follows with
rheumatologist Dr. ___ in ___.
No concern for active flare. Methotrexate was held during this
admission The patient can countinue to take humira under
rheumatology supervision.
CHRONIC ISSUES:
===============
#Hyperlipidemia
- Countinued atorvastatin 10mg daily
# DM Type II
- Continued home metformin and Trulicity
# Sciatica
- Continued gabapentin 300mg qHS for now
Transitional Issues:
====================
- Code status: full (confirmed)
- Contact: ___, sister: ___
- Discharge weight: 137 Kg
- Discharge Hb: 8.9
- Discharge WBC: 3.3 and ANC: 1.62
- Discharge Cr: 0.7
#Cirrhosis
[] Consider vaccination for hepatitis B
[] Follow up with Dr. ___
[] Monitor weight on every outpatient visit
[] Continue furosemide 20mg QD and spironolactone 50mg QD
[] Diet: good caloric intake. low sodium diet
#Pancytopenia
[] CBC with differential in one week at follow up visit
[] follow up parvovirus ab results
#Rheumatoid arthritis
[] Follow up with Dr. ___
[] Discontinued methotrexate
#Thyroid nodules:
[] Consider thyroid US to follow-up on lesions seen on CT chest
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Methotrexate 15 mg PO 1X/WEEK (___)
2. Gabapentin 300 mg PO QHS
3. lisinopril-hydrochlorothiazide ___ mg oral DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
6. Atorvastatin 10 mg PO QPM
7. Humira (adalimumab) 10 mg/0.1 mL subcutaneous EVERY 2 WEEKS
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. Spironolactone 50 mg PO DAILY
RX *spironolactone [Aldactone] 50 mg 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*1
3. Atorvastatin 10 mg PO QPM
4. Gabapentin 300 mg PO QHS
5. Humira (adalimumab) 10 mg/0.1 mL subcutaneous EVERY 2 WEEKS
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
==================
Liver cirrhosis
Secondary diagnosis
====================
Ascites
Pancytopenia
Rheumatoid arthritis
Hyperlipidemia
Type 2 diabetes mellitus
Sciatica
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___ ,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You came to the hospital because you notice an increase in
your abdomen girth and was found to have fluid in your belly.
- The fluid accumulated as a result of liver damage, called
cirrhosis.
What did you receive in the hospital?
- You underwent a procedure called a diagnostic paracentesis,
where a needle is used to sample the fluid in your abdomen. The
fluid did not show signs of infection.
- You underwent a procedure called a therapeutic paracentesis,
where a needle is used to remove the fluid in your abdomen. You
had two of this procedure and a total of 7 liters of fluid was
removed.
- You received medication (furosemide 20mg and spironolactone
50mg daily) that helped you get rid of the extra fluid on your
body.
- You also underwent a procedure called
Esophagogastroduodenoscopy (EGD), where a thin flexible tube (a
"scope") that can be looked through or seen on a TV monitor was
passed down your mouth to visualize your upper gut. Small
dilated veins (varices) were seen at the bottom of your
esophagus (swallowing pipe).
What should you do once you leave the hospital?
- Please continue to take your new medications as prescribed
(Furosemide 20mg daily and spironolactone 50mg daily).
- Please follow up with Dr. ___ within a week of
leaving the hospital in order to monitor you liver function.
- Please weigh yourself DAILY in the morning. If your weight
increases by ___ lbs in 3 days, please increase furosemide to 40
mg daily and
contact Dr. ___ office at ___
- Please follow up with Dr. ___ rheumatologist, and
Dr. ___ primary care physician.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10376769-DS-13 | 10,376,769 | 26,153,797 | DS | 13 | 2176-07-20 00:00:00 | 2176-07-22 11:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Biaxin / Shellfish
Attending: ___.
Chief Complaint:
___ pain and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo RHW with h/o chronic LBP s/p L4-5 fusion,
fibromyalgia, anxiety, depression, who presents with progressive
distal lower extremity numbness and weakness for the past 3
months.
The patient initially presented on ___ ___.
She had awoken that morning with severe numbness below the knees
bilaterally. Her legs were weak and she collapsed on attempting
to stand. She had a recent stomach flu a few days prior.
Examination demonstrated distal lower extremity weakness and
decreased sensation to pin and vibration, with diminished lower
extremity reflexes. There was concern for GBS. CSF was normal (0
cells, glucose 59, protein 24, neg CSF Lyme, neg bands). However
it was thought there was still benefit to treating empirically,
so patient received 3 doses IVIG. She developed fever to ___ F
after 3rd dose so no more were given. She also underwent MRI C,
T
and L spine, and MRI/A brain which were all unrevealing. Labs
were initially notable for CK almost 20K, attributed to fall,
but
this was mild and there was not prolonged down time. CRP 50, ESR
16, WBC 18.3. CK trended down with IVF and has been normal on
repeat checks since.
The pt was discharged to rehab and was then discharged home with
___. Neurologic work-up continued as an outpatient under care
of Dr. ___. EMG ___ showed acute length dependent
polyneuropathy with mixed axonal and demyelinating features.
Motor neuropathy and paraneoplastic Abs sent to ___ were
negative (GM1, GD1b, MAG, ___, CV2, amiphiphysin). Autoimmune
labs
neg ___, ANCA, SSa/b). On ___, CRP was down to 25, ESR 12.
The patient complains of severe pain, that was not part of the
initial presentation but began after returning home from rehab
and doing ___. It has become more severe and refractory to
medications in the past month. Pain includes R foot cramps,
sharp
pains at L posterior calf and feet, burning pain on soles of
feet, hypersensitivity to touch that is painful on L foot. Pain
is worse when putting pressure on the legs to stand, and on
touching the L foot. There are no paresthesias. She will
sometimes feel extreme cold but then legs are not cold to the
touch.
Pt also c/o losing muscle mass and bulk all over, including
upper
extremities, though there are no other symptoms in the upper
extremities (no weakness, numbness, tingling in hands/fingers).
She feels her health going downhill in general and is very
discouraged. She reports her L leg bends backwards on walking.
She had been using cane, but is now using a wheelchair.
Of note, the patient reports that her pain medications were
stolen from her 5 days ago. Since then she experienced severe
withdrawal symptoms (N/V/D and extreme pain). She had not slept
or ate well in days. She presented to ___ ED today, and her
neurologist felt she warranted additional workup since diagnosis
is unclear, and sent her to ___ ED. The patient reports she
was
supposed to have nerve and muscle biopsy tomorrow at ___. ___.
Past Medical History:
-fibromyalgia
-chronic LBP on narcotics
-s/p L4-5 fusion few years ago, "failed"
-GAD
-depression
-PTSD
-SBO s/p LOA
-COPD vs BOOP
Social History:
___
Family History:
negative for neurologic disease
Physical Exam:
At admission:
Vitals: T: 97.6 P:56 R: 14 BP:96/68 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: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with naming,
intact repetition and comprehension. Speech was not dysarthric.
Able to follow both midline and appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades. There was
initially horizontal diplopia on far right gaze but this
resolved
after a few seconds and did not return on repeat testing.
V: Facial sensation intact to light touch.
VII: No facial droop, upper and lower facial musculature full
strength and symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal quick lateral
movements.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
neck flexion and extension full strength
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5- 4 3 4 3 3
R 5 ___ ___ 5 5 5 5 5 4 5-
There is element of giveway and poor effort in all above where
weakness is noted.
-Sensory: No deficits to light touch or cold. Decreased pinprick
(50%) on left lower medial leg and medial and dorsal foot. Pin
on
left lateral foot causes severe burning.
Decreased vibratory sense at L>R great toes.
Intact proprioception to large amplitude movements at bilateral
great toes and DIPs. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2 2+ 1 0
R 2+ 2 2+ 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally, cannot perform HKS.
No overshoot or rebound on horizontal or vertical saccades
-Gait: deferred due to pain
Discharge Physical Exam: As above, except notable for normal
strength in upper and lower extremities, with notable giveway
weakness in the lower left extremity. Normal positioning of the
left leg/foot, improved from admission. The patient was able to
ambulate with a very mildly antalgic gait with a cane. Her
sensation testing was notable for persistent pain and burning
across the dorsum of her ___ in non dermatomal, non
radicular patterns.
Pertinent Results:
___ 06:50PM BLOOD WBC-18.8* RBC-6.18* Hgb-17.3* Hct-52.6*
MCV-85 MCH-28.0 MCHC-32.8 RDW-14.1 Plt ___
___ 06:50PM BLOOD Neuts-51.1 ___ Monos-5.2 Eos-0.9
Baso-1.6
___ 06:50PM BLOOD Plt ___
___ 06:50PM BLOOD ESR-4
___ 06:50PM BLOOD Glucose-82 UreaN-39* Creat-0.9 Na-136
K-4.2 Cl-95* HCO3-26 AnGap-19
___ 06:50PM BLOOD ALT-7 AST-23 AlkPhos-112* TotBili-0.4
___ 06:50PM BLOOD Albumin-4.5 Calcium-9.9 Phos-4.2 Mg-2.3
___ 04:10PM BLOOD CEA-5.2*
___ 06:50PM BLOOD CRP-7.7*
___ 04:10PM BLOOD HIV Ab-NEGATIVE
___ 06:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:10PM BLOOD CA ___ -PND
CXR: IMPRESSION: No acute cardiopulmonary process.
CT torso with contrast:
IMPRESSION:
1. Innumerable bilateral sub-2mm pulmonary nodules some of which
are calcified and shotty mediastinal lymphadenopathy.
Differential includes
tuberculosis/fungal infection/sarcoidosis or less likely
hematogenous mets
with calcification, ie osteogenic, mucinous, thyroid, breast
origin.
Calcification suggests a chronic granulomatous infection (TB)
should be
considered. Comparison with any old CT imaging is recommended.
2. Dilated CBD measuring up to 11-mm which abruptly terminates
at the
pancreatic head with no stone seen. Possible thickening of the
duodenum at the ampulla is suspicious for malignancy. Followup
ERCP/MRCP is strongly recommended.
3. 5mm indeterminate hepatic hypodensity.
MRI C-T-L-spine
IMPRESSION: Mild degenerative changes of the cervical,
thoracic, and lumbar spine as described above. Post-surgical
changes, status post disc spacers at L4-5 and L5-S1 levels. No
evidence of abnormal enhancement or abnormal signal in the
spinal cord.
MRI head with and without contrast:
IMPRESSION:
Unremarkable MRI of the head with and without contrast.
Brief Hospital Course:
___ yo RHW with h/o chronic LBP s/p L4-5 fusion, fibromyalgia,
anxiety, depression, who presents with progressive distal lower
extremity numbness and weakness for the past 3 months. Neuro
exam is signficant for weakness that is asymmetric L>R and
more prominent distally than proximally in the lower
extremities, though there is question of giveway/effort in
judging the true degree of the weakness. This also makes it
difficult to distinguish an upper vs lower motor neuron pattern.
There is
decreased pinprick mostly in L4 distribution up to the knee,
with hyperasthesia in L5. Vibration sense is also diminished L>R
great toe, and DTRs are diminished in lower extremities.
Etiology of this presentation is unclear despite extensive
outpatient workup including MRI brain and spine, EMG, LP, and
several lab studies.
The patient had vague, non-specific positive findings, including
elevated CRP which has trended down, and elevated CK at initial
presentation, as well as leukocytosis intermittently seen. The
patient was admitted and monitored. A CT of the abdomen was done
that showed a duodenal wall thickening. She received a EGD and
biopsy that revealed only a cyst and no signs of neoplasm. the
CT of chest showed multiple small pum nodules/calcifications
with mediatinal LAD, however these were thought for the most
part to be chronic (based on previous radiology reports from
___ and ___ faxed from PCP ___.
Over her week of hospitalization the patient gained weight and
her objective signs of weakness (left foot drop) improved. Prior
to hospitalization the patient was eating only one meal a day.
She was also treated with B12 for a low normal B12, that may
have also contributed to her improvement. The patient was very
uncomfortable and frustrated with a diagnosis of compression
neuropathy secondary to malnutrition.
The patient's chronic pain was treated while she was here on her
home regimen on ___ and gabapentin. Of note, when her
medications were at her home dosing the patient was very
somnolent, difficult to arouse and O2 sat to the low ___. This
may have contributed to the patient's decreased PO.
The patient received physical therapy during her time and was
much improved on discharge. She was able to ambulate with a cane
and was deamed ready for d/c home with ___ services. Her hospital
course was discussed with her primary neurologist who
coordinated a follow-up for her. She was discharged on the pain
regiment she was on inpatient as detailed below.
Medications on Admission:
Morphine SR (MS ___ 100 mg PO Q12H
Morphine Sulfate ___ 30 mg PO/NG Q6H:PRN pain Order date: ___
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing
Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheezing Order date:
Potassium Chloride 20 mEq PO DAILY Duration: 24
Aspirin 81 mg PO/NG DAILY
Polyethylene Glycol 17 g PO/NG DAILY:PRN
Amitriptyline 100 mg PO/NG HS
Pantoprazole 40 mg PO Q24H
Soma *NF* (carisoprodol) 350 mg Oral q8 pain
Fluticasone Propionate NASAL 1 SPRY NU DAILY
traZODONE 100 mg PO/NG HS:PRN insomnia
Lorazepam 1 mg PO/NG Q6H:PRN anxiety
Discharge Medications:
1. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for stomach upset.
2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
4. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*30 Tablet Extended Release(s)* Refills:*0*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
8. trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
10. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
11. carisoprodol 350 mg Tablet Sig: One (1) Tablet PO q8 ().
12. gabapentin 300 mg Capsule Sig: Instructions Capsule PO BID
(2 times a day): Take 600 mg in AM and afternoon. Take 900 mg at
bedtime.
Disp:*200 Capsule(s)* Refills:*0*
13. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
sob/wheezing.
14. morphine 15 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*21 Tablet(s)* Refills:*0*
15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Compression polyneuropathy, 2. Fibromyalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro Exam: AOx3, full strength in upper extremities. Largely
full strength in lower extremities with some giveway strength,
likely related to pain at the left ankle.
Discharge Instructions:
Ms. ___ you were admitted for further evaluation of your pain
and weakness. Your weakness improved dramatically with time,
nutrtional supplementation and B12. Your pain medications were
adjusted a bit as whenever these medications were increased to
your home regiment you became unarousable and your oxygen level
would drop down. This is an indication of over medication and is
dangerous. Therefore we will provide you prescriptions of the
medication doses that you were on here, as detailed in the
discharge medications.
Please contact your regular neurologist.
Followup Instructions:
___
|
10376802-DS-13 | 10,376,802 | 22,691,837 | DS | 13 | 2131-11-27 00:00:00 | 2131-11-27 19:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of hypertension,
HLD, presenting with 6 months of weakness.
Patient reports a 6 month history of weakness, worst in the
bilateral legs, as well as progressive fatigue and a weight loss
of about 20 lbs. Has had multiple visits to PCP and ___ for this.
Negative CTH and CXR on ___. Saw neurology in ___, at which
point neuromuscular disorder was considered but a systemic cause
of illness was thought to be more likely. Lab studies and
imaging
have been unrevealing. Patient also has had an evaluation at
___ for the same, and has had imaging of the
abdomen and pelvis that was reportedly unrevealing. Daughter
reports the patient's speech is also different from baseline.
He had some prior workup in ___, including upper endoscopy,
colonoscopy which was reportedly normal. He had some blood tests
as well. He had an MRI of something (he does not know what) they
told him they saw "a spot" in his liver and "a spot" in his
lungs. He was told these two spots did not explain his energy
and
he should not be concerned. They told him those spots were not
cancer. Blood work revealed mild normocytic anemia and elevated
calcium. The patient plans to see a hematologist about his
anemia.
In the ___:
Initial vital signs were notable for:
96.7 56 139/83 16 100% RA
Exam notable for:
Not in distress
RRR, no murmurs
Clear lungs
Abdomen soft, non-tender, non-distended
CNII-XII intact. No nystagmus. Bilateral lower extremities with
strength intact except for ___ strength in knee extension. Heel
to toe gait very limited due to difficulties with balance.
Positive Romberg.
Labs were notable for:
ALT 56
AST 52
LDH 454
Studies performed include:
CXR:
IMPRESSION:
No acute cardiopulmonary process.
Patient was given:
Consults:
Neurology:
Discussed with Dr. ___ attending and
outpatient
neurologist.
Patient with 6 months of fatigue, global weakness, with c/o
worsening gait. +20 pound weight loss and + BRBPR.
Exam no fatiguable ptosis/diplopia or weakness; ___ in UE and ___
bilaterally; gait with functional features.
There is no acute neurologic process - there is low likelihood
for myasthenia/ NMJ disorder based on history and exam. Prior
labs notable for normal TSH and mild anemia.
He needs workup for weight loss, concerning for an underlying
systemic illness, such as cancer.
- Dispo per ___: Per PCP referral, they recommended medicine
admission
- Patient can be followed as an outpatient or if admitted, as
an
inpatient on consult service.
Vitals on transfer:
98.1 51 129/85 16 100% RA
Upon arrival to the floor, patient reports above history. He
notes he has been experiencing polydipsia and polyuria. He has a
history of stuttering but notes a change in his speech with
slurred speech. He denies BRBPR or melena though chart review
suggests past hemorrhoids. On review he reports dry mouth and
dry
eyes. He has had no fever or chills. No dysuria.
==================
Past Medical History:
HTN
HLD
Social History:
___
Family History:
Father died of cancer ___ years (stomach)
mother - diabetes, psoriasis
3 healthy children
the rest of his family is healthy with no chronic conditions
Physical Exam:
Admission:
========================
___ 2219 Temp: 98.0 PO BP: 138/82 L Lying HR: 55 RR:
18 O2 sat: 98% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera with physiologic icterus and
without injection. MM dry.
NECK: Neck supple, non-tender, without masses.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normoactive bowels sounds, non distended, non-tender to
deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEURO:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive to interview. Language is fluent
with intact repetition and comprehension, although at times pt
has difficulty understanding some wording/phrasing ___ language
barrier. Normal prosody. There were no paraphasic errors. Speech
is not grossly impressive for dysarthria in ___. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 1+ 1+ 1+ 1+ 1+
R 1+ 1+ 1+ 1+ 1+
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Discharge:
General: alert, oriented, no acute distress. Non-cachectic. No
temporal wasting.
Eyes: Sclera anicteric. Pupils equal and reactive to light. ?
Cataracts visible bilaterally. ? ptosis on close inspection.
HEENT: MMM, oropharynx clear. Normal sustained
Neck: supple, no cervical, supraclavicular, postauricular,
occipital, or axillary LAD
Resp: clear to auscultation bilaterally.
CV: RRR. Grade ___ Systolic murmur heard in mitral position.
GI: soft, nontender, non-distended. Bowel sounds present.
MSK: warm, well perfused, 2+ pulses
Neuro:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive to interview. Language is fluent
(interview aided by ___ interpreter). Normal prosody.
There were no paraphasic errors. Speech was not dysarthric.
Strength still ___ but fatigability testing is improved.
Pertinent Results:
Admission:
___ 10:41PM %HbA1c-6.1* eAG-128*
___ 07:15PM K+-5.0
___ 05:25PM GLUCOSE-89 UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-6.7* CHLORIDE-102 TOTAL CO2-27 ANION GAP-11
___ 05:25PM estGFR-Using this
___ 05:25PM ALT(SGPT)-56* AST(SGOT)-52* LD(LDH)-454*
CK(CPK)-152 ALK PHOS-33* TOT BILI-0.6
___ 05:25PM ALBUMIN-5.0 CALCIUM-10.7* PHOSPHATE-4.1
MAGNESIUM-2.3
___ 05:25PM TSH-1.9
___ 05:25PM CORTISOL-6.9
___ 05:25PM ___ TITER-1:40* CRP-2.3
___ 05:25PM WBC-4.2 RBC-4.25* HGB-12.8* HCT-38.7* MCV-91
MCH-30.1 MCHC-33.1 RDW-12.8 RDWSD-42.5
___ 05:25PM NEUTS-42.9 ___ MONOS-12.8 EOS-1.9
BASOS-0.2 IM ___ AbsNeut-1.80 AbsLymp-1.77 AbsMono-0.54
AbsEos-0.08 AbsBaso-0.01
___ 05:25PM PLT COUNT-190
___ 05:15PM URINE HOURS-RANDOM
___ 05:15PM URINE UHOLD-HOLD
___ 05:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
Discharge:
___ 05:53AM BLOOD WBC-3.4* RBC-4.19* Hgb-12.7* Hct-37.5*
MCV-90 MCH-30.3 MCHC-33.9 RDW-12.5 RDWSD-41.0 Plt ___
___ 05:59AM BLOOD Neuts-28.9* Lymphs-57.4* Monos-11.1
Eos-2.1 Baso-0.5 AbsNeut-1.12* AbsLymp-2.22 AbsMono-0.43
AbsEos-0.08 AbsBaso-0.02
___ 05:53AM BLOOD Plt ___
___ 05:59AM BLOOD ___ PTT-29.6 ___
___ 05:53AM BLOOD Glucose-105* UreaN-16 Creat-0.8 Na-139
K-4.6 Cl-102 HCO3-25 AnGap-12
___ 05:53AM BLOOD ALT-55* AST-34 LD(LDH)-127 AlkPhos-41
___ 05:53AM BLOOD Albumin-4.5 Calcium-10.1 Phos-4.2 Mg-2.1
___ 08:33AM BLOOD calTIBC-299 Ferritn-402* TRF-230
___ 10:41PM BLOOD %HbA1c-6.1* eAG-128*
___ 05:58AM BLOOD RheuFac-<10 ___ dsDNA-NEGATIVE
Cntromr-NEGATIVE
Imaging:
- ___ CT - unremarkable. hepatic hemangiomas noted.
- ___ CXR - unremarkable
- ___ CT head w/o contrast - unremarkable
MRI Brain ___. No acute intracranial abnormality.
2. No evidence of a mass.
3. Punctate left frontal subcortical white matter T2/FLAIR
hyperintensity is nonspecific and likely of no clinical
significance.
EMG ___:
IMPRESSION:
Abnormal study. There is electrophysiologic evidence for a
pre-synaptic
neuromuscular transmission disorder as in ___
myasthenic syndrome.
A superimposed post-synaptic neuromuscular transmision disorder
(as in
myasthenia ___ cannot be confidently excluded.
Brief Hospital Course:
Mr. ___ is a ___ year old male with HTN and hyperlipidemia
who presents with subjective weakness, fatigue, change in speech
and weight loss over the past 6 months for expedited work up.
Extensive workup ordered. EMG highly suggestive of ___
Myesthenic Syndrome. Outpatient followup includes cancer
monitoring, neuromuscular neurologist.
Acute issues:
# Unexplained weight loss, weakness: Patient reported losing 20
lbs in 6 months, unintentional. Patient reports good appetite
without increased activity (more likely decreased activity,
given weakness). Aggressive workup was pursued, with no
neoplastic, metabolic, infectious, or endocrinological cause of
weight loss found.
However, a diagnosis of ___ was made via EMG, which is
known to be a paraneoplastic syndrome and associated with an
increased risk of developing clinically apparent cancer in the
next ___ years.
Pertinent workup is summarized below:
- CBC remarkable for slight anemia. Otherwise normal.
- BMP showed no electrolyte abnormalities.
- HIV serology was negative.
- Hep panel was unremarkable except for history of cleared Hep B
infection (HBcAb positive, HBsAg Neg).
- SPEP, UPEP were unremarkable. Peripheral smear was also
normal.
- TSH, PTH, and a.m. cortisol were normal.
- PTHrP is pending on discharge
- MRI of the head was normal.
- CT imaging of the chest and abdomen was significant only for
hepatic angiomas. No signs of malignancy. Consistent with CT
abdomen and chest from ___ (___.
- Review of colonoscopy from ___ records (___)
significant only for diverticulosis and internal hemorrhoids.
# Weakness
# ___ Myesthenic Syndrome (new diagnosis)
Evaluated as above. Neurology was consulted.
EMG showed:
Evidence for a pre-synaptic neuromuscular transmission disorder
as in ___ myasthenic syndrome. A superimposed
post-synaptic neuromuscular transmission disorder (as in
myasthenia ___ cannot be confidently excluded. Will need
follow-up with neuromuscular specialist, and will also need to
be aggressively screened and monitored for malignancy.
___ evaluation concerning for fall risk, impaired balance, and
impaired functional mobility. Functional mobility improved after
starting pyridostigmine and prednisone.
OT evaluation was unremarkable and they corroborated need for
outpatient ___.
Chronic issues:
# ?Diabetes. Patient's A1c was 6.1. Recommend workup and
treatment for possible diabetes as outpatient.
Transitional issues:
- Need to f/u pending lab results (PTHrP, ACh Receptor Ab,
rheumatology panel, second read on outpatient MRI and CT scan
from ___
- Need to establish care with neuromuscular specialist.
- Need to f/u with primary care provider for further cancer
workup including possible need for endoscopy/colonoscopy
- We are working on an appointment with the GI department to
schedule screening endoscopy/colonoscopy
- Will need to discuss short term disability with PCP on next
appointment.
Greater than ___ hour spent on care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Discharge Medications:
1. PredniSONE 10 mg PO DAILY
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
2. Pyridostigmine Bromide 60 mg PO QID
RX *pyridostigmine bromide 60 mg 1 tablet(s) by mouth four times
daily Disp #*90 Tablet Refills:*0
3. Atorvastatin 40 mg PO QPM
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
5.Outpatient Physical Therapy
Diagnosis: ___ Syndrome, gait instability
ICD 10: G73.1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ___ Myasthenic Syndrome.
Secondary: None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for unexplained weight loss and weakness.
What was done for me while I was in the hospital?
- We performed multiple tests to search for a possible cause of
your weakness and weight loss, including blood tests, CT tests,
and neurologic testing.
- We performed a test called electromyography (EMG), which
studies how electrical signals travel through your nerves and
muscles.
- Based on your symptoms and the results of your EMG, we
diagnosed you with ___ Myasthenic Syndrome (LEMS).
- We began treating your LEMS with mestinon and prednisone.
What should I do when I leave the hospital?
- Please note the new medications in your discharge worksheet:
Pyridostigmine Bromide 60 mg PO/NG QID.
- Your appointments are as below.
- You will need to follow up with a NEUROMUSCULAR NEUROLOGIST, a
neurologist who specializes in neuromuscular disorders, at
___.
- You will need to continue to be monitored and tested for
cancer. Please follow up with your primary care provider.
- Please take caution with daily activities at work and home.
Your weakness may improve with medication, but may still limit
your daily activities. You should see a physical therapist,
which we gave you a prescription for.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10376921-DS-16 | 10,376,921 | 24,327,960 | DS | 16 | 2172-06-06 00:00:00 | 2172-06-06 15:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin / Neurontin
Attending: ___.
Chief Complaint:
Left thigh rash
Major Surgical or Invasive Procedure:
___ ___ guided LP
History of Present Illness:
___ PMHx GERD, scoliosis s/p fusion age ___, DJD presenting with
rash on left thigh for 5 days, myalgias, malaise, headache, sore
throat, neck pain, L ear pain.
Patient first noticed red rash on the back of her left thigh on
___. She first noticed the rash because of a burning
sensation when she was sitting on it. She went to urgent care on
___ and was told to use hydrocortisone cream. The rash was
marked and she was told if it got worse to fill the prescription
for Keflex. ___ she noticed that the rash appeared to be
spreading and significantly more red/dark in the center. She
filled the Keflex and has taken 4 doses of 500 mg. Urgent care
initially thought this was a bug bite but patient cannot recall
any recent bites. She also denies exposure to ticks or being in
wooded areas. She did have a recent trip to Main weekend of ___
and was on the beach. ___ afternoon she had onset of sore
throat on the left side as well as left ear pain that is worse
with opening her mouth. Also feels diffuse myalgias and had
chills that night. Patient also endorsing a frontal headache and
a sharp pain on the left side of her neck with neck movement.
Denies neck stiffness. She had a fever of 101.2 this morning and
has had pain but no difficulty with swallowing. Also describes
nausea but denies vomiting, diarrhea, abdominal pain, sick
contacts, double vision. She has had decreased p.o. intake as
eating has been hurting her throat.
Past Medical History:
- GERD
- Scoliosis
Social History:
___
Family History:
FAMILY HISTORY:
- Mother with HTN
- MGM with T2DM, pancreatic cancer
- MGF with T2DM and leukemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Left medial thigh with large 8" area of erythema. Central
in erythematous area are two darker red raised areas with
smaller
pale areas within. Palpation of rash produces burning sensation
Neuro: Mild R eyelid droop/right side mouth droop/able to
wrinkle
forehead bilaterally, CN ___ grossly in tact. ___ strength
upper/lower extremities, grossly normal sensation,
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs:
24 HR Data (last updated ___ @ 1112)
Temp: 97.6 (Tm 98.6), BP: 115/75 (91-115/53-78), HR: 77 (67-84),
RR: 18 (___), O2 sat: 100% (96-100), O2 delivery: Ra
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Skin: Left medial thigh now with targetoid rash consistent with
erythema migrans. Reduced burning pain on palpation
Neuro: alert and oriented X3, CN ___ grossly in tact,
persistent R side mouth droop, eyelid droop, moving all
extremities independently
Pertinent Results:
ADMISSION LABS:
==================
___ 12:25PM BLOOD WBC-7.4 RBC-4.52 Hgb-13.3 Hct-41.0 MCV-91
MCH-29.4 MCHC-32.4 RDW-13.5 RDWSD-45.0 Plt ___
___ 12:25PM BLOOD Neuts-85.7* Lymphs-7.2* Monos-6.2
Eos-0.0* Baso-0.4 Im ___ AbsNeut-6.32* AbsLymp-0.53*
AbsMono-0.46 AbsEos-0.00* AbsBaso-0.03
___ 12:25PM BLOOD Plt ___
___ 12:25PM BLOOD Glucose-84 UreaN-4* Creat-0.5 Na-139
K-4.2 Cl-101 HCO3-25 AnGap-13
___ 12:43PM BLOOD Lactate-1.0
INTERIM LABS:
==============
___ 03:10PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-1 Polys-0
___ ___ 03:10PM CEREBROSPINAL FLUID (CSF) TotProt-26 Glucose-66
DISCHARGE LABS:
===============
___ 06:33AM BLOOD WBC-6.0 RBC-4.08 Hgb-12.3 Hct-37.4 MCV-92
MCH-30.1 MCHC-32.9 RDW-13.9 RDWSD-46.9* Plt ___
___ 06:33AM BLOOD Neuts-61.6 ___ Monos-8.8 Eos-2.8
Baso-0.3 Im ___ AbsNeut-3.68 AbsLymp-1.56 AbsMono-0.53
AbsEos-0.17 AbsBaso-0.02
___ 06:33AM BLOOD Plt ___
___ 06:33AM BLOOD ___ PTT-25.0 ___
___ 06:33AM BLOOD Glucose-83 UreaN-5* Creat-0.5 Na-145
K-4.4 Cl-110* HCO3-22 AnGap-13
___ 06:33AM BLOOD ALT-15 AST-22 AlkPhos-64 TotBili-<0.2
___ 06:33AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0
MICROBIOLOGY:
==============
___ 12:20 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 12:25 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 4:30 pm URINE**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 12:25 pm Blood (LYME) **FINAL REPORT ___
Lyme IgG (Final ___: NEGATIVE BY EIA.
Lyme IgM (Final ___: NEGATIVE BY EIA.
___ 3:10 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
IMAGING:
=========
___ Lower Extremity US:
IMPRESSION:
Subcutaneous edema which may relate to cellulitis. No drainable
fluid
collection.
Brief Hospital Course:
___ PMHx GERD, scoliosis s/p fusion age ___, DJD, presenting with
expanding rash on left thigh for 5 days, myalgias, malaise,
headache, sore throat, neck pain, L ear pain. Found to have
likely early disseminated lyme disease.
ACUTE/ACTIVE PROBLEMS:
=======================
#Fever
#Sore Throat
#Myalgias
#R CN 7 palsy
#Left thigh rash
Patient initially presented to urgent care for left thigh rash
w/ burning sensation on ___ and was prescribed hydrocortisone
w/ Keflex RX if things worsened. The rash expanded over the next
3 days and she developed systemic symptoms including fever,
myalgias, sore throat, ear pain, neck pain. Patient filled and
took 4 doses of Keflex before presenting to ___ ED ___. She
was started on IV abx for treatment of cellulitis and was in the
ED overnight for observation and had expansion of her rash so
was admitted. On admission she was noticed to have mild drooping
of her R eyelid and mouth concerning for a CN7 palsy. With her
systemic symptoms, neck pain, and CN 7 palsy her presentation
was most concerning for a meningitis. Ddx included lyme or vzv
meningitis given the rash. She was started on empiric therapy
for lyme meningitis with IV Ceftriaxone 2g Q24H as this was felt
to be the most likely diagnosis. ___ guided LP ___ was
unrevealing for an infection (TNC 1, gram stain negative,
culture pending). A VZV/HSV DFA test was performed however
sample was inadequate and the test was unable to be interpreted.
Dermatology was consulted to evaluate her rash and they felt
that her rash was most consistent with lyme. Given dermatology's
evaluation and her clinical picture she was felt to have early
disseminated lyme disease with an isolated CN 7 palsy. Her serum
lyme serologies came back negative during admission and while
this is less likely with early disseminated disease it is still
within the realm of possibility. She was started on amoxicillin
to complete a 14 day course of therapy ending ___. Therapy with
doxycycline was deferred as patient is currently breastfeeding
and wanted to continue. An EKG was checked before discharge to
rule out lyme carditis. Her EKG showed normal sinus rhythm, no
evidence of heart block, PR interval wnl.
CHRONIC/STABLE PROBLEMS:
========================
# Chronic back pain. Continued pain management with oxycodone,
Tylenol
#GERD. Continue Pantoprozole 40mg QD
TRANSITIONAL ISSUES
============================
[ ] Abx course for Lyme: Amoxicillin to complete 14 days course
to complete ___.
[ ] If patient returns to care with fevers, myalgias, chills,
etc would test for anaplasma and consider treatment with
rifampin (safe in breastfeeding).
# Code status: Full (presumed)
Attending Addendum:
I have seen and examined the patient on the day of discharge and
agree with the note by the medical resident. On the last hour
she was here, her leg rash evolved into a classic target lesion.
She is safe to be discharged on Amoxicillin for Lyme which is
safe for breast feeding. I spent > 30 min in D/C planning and
coordination of care.
- ___ MD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 5 mg PO QHS:PRN insomnia
2. Nexium 20 mg Other DAILY
3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain -
Moderate
4. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as
needed for pain or headache Disp #*30 Tablet Refills:*0
2. Amoxicillin 500 mg PO Q8H Duration: 10 Days
RX *amoxicillin 500 mg 1 capsule(s) by mouth every 8 hours Disp
#*30 Capsule Refills:*0
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *ibuprofen [Advil] 200 mg 3 tablet(s) by mouth every 8 hours
as needed for pain or headache Disp #*30 Tablet Refills:*0
4. Diazepam 5 mg PO QHS:PRN insomnia
5. Nexium 20 mg Other DAILY
6. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN Pain -
Moderate
7. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
=======================
Early disseminated Lyme disease
Secondary diagnoses
========================
Cranial nerve 7 palsy
Chronic back pain
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You had a rash and it was not getting better with antibiotics.
WHAT HAPPENED WHILE YOU WERE HERE?
- We were concerned that you had Lyme disease and sent off some
blood tests. The test was negative for Lyme but sometimes early
on the disease this can be negative.
- Since you had a slight droop on your face and a headache we
were concerned that you might have meningitis as well so you had
a lumbar puncture. This did not show any infection.
- You were evaluated by the dermatologists and they felt that
your rash was consistent with Lyme disease.
- We treated you with IV ceftriaxone for Lyme disease and
transitioned you to antibiotics by mouth at the time of
discharge.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Continue taking your antibiotics for a total of 14 days, you
will need 11 more days of antibiotics once you leave the
hospital.
- If you start having fevers, chills and body-aches then return
to urgent care as you may have anaplasma (which is another tick
illness) and you will need a different antibiotic. Rifampin is
safe with breastfeeding and can be used for treatment if you do
not want to take doxycycline.
- Follow up with your doctor.
It was a pleasure taking care of you,
Your ___ Medicine Team
Followup Instructions:
___
|
10377337-DS-2 | 10,377,337 | 21,770,611 | DS | 2 | 2126-03-31 00:00:00 | 2126-04-12 12:05:00 |
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 distension
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy and loop ileostomy creation.
History of Present Illness:
___ with no PMH presents with worsening abdominal distension and
pain over past 3 weeks. Patient has history of near total
colectomy (per patient) for sigmoid volvulus 20+ years ago ___.
Normally has ___ loose stools but over past 3 weeks has had
less stool and decreased appetite. Denies any nausea/vomiting.
Last
BM was 2 days ago. Passing small amount of flatus. Over past
day, significantly increased distension and discomfort prompting
visit to ER ___. There, CT consistent with SBO with
pneumoperitoneum. Transferred here urgently for further care.
Past Medical History:
PMH: obesity
PSH: ___ - colectomy for Sigmoid volvulus (reported as near
total colectomy and reanastomosis per patient)
Social History:
___
Family History:
DM, HTN, HLD in parents
Physical Exam:
Vitals: T98.2, HR70-80, BP120/60 SpO298%on RA
Gen: NAD, AAOx3, calm, pleasant
HEENT: trachea midline
CV: RRR
Lungs: CTAB
Abd: grossly distended and protuberant, + tympanitic, non-tender
throughout except for mild tenderness in LUQ, no rebound, no
guarding, midline laparotomy incision well-healed
Extr: No peripheral edema
Discharge Physical Exam:
VS: T: 97.1, P: 81, BP: 114/64, RR: 16, O2: 97% RA
General: A+Ox3, NAD
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, mildly tender to palapation. Stoma
beefy red, flatus in bag. Midline incision well approximated, no
erythema or drainage
Extremeties: no edema
Pertinent Results:
___ 04:50PM URINE HOURS-RANDOM CREAT-170 SODIUM-LESS THAN
CHLORIDE-37
___ 12:50PM GLUCOSE-147* UREA N-12 CREAT-0.7 SODIUM-136
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
___ 12:50PM WBC-7.1 RBC-4.71 HGB-13.4 HCT-41.9 MCV-89
MCH-28.5 MCHC-32.0 RDW-12.5 RDWSD-40.8
___ 12:50PM PLT COUNT-444*
___ 04:20AM GLUCOSE-142* UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-29 ANION GAP-15
___ 04:20AM CALCIUM-8.6 PHOSPHATE-4.7* MAGNESIUM-1.8
___ 04:20AM WBC-6.5 RBC-5.52* HGB-15.9*# HCT-49.6*#
MCV-90 MCH-28.8 MCHC-32.1 RDW-12.6 RDWSD-41.3
___ 04:20AM NEUTS-70.4 ___ MONOS-4.2* EOS-3.2
BASOS-0.6 IM ___ AbsNeut-4.57 AbsLymp-1.39 AbsMono-0.27
AbsEos-0.21 AbsBaso-0.04
___ 04:20AM PLT COUNT-597*
___ 04:20AM ___ PTT-31.2 ___
___ 11:06PM LACTATE-1.1
___ 10:45PM GLUCOSE-125* UREA N-16 CREAT-0.8 SODIUM-136
POTASSIUM-3.6 CHLORIDE-93* TOTAL CO2-31 ANION GAP-16
___ 10:45PM cTropnT-<0.01
___ 10:45PM WBC-8.5 RBC-4.49 HGB-12.8 HCT-39.6 MCV-88
MCH-28.5 MCHC-32.3 RDW-12.4 RDWSD-39.8
___ 10:45PM NEUTS-50.8 ___ MONOS-7.5 EOS-19.8*
BASOS-0.5 IM ___ AbsNeut-4.34 AbsLymp-1.81 AbsMono-0.64
AbsEos-1.69* AbsBaso-0.04
___ 10:45PM PLT COUNT-495*
___ 10:45PM ___ PTT-33.3 ___
CT A/P (OSH): grossly distended SB loops, collapsed SB loops in
LLQ, pneumoperitoneum
Brief Hospital Course:
Ms. ___ is a ___ female with history of sigmoid
volvulus s/p total abdominal colectomy with ileorectal
anastamosis (___) who was transferred from an outside hospital
(OSH) with small bowel obstruction and pneumoperitoneum
necessitating urgent surgical intervention. On ___, she
underwent an exploratory laparotomy, decompression via an
enterotomy, and loop ileostomy. Intra-operatively, no source of
obstruction or perforation was found. The patient remained
intubated to the ICU given the extent of the operation.
On POD1, the patient was successfully extubated. Pain was
controlled on PCA and she was kept NPO/IVF. She received 7
liters total of fluid boluses for low urine output which she
responded appropriately to.
When medically stable, the patient was transferred to the
step-down surgical floor.
On POD3, the patient's NGT was removed and she was started on a
clear liquid diet which she tolerated well. She received another
fluid bolus for low urine output. On POD3, her foley was
removed and she voided independently.
On POD4, the patient's PCA was discontinued and she was started
on oral oxycodone and acetaminophen for pain control with
dilaudid IV for breakthrough.
On POD4, the patient experienced emesis and was made NPO. On
POD6, a nasogastric tube was reinserted. On POD7, the patient's
antibiotic regimen was discontinued as there was no sign of
infection.
On POD8, the patient had flatus present in her ostomy bag. On
POD9, the patient had a PICC placed to receive TPN.
On POD10, a small bowel biopsy from the ostomy site was obtained
for workup of a dysmotility disorder per the Gastrointestinal
team. On POD12, the patient's nasogastric tube was removed and
she was started on a clear liquid diet which was well-tolerated.
On POD13, she was advanced to a regular diet which was
well-tolerated. On POD14, TPN was discontinued.
On POD14, the Gastrointestinal team performed another biopsy of
the patient's ostomy site for workup of dysmotility.
The rest of the ___ hospital course is reviewed by systems
below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral pain medication once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Please refer to note above for GI and GU specifics.
At the time of discharge, the patient was voiding appropriately
and tolerating a regular diet. The patient's intake and output
were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection. Her IV antibiotics were discontinued as there was no
concern for infection.
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. She was discharged to home
with Visiting Nurse ___
Of note is that the patient was discharged home with an
incorrect follow-up appointment with the ___
___. The patient was contacted at home and notified of the
error and she was provided with a phone number to call the GI
clinic to arrange for a follow-up appointment. The patient
verbalized understanding.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. LOPERamide 2 mg PO BID:PRN High ostomy output
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tab by mouth
twice a day Disp #*30 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Q24H Disp #*30
Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN pain
do NOT exceed 3gm in 24 hours
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumoperitoneum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
___ were presented to the ___
on ___ with complaints of abdominal pain. ___ were
admitted to the Acute Care Surgery Trauma team.
On ___, ___ underwent a procedure called an Exploratory
Laparotomy with loop ileostomy creation. ___ were also seen by
the Gastrointestinal team and were worked up for a
gastrointestinal dysmotility disorder.
___ are recovering well and are now ready for discharge. A
visiting nurse ___ come to your home to assess your ostomy.
Please follow the instructions below to continue your recovery:
___ have a new ileostomy. The most common complication from a
new ileostomy placement is dehydration. The output from the
stoma is stool from the small intestine and the water content is
very high. The stool is no longer passing through the large
intestine which is where the water from the stool is reabsorbed
into the body and the stool becomes formed. ___ must measure
your ileostomy output for the next few weeks. The output from
the stoma should not be more than 1200cc or less than 500cc. If
___ find that your output has become too much or too little,
please call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if ___ notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to ___ by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
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 steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
10377337-DS-3 | 10,377,337 | 27,427,119 | DS | 3 | 2126-06-10 00:00:00 | 2126-06-12 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lactose / shellfish derived
Attending: ___.
Chief Complaint:
abdominal pain, decreased ostomy output
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female s/p colectomy for volvulus (___) and loop
ileostomy for decompression of severe small bowel dilation (___) now presenting with 5 days of abdominal pain and 3 days of
decreased ostomy output. Her first symptom was mild gassy pain
in
R abdomen five days ___ night) which self resolved. She
was asymptomatic for 48 hours then developed sudden ___
"crampy/gassy" pain in R abdomen, +nausea. No alleviation with
Tylenol or gas-X. She manually evacuated her small bowel into
the
ostomy bag by applying external pressure which ameliorated but
did not resolve her pain. The following day (___), she noted
her ostomy output was pasty and substantially decreased in
volume
from her baseline output of 1000-1400cc/day. For these past two
days she has experienced waxing and waning pain (primarily RUQ
but migratory across abd) which is exacerbated by POs, bloating
(R abd > L), total ostomy output of 1 tsp since ___ (none
in >24h), and no gas in ostomy bag.
On ___, pt saw Dr. ___ had IV/PO contrast CT showing
"moderately dilated loops of small bowel and decompressed bowel
distally without an obstructive appearance", new mild
perisplenic
ascites, and multiple areas of soft tissue density along small
bowel consistent with adhesions. Also saw Dr. ___
prescribed ___ 550mg tid for possible motility d/o. She
has
been on full liquid diet since ___.
Of note, full thickness pathology specimens of small bowel on
___ and ___ showed prominent eosinophilic infiltration.
Past Medical History:
PMH: obesity
PSH: ___ - colectomy for Sigmoid volvulus (reported as near
total colectomy and reanastomosis per patient)
Social History:
___
Family History:
DM, HTN, HLD in parents
Physical Exam:
Physical Exam:
Vitals:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, no M/G/R. Brisk capillary refill <2s.
PULM: Clear to auscultation b/l, no W/R/R.
ABD: Markedly distended. Well healed recent midline incision on
top old fully healed midline incision scar. Decreased bowel
sounds in RUQ & mid-R, none on L. Soft, slightly tender in R
mid-abdomen; no rebound or guarding. Tympanic to percussion.
Ostomy appears healthy.
Ext: No ___ edema, ___ warm and well perfused.
Discharge Physical Exam:
VS: 98.2, 72, 117/73, 18, 95%ra
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, nontender to palpation,
mildly distended. Midline Incision: clean, dry and intact, open
to air, healing scar. Ileostomy bag with gas and stool.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 06:11AM BLOOD WBC-6.0 RBC-4.72 Hgb-13.6 Hct-41.0 MCV-87
MCH-28.8 MCHC-33.2 RDW-13.7 RDWSD-43.7 Plt ___
___ 11:50AM BLOOD WBC-7.7 RBC-4.86 Hgb-13.9 Hct-41.6 MCV-86
MCH-28.6 MCHC-33.4 RDW-13.8 RDWSD-43.1 Plt ___
___ 01:03PM BLOOD Glucose-72 UreaN-9 Creat-0.7 Na-139 K-3.9
Cl-102 HCO3-19* AnGap-22*
___ 06:11AM BLOOD Glucose-76 UreaN-10 Creat-0.6 Na-142
K-3.5 Cl-102 HCO3-25 AnGap-19
___ 03:40PM BLOOD Glucose-82 UreaN-10 Creat-0.6 Na-140
K-3.6 Cl-100 HCO3-26 AnGap-18
___ 01:03PM BLOOD Calcium-9.1 Phos-3.7 Mg-1.5*
___ 06:11AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.8
___ 03:40PM BLOOD Calcium-9.2 Phos-4.0 Mg-1.9
Imaging:
CT A/P: Status post subtotal colectomy, left lower quadrant loop
ileostomy, and ileocolonic anastomosis with dilated loop of oral
contrast filled loop of bowel in the right hemi-abdomen which
appears to come to an abrupt transition point within the
midabdomen with distally decompressed loops difficult to trace.
Findings are concerning for a small bowel obstruction which in
the presence of air distally is at least partial. No evidence of
ischemia. Loop of bowel at the ileostomy site is newly dilated
and air filled relative to prior examination.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain and
decreased ostomy output. Admission abdominal/pelvic CT was
concerning for a partial small bowel obstruction. The patient
was hemodynamically stable. She was kept nothing by mouth with
IV fluids and serial abdominal exams. Her stoma was digitalized
with a red rubber catheter and the patient soon after had stool
and gas coming from her ostomy. Gastroenterology was consulted,
to help distinguish if this was a dysmotility issue or
obstructive problem. A loopogram was obtained, which showed
focal transition point likely secondary to adhesions in the
proximal loop of the ileostomy and no obstruction of the distal
loop of the ileostomy to the rectum. A barium enema showed the
colorectal anastomosis was patent with no evidence of
obstruction, and contrasts passing from the rectum through the
colorectal anastomosis.
Pain was well controlled and slowly resolved once bowel function
returned and ostomy was putting out stool. 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. There was gas and stool in her ostomy. 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. She had
follow-up scheduled with her Gastroenterologist and in the ___
clinic.
Medications on Admission:
Medications:
___ 550mg tid (started ___
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with abdominal pain and decreased
ostomy output, concerning for a bowel obstruction. You were
treated with bowel rest and IV fluids. A catheter was passed
through your stoma to attempt to digitalize the opening. Since
then, you started having gas and stool in the ostomy bag. The
Gastroenterologists were consulted while you were here, and a
barium enema study showed No evidence of obstruction or leak at
the colorectal anastomotic site. You are now tolerating a
regular diet and your pain has resolved, and there is normal
ostomy output. You are ready to be discharge home to continue
your recovery. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids
Followup Instructions:
___
|
10377337-DS-4 | 10,377,337 | 21,921,564 | DS | 4 | 2126-06-26 00:00:00 | 2126-06-26 15:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lactose / shellfish derived
Attending: ___.
Chief Complaint:
partial small bowel obstruction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
obesity, lactose intolerance, bowel
dysmotility & possible bacterial overgrowth (followed by Dr.
___, parastomal hernia
Past Medical History:
___: ___ - colectomy for Sigmoid volvulus (reported as near
total colectomy and reanastomosis per patient)
Social History:
___
Family History:
DM, HTN, HLD in parents
Physical Exam:
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, nondistended, ostomy pink,
functioning, with tube in place
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 05:50AM BLOOD WBC-6.9 RBC-4.41 Hgb-12.8 Hct-38.7 MCV-88
MCH-29.0 MCHC-33.1 RDW-13.5 RDWSD-43.3 Plt ___
___ 05:50AM BLOOD Glucose-103* UreaN-8 Creat-0.8 Na-141
K-3.8 Cl-102 HCO3-28 AnGap-15
Brief Hospital Course:
Ms ___ was admitted following episodes of nausea/low ostomy
production. In the emergency department, her stoma was digitized
and subsequently intubated, resulting in the passage of flatus
and stool. Once she was admitted, she was made NPO with
intravenous fluids. Overnight, her stoma continued to be
productive, and by morning she reported resolution of her
symptoms. She tolerated a regular diet for breakfast and lunch,
was voiding appropriately, was walking without assistance, and
reported ostomy output of 600cc for the first 12 hours of the
day. At this time, she was discharged with follow up.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Rifaximin 550 mg PO TID
3. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Rifaximin 550 mg PO TID
3. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were admitted for management of your bowel obstruction that
resolved s/p intubation overnight. ___ will go home with a tube
in your stoma, which can be removed when it falls out. Should
___ experience further symptoms, please call the general surgery
office at ___
Followup Instructions:
___
|
10377337-DS-6 | 10,377,337 | 21,624,770 | DS | 6 | 2126-09-30 00:00:00 | 2126-10-04 18:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lactose / shellfish derived
Attending: ___
Chief Complaint:
Hypotension, hyonatremia, poor PO intake
Major Surgical or Invasive Procedure:
___ PICC line placement
History of Present Illness:
Ms. ___ is a ___ with history of sigmoid volvulus s/p
colectomy (___) and perforated viscus ___ small bowel
obstruction s/p loop ileostomy (___), recently hospitalized
from (___) for a high grade small bowel obstruction
requiring exploratory laparotomy, lysis of adhesions, reduction
of internal hernia (___), small bowel resection (___), and
formation of end ileostomy and fascial closure (___). She was
discharged to rehab after an extended hospital stay on POD 35.
Her hospital course was complicated by high ileostomy output and
hyponatremia. She was subsequently discharged to rehab and last
seen in clinic on ___. At that time, Ms. ___ noted that she
had done well at rehab and was discharged home. Last ___, she
was found to be hypotensive by her ___ and sent to ___
for fluid hydration (not admitted). Over the weekend, she
continued to have poor PO intake given poor appetite. She notes
that her ostomy has had more formed stool but low amounts given
her poor PO intake. Denies nausea, vomiting, fevers, chills. On
evaluation this morning, her ___ found her severely orthostatic
and hyponatremic. On arrival to the ED, she was found to be
hypotensive to 68/41 and was given multiple fluid boluses. No
altered mental status. Surgery was consulted for further
evaluation.
Past Medical History:
PMH: obesity, lactose intolerance, bowel dysmotility & possible
bacterial overgrowth (Dr. ___, parastomal hernia
PSH:
___ - Colectomy for Sigmoid volvulus (reported as near total
colectomy and reanastomosis per patient)
Social History:
___
Family History:
DM, HTN, HLD in parents
Physical Exam:
Admission Physical Exam:
Vitals: 98.7 130 68/41 18 100%RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: tachycardic, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: soft, well healing midline incision, ostomy pink and
stool/gas
in ostomy bag, nontender, nondistended, no rebound/guarding
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.5 94 112/60 16 98% RA
GEN: Awake, alert, sitting up in bed.
HEENT: No deformity. PERRL, EOMI. neck supple, trachea midline.
Mucus membranes pink/moist.
CV: RRR
PULM: Clear to auscultation bilaterally.
ABD: Soft, non-tender, mildly distended. Midline surgical
incision progressively healing with no signs of infection.
Ostomy pink, liquid tan output in bag.
Ext: Warm and dry. Mild edema to left arm and left leg. ___
pulses.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
Imaging:
___ CXR: In comparison with the study of ___, there
is no change in the appearance of the heart and lungs.
Continued elevation of the left hemidiaphragm, but no acute
pneumonia or vascular congestion.
There is an placement of a left subclavian PICC line that
extends to about the level of the cavoatrial junction. The
right PICC line is been removed.
___ ECG: Clinical indication for EKG: I95.1 - Orthostatic
hypotension
Sinus tachycardia. Intraventricular conduction delay.
Non-specific ST-T wave changes. Compared to the previous tracing
of ___ no significant change.
___ CT Abdomen/Pelvis:
1. There are sequentially dilated and decompressed small bowel
loops near the ileostomy. Appearance is not that of a bowel
obstruction.
2. ___ pouch contains intraluminal contrast without
visible fistula.
3. Small bilateral pleural effusions. Small ascites is slightly
increased
than before.
___ 04:24AM BLOOD WBC-4.3 RBC-2.86* Hgb-8.3* Hct-27.2*
MCV-95 MCH-29.0 MCHC-30.5* RDW-18.5* RDWSD-64.4* Plt ___
___ 03:23AM BLOOD WBC-5.1 RBC-2.89* Hgb-8.6* Hct-27.3*
MCV-95 MCH-29.8 MCHC-31.5* RDW-18.8* RDWSD-64.0* Plt ___
___ 02:53AM BLOOD WBC-6.7 RBC-2.92* Hgb-8.4* Hct-27.3*
MCV-94 MCH-28.8 MCHC-30.8* RDW-18.6* RDWSD-63.6* Plt ___
___ 06:05AM BLOOD WBC-5.7 RBC-3.12* Hgb-9.1* Hct-28.7*
MCV-92 MCH-29.2 MCHC-31.7* RDW-18.8* RDWSD-62.9* Plt ___
___ 04:32AM BLOOD WBC-5.7 RBC-3.38* Hgb-9.8* Hct-30.3*
MCV-90 MCH-29.0 MCHC-32.3 RDW-18.4* RDWSD-60.3* Plt ___
___ 05:10AM BLOOD WBC-6.3 RBC-3.50* Hgb-10.0* Hct-31.0*
MCV-89 MCH-28.6 MCHC-32.3 RDW-18.5* RDWSD-59.5* Plt ___
___ 05:20AM BLOOD WBC-5.7 RBC-3.44* Hgb-9.9* Hct-31.1*
MCV-90 MCH-28.8 MCHC-31.8* RDW-18.3* RDWSD-60.2* Plt ___
___ 02:00PM BLOOD WBC-8.9 RBC-4.06 Hgb-11.7 Hct-35.8 MCV-88
MCH-28.8 MCHC-32.7 RDW-18.0* RDWSD-57.6* Plt ___
___ 02:00PM BLOOD Neuts-62.4 ___ Monos-8.4 Eos-0.7*
Baso-0.4 Im ___ AbsNeut-5.57# AbsLymp-2.44 AbsMono-0.75
AbsEos-0.06 AbsBaso-0.04
___ 02:00PM BLOOD ___ PTT-26.4 ___
___ 04:24AM BLOOD Glucose-134* UreaN-14 Creat-0.3* Na-140
K-4.4 Cl-108 HCO3-30 AnGap-6*
___ 03:23AM BLOOD Glucose-110* UreaN-14 Creat-0.3* Na-137
K-4.1 Cl-103 HCO3-31 AnGap-7*
___ 02:53AM BLOOD Glucose-128* UreaN-14 Creat-0.3* Na-137
K-3.9 Cl-104 HCO3-31 AnGap-6*
___ 06:05AM BLOOD Glucose-126* UreaN-13 Creat-0.3* Na-137
K-3.6 Cl-103 HCO3-32 AnGap-6*
___ 05:34AM BLOOD Glucose-112* UreaN-13 Creat-0.3* Na-136
K-3.8 Cl-102 HCO3-28 AnGap-10
___ 04:32AM BLOOD Glucose-118* UreaN-13 Creat-0.3* Na-134
K-3.7 Cl-100 HCO3-26 AnGap-12
___ 05:10AM BLOOD Glucose-89 UreaN-10 Creat-0.4 Na-132*
K-3.5 Cl-101 HCO3-25 AnGap-10
___ 05:20AM BLOOD Glucose-82 UreaN-11 Creat-0.5 Na-133
K-3.6 Cl-97 HCO3-27 AnGap-13
___ 02:00PM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-129*
K-4.2 Cl-90* HCO3-29 AnGap-14
___ 04:24AM BLOOD Calcium-7.2* Phos-4.2 Mg-1.8
___ 03:23AM BLOOD Calcium-7.3* Phos-4.0 Mg-1.8
___ 02:53AM BLOOD Calcium-7.0* Phos-3.8 Mg-1.9
___ 06:05AM BLOOD Calcium-7.0* Phos-3.9 Mg-1.7
___ 05:34AM BLOOD Calcium-6.8* Phos-3.6 Mg-1.5*
___ 04:32AM BLOOD Calcium-7.0* Phos-3.2 Mg-1.8
___ 05:10AM BLOOD Calcium-6.9* Phos-3.2 Mg-2.0
___ 05:20AM BLOOD Albumin-1.3* Calcium-6.9* Phos-4.0
Mg-1.5* Iron-42
___ 02:00PM BLOOD Calcium-7.4* Phos-3.5 Mg-1.6
___ 05:20AM BLOOD calTIBC-61* TRF-47*
___ 05:20AM BLOOD Triglyc-52
Brief Hospital Course:
Ms. ___ is a ___ yo F with a complicated past
medical/surgical history of dismotility with a recent
hospitalization (___) for a high grade small
bowel obstruction requiring exploratory laparotomy, lysis of
adhesions, reduction of internal hernia, small bowel resection,
and formation of an end ileostomy and fascial closure. Her prior
hospital course was complicated by high ileostomy output and
dehydration. She presented to the emergency department on
___ with hypotension, hyponatremia, and poor PO intake. She
was admitted to the Acute Care Surgery Service for IV fluid
hydration and continued management of her output.
The gastrointestinal team was consulted and recommended a ___
day course of Rifaximin and slow titration of antimotility
agents as needed for high output.
Nutrition was consulted for inadequate PO intake and recommended
TPN, trending body weight, and encouraging PO intake. She had a
PICC line placed on ___ and TPN was started on HD3 which
was tolerated well.
The remainder of her hospital course can be summarized below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral dilaudid.
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 had decreased PO intake. She was given IV
fluid for decreased urine output which improved. On HD3 she was
noted to have decreased ostomy output in relation to decreased
PO intake. She was started on Rifaxamin on HD6 for bacterial
overgrowth. She was noted to have discharge from her rectum with
similar character as her ileostomy output and therefore had a CT
scan of her abdomen/pelvis. The scan showed a small fistula.
This does not appear to be causing any medical issues and
therefore does not require an intervention at this time.
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,
stable on a TPN regimen, ambulating, voiding without assistance,
and pain was well controlled. Visiting nursing services were
arranged. 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:
ERGOCALCIFEROL (VITAMIN D2) 50,000 units weekly
HYDROMORPHONE 2mg tabs q4hr prn pain
METHOCARBAMOL 500 mg tablet TID prn spasms
OMEPRAZOLE 20mg daily
ONDANSETRON 4mg TID prn nausea
ACETAMINOPHEN 650mg q 6 hours prn pain
SACCHAROMYCES BOULARDII 250mg capsule BID
SIMETHICONE 40mg QID prn gas
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
3. Calcium Carbonate 500 mg PO TID
4. Famotidine 20 mg PO Q12H
5. Simethicone 80 mg PO QID:PRN gas pain
6. Sarna Lotion 1 Appl TP QID:PRN rash/dry skin
7. Rifaximin 400 mg PO/NG TID Duration: 7 Days
RX *rifaximin [Xifaxan] 200 mg 2 tablet(s) by mouth three times
a day Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Dehydration
Orthostatic hypotension
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service at ___ on
___ with hypotension (low blood pressure), low sodium, and
decreased appetite. You were given IV fluids and started on TPN
for nutrition. You are having drainage from your rectum. You had
a CT scan to assess for a fistula (connection) between you small
intestine and colon. The CT scan showed a small fistula, but
does not require surgical intervention and will not interfere
with your current nutrition or activity.
You are now doing better, tolerating a regular diet, stable on a
TPN regimen, and ambulating independently. You are ready to be
discharged to home with ___ services.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
___
|
10377337-DS-8 | 10,377,337 | 29,632,784 | DS | 8 | 2127-09-24 00:00:00 | 2127-09-24 16:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lactose / shellfish derived
Attending: ___.
Chief Complaint:
Abdominal pain, distension, decreased ostomy output
Major Surgical or Invasive Procedure:
___: sigmoidoscopy
History of Present Illness:
Ms. ___ is a ___ female well-known to the ___
service with a history of bowel dysmotility, recurrent SBOs, and
multiple prior abdominal operations including remote
sigmoidectomy for volvulus, and more recently ___ - ___
multiple abdominal explorations for obstruction ultimately with
creation of an end-ileostomy. She was recently admitted to ___
from ___ to ___ with a recurrent SBO, which resolved
spontaneously without intervention on HD#1. She returns today
due to concern for recurrence of her symptoms.
She reports that starting the day after her discharge, she began
to note a return of her abdominal pain, distension, and a steady
decrease in her ostomy output from her usual baseline and
minimal flatus in the bag. She had an episode of nausea and
small-volume non-bloody, non-bilious emesis yesterday. She has
had poor appetite and minimal PO intake over the past day. She
has had no fevers/chills.
Past Medical History:
Past Medical History: Obesity, bowel dysmotility (follows with
Dr. ___, parastomal hernia
Past Surgical History: Sigmoid colectomy for volvulus (___),
exploratory laparotomy/loop ileostomy ___ ___,
exploratory laparotomy/LOA/reduction of internal hernia with
open
abdomen (___), exploratory laparotomy/SBR/abdominal washout
(___), exploratory laparotomy/fascial closure/end-ileostomy
(___)
Social History:
___
Family History:
DM, HTN, HLD in parents
Physical Exam:
Admission Physical Exam:
Vitals: 98.0 86 ___ 99%RA
GEN: A&O, interactive and cooperative
HEENT: No scleral icterus
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, mildly distended, tender with palpation in the upper
abdomen, no rebound/guarding, stoma pink and healthy-appearing
with no stool output visible, well-healed old surgical scars
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
Vitals: 97.9 71 120/78 16 98%RA
GEN: A&O, interactive and cooperative
HEENT: No scleral icterus
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, minimally distended, nontender abdomen, no
rebound/guarding, stoma pink and healthy-appearing with stool
output visible, well-healed old surgical scars
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
IMAGING:
___: CT Abdomen/Pelvis:
Small-bowel obstruction with point of obstruction just proximal
to the
ileostomy in the left lower quadrant abdominal wall.
___: CXR:
Study of ___, the tip of the nasogastric tube is in
the upper
thoracic esophagus. No evidence of acute cardiopulmonary
disease. In chronic elevation of the left hemidiaphragmatic
contour with extremely dilated loops of gas filled bowel.
LABS:
___ 05:15AM BLOOD WBC-3.5* RBC-4.49 Hgb-13.2 Hct-39.5
MCV-88 MCH-29.4 MCHC-33.4 RDW-12.6 RDWSD-40.6 Plt ___
___ 06:00AM BLOOD WBC-3.6* RBC-4.60 Hgb-13.2 Hct-41.0
MCV-89 MCH-28.7 MCHC-32.2 RDW-12.7 RDWSD-41.7 Plt ___
___ 05:40AM BLOOD WBC-4.6 RBC-4.84 Hgb-13.7 Hct-43.0 MCV-89
MCH-28.3 MCHC-31.9* RDW-12.9 RDWSD-42.5 Plt ___
___ 11:00AM BLOOD WBC-8.7# RBC-5.68* Hgb-16.3* Hct-49.1*
MCV-86 MCH-28.7 MCHC-33.2 RDW-13.1 RDWSD-40.9 Plt ___
___ 05:40AM BLOOD Glucose-89 UreaN-5* Creat-0.6 Na-142
K-3.8 Cl-105 HCO3-26 AnGap-15
___ 05:15AM BLOOD Glucose-73 UreaN-7 Creat-0.7 Na-143 K-3.6
Cl-104 HCO3-25 AnGap-18
___ 06:00AM BLOOD Glucose-86 UreaN-7 Creat-0.7 Na-143 K-3.9
Cl-102 HCO3-25 AnGap-20
___ 05:40AM BLOOD Glucose-108* UreaN-7 Creat-0.7 Na-142
K-4.0 Cl-103 HCO3-26 AnGap-17
___ 11:00AM BLOOD Glucose-119* UreaN-11 Creat-0.8 Na-137
K-4.6 Cl-95* HCO3-24 AnGap-23*
___ 05:40AM BLOOD Calcium-8.8 Phos-4.4 Mg-1.9
___ 05:15AM BLOOD Calcium-8.7 Phos-4.5 Mg-1.8
___ 06:00AM BLOOD Calcium-9.0 Phos-4.5 Mg-1.8
___ 05:40AM BLOOD Calcium-9.0 Phos-4.9* Mg-1.9
___ 11:34AM BLOOD Lactate-1.6
Brief Hospital Course:
Ms. ___ is a ___ y/o F w/ hx of bowel dysmotility, recurrent
SBOs, and
multiple prior abdominal operations, who presented to ___ with
abdominal pain, distention and decreased ostomy output. Imaging
revealed a small bowel obstruction. The patient was made NPO
started on IVF and had a NGT placed. The patient was admitted
to the Acute Care Surgery service for further non-operative,
conservative care. On HD2, the patient passed flatus and had a
bowel movement and the NGT was removed. The patient underwent GI
ileoscopy where they had found that the ileostomy was opened and
dilated without twisting or obstruction. On HD3, a malecot was
placed into the ostomy with immediate return of gas and stool
contents later in the afternoon. On HD4, the patient continued
to pass flatus and stool, and she was written for a clear liquid
diet which she tolerated. GI recommended slow DAT, that SBO was
most likely secondary to the patient's known GI dysmotility and
recommended against erythromycin or reglan. On HD5, the patient
was written for a regular diet which was well-tolerated. The
patient expressed that she would like to go home with a malecot
drain to help decompress herself at home if needed. The patient
was supervised using a malecot and received one for home.
The patient was alert and oriented throughout hospitalization;
pain was initially managed with IV morphine and was then
discontinued as the patient did not request any pain medicine.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored. The patient remained
stable from a pulmonary standpoint; vital signs were routinely
monitored. Good pulmonary toilet and early ambulation were
encouraged throughout hospitalization. The patient's intake and
output were closely monitored. The patient's fever curves were
closely watched for signs of infection, of which there were
none. The patient's blood counts were closely watched for signs
of bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 20 mg PO Q12H
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Calcium Carbonate 500 mg PO TID
4. Simethicone 80 mg PO QID:PRN gas pain
Discharge Medications:
1. Simethicone 80 mg PO QID:PRN gas pain
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Calcium Carbonate 500 mg PO TID
4. Famotidine 20 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with a small bowel
obstruction. You were initially restricted from eating, started
on IV fluids for hydration, and had a nasogastric tube placed
for bowel decompression. This tube was later removed when you
had return of bowel function. The stoma was opened with a
catheter, and you underwent sigmoidoscopy by Gastroenterology.
Your diet was gradually advanced and you are now tolerating a
regular diet. You are now medically ready to be discharged
home. Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
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